Psychotherapy

ASPECTS OF THERAPY

A. Free Choice

- Client must want therapy for change

B. Hopes & Expectations

1. Expectations about the futureaffect the present

=> Belief that therapy will work= powerful treatment itself

Placebo effects

Hormones & immune system

2.Different expectations of therapy by client & therapist

=> increase similarity in expectancies

C. Therapist-Client Interaction

1. Therapist Qualities

“Nonspecific Factors”

- Empathy- Warmth

- Genuineness

Experience

Client-therapist matching

2. Therapeutic Alliance

- Joint goals & how to achieve them

- Therapist’s cooperative spirit

- Client’s ability to trust

=> Stronger alliance = better outcome

Insight-Oriented Therapies

Psychoanalysis & Psychoanalytic Psychotherapy

1.Assumptions

a) Disorder = childhood problems& unconscious conflicts

b)Purpose of Symptoms = express conflict & protect from conscious awareness of conflict

c)Goal of therapy = uncover conflict to free person from symptoms

Methods

a)Therapist behavior

Anonymous

Abstinent

Ambivalent

b) Free association & dream interpretation

- analyst interprets

c)Transference

- patient comes to regard therapist as parent& enacts old relationship

d)Countertransference

- therapist develops personal feelings for client

Psychoanalysis vs. PsychoanalyticPsychotherapy

a)Time & Expense

- 5 times/week for 5+ years

vs. 1-2 times/week for 1-2 years

b)Interaction:

- little vs. much therapist input

- couch vs. chair

- focus = child sexuality & aggression vs. other issues

Humanistic Therapy

Assumptions

a)Optimistic: People are good & seek self-actualization

b)Disorder = incongruence

- parents don’t provide unconditional positive regard

- person conforms to them

c) Goal of therapy = client accepts self

- restructure self-concept to match reality

- strive toward self-actualization

Methodsa) Therapist behavior = nonjudgmental, warm,

genuineb) Relationship: Therapist & client are equals

- “client” vs. “patient”- therapist is nondirective- client knows what is best- needs facilitator to discover

c) Method - therapist mirrors/reflects client

Gestalt Therapy

Assumptions

a)Disorder = out of touch with true self

- not accepting gestalt (whole)

b)Goal of therapy

- improve awareness of self-aspects

- take responsibility for them

Methodsa)Therapist behavior = confrontational &

directiveb)Nonverbal cuesc)Role-playing - act out relationships

- “empty chair”- letter writing

d)Dream interpretation

Cognitive-Behavioral

• WHY of behavior is unimportant

• Change current thoughts/behaviors

(sx focus)

Ellis’ Rational Emotive Therapy (RET)

1.Assumptions

a) Disorders = irrational beliefs

- perfectionism

b) Goal of Therapy = substitute rationalfor irrational thoughts

Methods

• Therapist Behavior: dispute beliefs

- Therapist as Educator

- Therapist & client are active

- Homework

Beck’s Cognitive Therapy

1.Assumptions

a) Disorders = irrational beliefs

- irrational beliefs differ by disorder

- Affect, Behavior, & Cognition

b) Goal of Therapy = change irrationalbeliefs

Methods

a)Therapist: warm, but disputes

b)Guided Imagery: move from unrealistic fantasies toward realistic gratification

c)Homework

- test out irrational beliefs

- situational analysis

Behavior Therapy

1.Assumptions

a) Disorders = learned responses that can

be unlearned

- Behavior is situationally specific sotreatment must be specific

b) Accept client’s report as valid

c) Goal of Therapy = change maladaptive behavior

- substitute adaptive behavior

Methods

a) Therapist Behavior

- directive, gives advice

- also warm

- Client controls focus of therapy

- Therapist = how to change

b) Functional Analysisreinforcements & contingenciesProblem - What Antecedents - When

- WhereConsequence - How (is problem rewarded)- Change cues/contingencies to change behavior

c)Flooding

- expose to worst fears until person can tolerate without anxiety

- imaginal or in vivo

d)Systematic Desensitization

- gradually expose to fear

- start with least fearful

- in vivo or imaginal

- with or without relaxation

e)Aversive Conditioning

- pair negative behavior with aversive stimulus

- in vivo or imaginal

- last resort

Family & Couples Therapy

Assumptions

a)Disorder occurs in context of family & marital relationships

- Communication = biggest problem

- Relationship issues

b) Goal of Therapy = change interactions so that “patient” no longer needs the problem behavior

Methods

a)Problem-Solving:

State problem

*Restate in other’s words

Suggest solutions

Evaluate solutions

Agree on solution & try it

b)Structural Family Therapy

- problems in family structure

- change by “unbalancing” current system

c)Family Systems Tx

- reduce over-involvement

- promote healthy individuation

Group Therapy

Assumptions

a)Advantages

- Not alone in problem

- Additional support of group members

- Some problems = relevant for groups

- Cheaper

b)Disadvantages

- self-disclosure to many

- confidentiality

- less therapist attention

Methods: General

- 8-10 people in circle

- All provide feedback & support

- Therapist is less directive

- Therapist may self-disclose

Methods: Specific

a)Psychodrama - each person’s problems enacted as a play

b)Assertiveness Training

passive — assertive — aggressive

c)Social Skills Training

Eclecticism

Technical Eclecticism

• Use techniques of different orientations

• Theory: either one or none

• Many therapists

Theoretical Eclecticism

• Integrate different theories

• Based on common principles of behavior and on nonspecific factors

• Problem = basic assumptions of theories conflict

• Challenge = rigid adherence to one theoryvs. superficial knowledge of several

**Must have a plan, conceptualization of each case that drives therapy

Effectiveness of Psychotherapy

• Outcome studies

• Meta-analysis

- statistical combination of many studies

Smith & Glass (1977)

• 375 controlled studies

• Average client better than 75% of controls

Smith, Glass, & Miller (1980)

• 475 controlled studies

• Average client better than 80% of controls

• Some research: Effectiveness generalizes to real therapy (external validity)

• Other research: research therapy vs. clinic therapy

• Effects seen in 3-4 months for 50%

• Effects seen in 6 months for 75%

• But, many clients terminate early

• Few differences among therapy types

Issues

• Match therapy to problem

• Match therapy to client

Ethical & Legal Issues

Clients’ Rights

1.To treatment

- cannot just be confined

2.To efficacious treatment

- statistical vs. clinical significance

- 70% spontaneous remission

- but therapy is better

- continued improvement

- right to not be abused

Must terminate therapy (refer to someone else) if

- not efficacious

- problem between therapist & client

3.To confidentiality

- increases trust & disclosure

- exceptions:

suicide/homicide

child abuse

subpoenas

4. To informed consent

- explanation of treatment, purpose, & projected outcome

5. To refuse treatment

- a limited right

Forensic Psychology

Determining mental competency

1. For involuntary commitment

2. At the time of committing a crime

Criteria

- result of a mental disease or defect

- can’t appreciate wrongfulness

- can’t conform behavior to the law

Frequency

- almost never used

- rarely effective when used

- when used and person NGRI,more time in hospital than in jail

3. At time of trial

- participate in own defense

4. At time of execution

- retribution