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