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?