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Chapter 7

Chapter 7 - Psychological Treatment Textbook Notes Psych 1X03

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Textbook Notes Psych 1X03 Chapter 7: Psychological Treatment  Barriers to seeking psychological treatment o Internal – eg/ self defeating thoughts about why treatment wouldn’t work or help o External – eg/ lack of funds to pay for treatment Section 1: Diversity of Treatment Consumers  8% of adults report to consulting a professional about mental or emotional health in the past year Tailing Treatment to the Disorder  There is a large diversity of disorders (discussed in ch 6)  Conceptualization (accurate and comprehensive clinical diagnosis) of a psychological condition is an important precursor to choosing appropriate treatment  Ego syntonic disorders – those in which the symptoms of the disorder are perceived by the individual with the disorder as valued or advantageous  Ego dystonic disorders – those in which the symptoms are perceived by the individual as undesirable Tailing Treatment to the Individual  Select risk and protective factors can influence the development and expression of mental health problems  Effective psychological treatment should account for individual, family, social, circumstantial and cultural contexts within which the client presents for treatment  States of Changes (Prochaska and DiClemente) o Precontemplation – identified by an inability or unwillingness to acknowledge the existence of a problem o Contemplation – the individual acknowledges the existence of the problem, but may be unsure or unwilling to change the problem o Preparation – associated with recognition of the problem and preparation for change o Action – involves taking active steps to change the behaviour o Maintenance – represents the continuation of healthy habits, formed at the action stage, watching out for potential stressors that may trigger re-emergence of unhealthy behaviour o Relapse – (not necessarily a stage) full re-emergence of old unhealthy patterns of behaviour  Often returns the afflicted individual back to the precontemplation stage of change  Leads to the use of different interventions at different stages of change Section 2: Diversity of Treatment Providers Range of Provider Backgrounds and Licensure  Providers of mental health services come from a wide range of professional backgrounds and experiences  Practioners of non-traditional methods have ample room for creativity, although there are laws and regulations to provide some degree of consumer protection o Psychologist – restricted to individuals who hold a doctoral degree in psychology (in most provinces and states) o Therapist – freely available to be used by any would-be provider of mental health services  Licensed psychologists – psychologists with specific training and certification in clinical or counseling psychology  Psychiatrists – medical doctors who have advanced training and certification in the practice of psychiatry  Many professionals are subject to licensure requirements (basic competencies or skill) Textbook Notes Psych 1X03 The Art and Science of psychological Treatment  Therapeutic Relationship – has an important effect on treatment outcome o The quality of the therapeutic relationship between client and therapist accounts for as much of the treatment outcome as does the treatment methods o Demonstrably Effective  Degree to which the client and therapist are able to form a working alliance (in individual therapy) or group cohesion (in group therapy)  Degree to which the therapist is able to demonstrate empathy (understanding of the clients emotions and thoughts)  Degree to which the therapist collects and responds to feedback from the client o Probably Effective  Positive regard (therapists views the client as a fundamentally good person  Goal consensus  Collaboration Section 3: Diversity of Treatment Options  Two categories-psychological and biomedical o Combination treatment – two types of treatment given at the same time or one after another o Depends on presenting symptoms, consumer preferences and provider offerings  Evidence-based practice – movement on medicine influenced the emphasis on understanding the utility of treatment 1. Client care is enhanced by the use of up-to-date knowledge 2. There is a gap between advances in knowledge and individual clinicians abilities to keep up with these advances 3. Summaries of evidence presented by experts will bridge the gap and enable clinicians to keep up with important advances o Clinicians should be held accountable for keeping the practices up to date o Led to the creation of expert panels that set up decision rules for evaluating evidence for specific treatments and applied these rules to create lists of empirically supported therapies  Concerns o The extent to which clinicians would be forced to restrict their practices to treatments on the list, either managed care companies or by the threat of potential malpractice lawsuit o Existence of the list would prevent clinicians from using treatments they had previously found useful, but lacked formal research support, and prevent them from trying new and potentially innovative strategies o Questions about the validity of the process by which treatments were deemed to be empirically supported o Addressed issues of efficacy and effectiveness  Efficacy – the ability of a treatment to produce a desired effect in highly controlled settings o Efficacy studies are the cornerstone of pharmacological treatment research o Studies designed to demonstrate, in a highly controlled setting, that a medication has a desirable effect on a medical condition of interest o Randomized controlled trial design is used – participants with the medication (control group) gets a placebo  Single-blind trial – study participants are not aware which group they are in  Double-blind trial – neither the participant nor the researcher is aware which group the participant is in o Issues: Textbook Notes Psych 1X03  Identifying clients with a single, specific condition of interest  Eg/ clients with just depression, but no anxiety or substance use  Operationalizing the new treatment o Eg/ writing detailed treatment manuals for psychological treatments  Selecting appropriate “placebos” o Eg. Waitlist groups, education-only groups  “Blinding” both the participant and the researchers (virtually impossible)  Evaluating treatment outcomes o Eg/ how is “improvement” operationalized? How are potential biases in making this judgment dealt with?  Effectiveness – the ability of a treatment to produce a desired effect in real-world settings o Effectiveness studies attempt to gauge the utility of a treatment for a real client in an ordinary treatment setting o Prevalence of comorbidity of psychological disorders is high  Anxiety and mood disorders tend to co-occur o Effectiveness studies relax many of the methodological controls of efficiency studies, in order to study treatment in a more naturalistic setting  Eg/ 4000+ respondents to a survey, asked those who had received treatment for a mental health problem about their experience 9 out of 10 reported symptom improvement after treatment Longer therapy was associated with greater reported treatment The degree of symptom improvement was not different depending in the profession of the therapist The degree of symptom improvement was not different depending on whether individuals reported receiving psychotherapy alone or plus medication o Weaknesses o The respondents may be a representative sample of the population of individuals who seek out and persist with treatment for psychological disorders, but they may not be a representative sample of the entire population o Absence of a control group of similar individuals who did not receive treatment  Without control group (preferably one to which participants were randomly assigned across the entire study), we are unable to differentiate the effects of psychotherapy from “placebo” effect such as expectations of improvement associated with any therapy, and related effects such as social contact and the simple passage of time o Potential bias in the self-report data o Limitations of the scale by which improvement was measured  Evaluating The Evidence o Generated comprehensive list of questions that can be used to guide research oh psychological treatment (Alan Kazdin)  Represent a movement in the field beyond the generation of simple lists of empirically supported treatments, or lists of specific clients and therapists qualities that predict good outcomes  What is the effect of treatment compared to no treatment?  What specific treatment components contribute to positive change?  What treatment components can be added to optimize change?  What characteristics of the treatment can be changed to improve outcomes?  How effective is this treatment compared to other treatment for this problem?  What contextual features mediate (cause) and moderate (influence) therapeutic change? Textbook Notes Psych 1X03  To what extent are treatment effects generalizable to other psychological problems and other treatment settings? Section 4: Historical Psychological Treatments  Psychotherapy – “talk therapy”, the process of treating mental and emotional problems through verbal communication between a client and therapist Psychoanalytic and Psychodynamic Therapy  Freudian Psychoanalysis o Thought as the first of the “talk” therapies o Iconic image – client lying on a couch with a doctor taking notes just out of the clients line of sight o Worked primarily with females suffering from hysteria o Developed rich theories on the origins and treatment of psychological disorders  Conceptualization of Psychological Maladjustment (Freud) o Classic Psychoanalysis – psychological distress is thought to arise from the presence of internal, unconscious conflicts, usually rooted in psychological trauma associated with childhood development o Psyche (the mind) contains three levels of awareness  Conscious – containing the thoughts and actively brought to mind as needed  Preconscious – the contents the thoughts and actively brought to mind as needed  Unconscious – where a vast repository of inaccessible thoughts, repressed traumatic memories and primitive urges resides o Three segments f personality that reside at different levels of consciousness  Id – operating at the unconscious level, motivated to fulfill innate primitive instincts  Ego – bridging the unconscious, preconscious and conscious levels of awareness, is responsible for executing the urges of the id in a way that is acceptable to the external environment  Superego – bridges all three levels of consciousness and seeks to govern behaviour in such a way that is congruent with internalized parental and societal standards of morality o Unsuccessful management of the conflicting urges of the id, ego and superego, taking place at the unconscious level, is thought to drive unhealthy behaviours and cause anxiety and distress o Goal of psychoanalytic therapy – resolve suffering by bringing unconscious conflicts into conspicuous conflicts into conscious awareness, providing the client with insight, and enabling them to delve deeper in search of further unconscious conflicts  Thought the relieve psychological distress through catharsis and free the client to develop more adaptive patterns of behaviours  Therapeutic Techniques o In order to successfully complete psychoanalysis therapy, the client must bring thoughts, emotions, memories and actions of the unconscious into conscious awareness  Made difficult by ego defense mechanisms that prevent unconscious material from coming to light o Analyst must circumvent the defenses of the ego, allowing the client to reveal material that may provide insight into the unconscious o Number of techniques to diminish the influence of the ego and facilitate access to the unconscious (Freud)  Iconic couch and distant therapist – places clients at ease and minimize the feeling of being observed Textbook Notes Psych 1X03  Free association – client is encouraged to let his/her mind wander, reporting the content to the therapist without self-censorship  Analyst attends to the content with minimal verbal feedback o Facilitates the clients sense of being alone with their thoughts o Fosters an environment where truly uncensored associations can be reported – which provides the analyst with clues as to the secrets of the unconscious  Dream analysis  The state of dreaming was believed to be one in which the defenses o the ego relaxed  Dreams were understood to involve two levels of content o Manifest Content – the described elements of the dream itself o Latent content – the true underlying meaning of the dream  Analysis of Resistance  Analyst is cued to the emergence of painful or potentially embarrassing thoughts and feelings by the clients resistance (either unwilling or inability) to discuss certain topics  Freud believed that the more potentially damaging the emergence of an unconscious thought or memory could be, the more clients would be motivated to steer clear of it o Freud emphasized the analyst-client relationship in therapy  Transference – the process by which a clients thoughts, feelings and drives developed in early childhood and experienced in significant relationships are expressed, or “Transferred” onto the relationships with the analyst  Analysis of the clients thoughts, feelings and behaviours toward the analyst can provide insight into t=unconscious conflicts causing distress in the clients relationships with others  Counter-Transferences – the analysts reactions to the clients transference  In classic psychoanalysis, the therapist undertakes significant personal psychoanalysis to gain insight into his or her counter-transference reactions, with the aim of minimizing them and presenting a blank slate for the client to re- enact their own relationship style, free from the potentially modifying influence of any reactions from the analyst o Techniques can cause catharsis associated with bringing unconscious material into conscious awareness o The material generated using the techniques serve as the raw material for interpretation  To form interpretations – analysts must sift though the content generated through free association, dream analysis, analysis of resistance and transference, identifying patterns, illuminating hidden conflicts and explaining the true meaning of the clients thoughts, feelings, drives and conflicts  provide insight, enabling the client to work through identified conflicts and delve deeper into the unconscious to discover further truths  Critique o Freud’s conceptualization of psychological maladjustment relies heavily on constructs that cannot be directly observed and are difficult to validate scientifically  Constructs – unconscious conflicts o Mechanism is not possible to test scientifically  Mechanism – by bringing unconscious conflicts into conscious awareness, thereby providing the client with insight Textbook Notes Psych 1X03  IF a client improves clinically, it is assumed to be because they gained insight  If a client gained insight but does not improve clinically, it is assumed to be the case that the insight was not fully accepted o Limited generalizability  To participate, a client must be intelligent, motivated, articulate, and rational  Psychodynamic Approach – modern iterations of psychoanalytic therapy o More active stance, engaging with the client to discover areas of present-day conflict (rather than childhood) o Interpersonal therapy is a specific psychodynamic approach that is time-limited, present- focused, empirically supported for the treatment of depression and applicable to a broader range of psychological problems  Therapy focuses on current relationships and issued within those relationships  By helping the client to learn to solve present relationship problems, the goal is to provide them with skills to develop more healthy relationships, reducing the psychological symptoms that invariably come with unhealthy relationships with others Behavioural Therapy  Psychoanalyst vs. Behaviorist o Only similarity – to some degree, based on historical personal experience o Psychoanalyst – constructs arguably subjective interpretations of a clients underlying drives, motives and conflicts based on elaborate theories of development and personality and bestows these enlightened interpretations on the client to effect change o Behaviorist – ignores the client unobservable internal state, and focuses instead on observable behaviours, seeking to allow for positive change in a measureable way  Built on principles of classical and operant conditioning articulated by the likes of Pavlov, Thorndike and Skinner  Behaviour therapist; considers self as an applied scientist, identifying a clients problematic behaviours, uncovering the reinforcement contingencies that perpetuate them, and implementing strategies to eliminate them  Conceptualization of Psychological Maladjustment o Symptoms and disorders arise as a result of maladaptive learning histories that give rise to problematic behaviours  Consequences of maladaptive behaviours are often negative, leading to psychological distress o Modifying a clients present-day maladaptive behaviour patterns and replacing these patterns with more adaptive alternatives will lead to positive consequences for the client, including a reduction in psychological distress  Positive consequences positively reinforce the adaptive behaviours, increasing the likelihood that the positively changes behaviours will persist over time o Positive therapeutic change can occur without attention to the clients internal thoughts and feelings  Would not deny existence of the clients internal world; but regard it as unobservable, immeasurable and unessential for effecting behavioural change o Early life learning history is not typically a focus of attention  Seeking insight into how the behaviours evolved is not required – goal is to change the present day maladaptive behaviours  Therapeutic Techniques o Systematic Desensitization (Joseph Wolpe) – principles of classical conditioning are used to decouple fear stimulus-response association Textbook Notes Psych 1X03  Achieved by taking gradual steps to counter-condition the feared stimulus with an adaptive response that is incompatible with fear  First Stage; relaxation training – the therapist instructs the client in skills such as progressive muscle relaxation and abdominal breathing  Client and therapist work at these skills until the client is able to efficiently and effectively put themselves in a relaxed state on demand  Next Stage; generate an anxiety hierarchy – feared stimulus are listed out in order of least to most anxiety provoking  May include both imagined events and real-world events  Therapist and client work up the hierarchy, from least threatening to most  The conditioned fear responses are slowly extinguished through exposure  Therapist guides the client in putting self in given feared situation  Goal – over repeated trials, to slowly and progressively re-condition the previously feared stimuli in the hierarchy with an adaptive relaxation response  Once a stimulus can be reliably encountered without fear, the client and therapist move up the ladder to the next feared item until the most feared stimuli can be encountered without anxiety o Behaviors Modification – based on principles of operant conditioning  Analysis of the consequences of specific behaviours is undertaken to understand how certain contingencies either increase or decrease the likelihood of recurrence of the behaviours  By analyzing behaviours and the resulting contingencies – can see escalating 1 pattern of maladaptive-behaviours is closely tied to pattern of initial positive reinforcement and later negative reinforcement 3 o Eg/ Drug-seeking behaviour , felt good when take pills , felt relief from withdrawal wen took pills 3  Adjusting real and perceived consequences of maladaptive behaviour to shift the balance of reinforcement and punishment such that the problematic behaviours are more likely to decrease in frequency – emphasize negative consequences  Identify and reinforce positive consequences of an emerging sober lifestyle  Critiques o Generalizability of techniques – skills learned in therapy relationship may not easily translate into the real world setting o Ethics of behaviour modification – although clients provide informed consent, some critics argue that it is unethical for one person to endeavor to change the behaviour or another Humanistic/Client-Centered Therapy  Psychodynamic and behaviorist approaches – too manipulative and mechanistic  Prefers the term “client” to “patient”  Humanist/Client-Centered Therapy – emphasizes and celebrates the autonomy of the individual client (Carl Rogers) o Person is not perceived as a collection of unconscious drives and conflicts, nor a set of adaptive and maladaptive behaviours o Client is treated as a whole person, expert in their own feelings, thoughts and desires o Goal – work with clients, joining in clients current thoughts, feelings and struggles, and working together to enable them to follow clients own innate tendencies toward self- actualization (realization of full human potential)  Conceptualization of Psychological Maladjustment Textbook Notes Psych 1X03 o Psychological distress develops when a persons sense of self-concept becomes incongruent with their experience  Self-concept – internal representation of themselves as a worthwhile human being  Experience – moment-to-moment interactions with the external world o Precursors of the development of incongruence – the formation of conditions of worth within the self-concept o Self-concept heavily influenced by relationships with significant others o Healthy self-concept contain few conditions of worth and developed through the experience of unconditional positive regard in relationships  Especially formative relationships with caregivers in early life o Unconditioned Positive Regard – demonstrate, through words and actions, an unwavering empathy for their feelings, understanding of their thoughts and prizing of their inner experience as a human being  Individuals in such a relationship develop a self-concept that is free from restrictive conditions of worth  Eg/ Unconditioned Positive Regard – mother praises son in JK for getting an A “Johnny I am so proud of you always and happy you earned an A in class” – pride in Johnny that is not dependent on his earning an A  Eg/ Conditional Positive Regard – “Johnny, I am proud of you when you earn A’s”  Does not dictate universal acceptance of behaviour  Eg/ Unconditioned Positive Regard – “Johnny, I can see that you’re upset and I understand your feelings, but throwing food at the table is not an acceptable action”  Eg/ Conditioned Positive Regard – “Johnny, you are a bad boy for throwing your food”  Therapeutic Techniques o Authoritative stance employed by psychoanalysts and behavioural therapists serve as opposing exampled to the application of the humanist philosophy – so what is the role of a therapist in a therapeutic relationship? o Nondirective Therapy (later called client-centered therapy) – the therapists techniques were restricted to reflection and response to the clients stated thoughts and feelings; therapist should never direct the conversation o Goal –enhance healthy functioning by enhancing a persons congruence between self-concept and experience o Goal can be achieved in the context of a safe, social relationship in which the client is free to discover and explore their areas of incongruences (Rogers) o Therapists task – foster this social environment by demonstrating three core conditions 1. Unconditional Positive Regard – through words and actions, therapist shows client that they are a person of worth and goodness and that no revelation, no matter how embarrassing or anxiety-provoking, will be met with judgmental attitude by the therapist 2. Empathy – therapist makes every effort to understand the clients feelings in the moment, and validates those feelings back to the
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