12/6/11

1

Who Seeks Treatment?

15% of U.S population in a given year Most common presenting problems

•  Anxiety and Depression

Women more than men People with Medical insurance People with higher levels of education However, many people still do not seek help

because of the stigma attached to treatment

Psychotherapy

We will limit ourselves to 4 types: •  Psychodynamic-Unconscious conflicts and motivations •  Humanistic-Importance of self-esteem, self

understanding, support in moving toward positive mental health

•  Behavioral-actions learned through basic learning principles can lead to serious maladaptive behavior

•  Cognitive-habitual ways of thinking affect our moods and our interactions with others

Psychoanalysis

Freud’s psychodynamic approach has had a strong influence in our understanding of psychotherapy.

Freud began career treating patients with Hysteria •  Demonstrated that physical symptoms

had Psychogenic causes. The Case of Anna O.

•  Patient fixated psychic energy as a result of unconscious conflicts

•  Anna’s understanding of her problems led to cure.

Psychoanalysis- Sigmund Freud

Source of Problem: •  Unresolved conflicts from early childhood (first five years) •  The conflicts are unconscious and unknown to the patient •  Patient develops symptoms which indicate the conflict exists

Basis for recovery: •  Insight into the unconscious source of current feelings and

drives that give rise to maladaptive behavior . •  Therapist’s job is to uncover source of the hidden conflicts

and liberate the affect that supports them (catharsis). Techniques to gain access to unconscious conflicts :

•  Free association and resistances •  Dream interpretation •  Transference, acting toward therapist as though source of

conflict

Psychoanalysis

•  Primary talk therapy •  Takes a long time and is expensive. •  The therapist is in control and decides whether

patient improving. •  “Good” patients tend to be intelligent,

articulate, and motivated, also rich.

12/6/11

2

Humanistic Approach to Psychotherapy

Humanistic Psychotherapy grew out of: •  A reaction to non-democratic and authoritarian

psychodynamic approach of Freud. •  Existential Philosophy which stresses that each person

must decide for themselves what is a full and meaningful life

Humanistic Approach assumes: •  Every person inherently good and naturally strives and

is capable of developing their own inherent human potential.

•  Need for positive self-regard to be able to make positive choices (actualizing your potential)

Client (person) Centered Therapy Carl Rogers called his therapy Client Centered, in

contrast to the hierarchical doctor/patient relationship emphasized by Freud.

Source of problem •  Rogers saw low self esteem as a major problem as a result of

a Self Concept that was Incongruent with what was their Ideal self Concept.

•  Parents who treated their Conditional positive regard by withholding their love if child didn’t meet their expectations created incongruence. This could be real or imagined.

•  Incongruence prevents self-actualization because an individual has a a need to distort reality to hide shortcomings in order to feel worthy of affection. Defensive maladaptive adaptive behavior leads to problems with others, and prevents optimal development.

Client Centered Therapy

Basis for recovery •  Healing of the client comes with Unconditional

Positive Regard: The granting of love and approval regardless of an individual's behavior allows realize their human potential.

•  Being able to accept oneself as you actually are (achieving congruence) leads to an openness to change and becoming a fully functioning person.

Rogers Client Centered Therapy Main Therapeutic Techniques:

•  Providing an environment for the client to discover the reality of their condition by helping client to clarify their feelings, and supporting change.

•  Requires special Characteristics of therapist for acceptance: –  Unconditional positive regard –  Empathy –  Genuineness

•  Mirroring. Therapist actively listens and repeats or rephrases thoughts and feelings expressed by client to help them become aware of what they are actually feeling. To reflect the reality they are saying is there.

Mirroring: Clarifying Feelings

"I thought I'd have something to talk about--then it all goes around in circles. I was trying to think of what I was going to say. Then coming in here it doesn't work out....I tell you, it seemed that it would be much easier before I came."

Rogers: “You thought you would have more to say before you came here”

12/6/11

3

Rogerian Reflections

"I tell you, I just can't make a decision: I don't know what I want. I've tried to reason this thing out logically--tried to figure out which things are important to me."

Rogers: “It seems confusing to you and you don’t know what to do.”

Rogerian Reflections

"I find myself and my thoughts getting back to the days when I was a kid, and I cry very easily. The dam would break through."

Rogers: “When you think about the time when you were a child you feel yourself becoming emotional.”

Mirroring causes both the therapist and the

patient to gain greater insight into underlying conflicts in the self-concept.

Client: Let's put it this way. My stepfather and I are not on the happiest terms in the world.

Therapist: But part of what really makes for difficulty is the fact that you and your stepfather, as you say, are not... the relationship isn't completely rosy.

Client: Let's just put it this way, I hate him and he hates me. It's that way.

Therapist: But you really hate him and you feel he really hates you.

Client: Well, I don't know if he hates me or not, but I know one thing, I don't like him whatsoever.

Therapist: You can't speak for sure about his feelings because only he knows exactly what those are,but as far as you are concerned...

Client: ... he knows how I feel about it.

Therapist: You don't have any use for him.

Client: None whatsoever. And that's been for about eight years now.

Therapist: So for about eight years you've lived with a person whom you have no respect for and really hate.

Client: Oh, I respect him.

Therapist: Ah. Excuse me. I got that wrong.

Client: I have to respect him. I don't have to, but I do. But I don't love him, I hate him. I can't stand him.

Therapist: There are certain things you respect him for, but that doesn't alter the fact that you definitely hate him and don't love him.

Client: That's the truth. I respect anybody who has bravery and courage, and he does.

Therapist: ... You do give him credit for the fact that he is brave, he has guts or something.

Client: Yeah. He shows that he can do a lot of things that, well, a lot of men can't.

Therapist: M-hm, m-hm.

Client: And also he has asthma, and the doctor hasn't given him very long to live. And he, even though he knows he is going to die, he keeps working and he works at a killing pace, so I respect him for that, too.

Therapist: M-hm. So I guess you're saying he really has...

Client: .. .what it takes.

Behavior Therapy Behavior Therapy a reaction to the vague and

non-scientific approach of other therapies. •  Reaction against medical model. Patient not “sick” but

has learned to respond in maladaptive ways •  Application of principles of operant and classical

conditioning for therapeutic effect. •  Unlike any of the other therapies, behavior therapy is

not “talk” therapy. Source of problem:

•  The environmental contingencies of reinforcement and punishment that support the maladaptive behavior.

•  Symptom oriented. Symptoms are learned responses not indicators of a “disease.” Get rid of symptom and disease is gone. Symptom substitution, no problem

•  Insight into past childhood conflicts not important.

Behavior Therapy

Therapeutic Techniques: •  Change contingencies that support maladaptive

behavior and reinforce new responses to replace them. •  Because it is a science based therapy it is very

concerned with immediate, measureable results.

Behavioral Cure for Bedwetting

Developed by Hobart Mowrer in 1940s

12/6/11

4

Systematic Desensitization

Systematic Desensitization is used to extinguish fear behavior to phobic stimuli. •  Problem in phobias is that fear of stimulus reinforced

by avoidance behavior.

Systematic Desensitization

Systematic desensitization for phobic reactions •  Uses anxiety hierarchy and counteract emotion through

reciprocal inhibition. •  Very successful in treatment of phobias.

Anxiety hierarchy and reciprocal inhibition 0 Beginning a new course 10 A professor announces a quiz in two weeks 30 A professor announces a major exam in three weeks 45 Reading the material to be given on the exam 55 A fellow student asks you if you know the material 70 Studying with other students several days before the exam 80 Hearing students talk about things that you don’t know 90 Walking down the hallway to the exam room 100 Looking at the exam and finding a question you don’t know the

answer to.

Techniques in Behavioral Therapy

Implosion or flooding therapy. •  A sudden and large-scale exposure to the object under

controlled conditions •  Assumption is that the sympathetic nervous system

cannot maintain a panic state for very long and that the level of arousal will decline, extinguishing the fear.

Technology has changed methods •  Digital Reality helmets can expose patients to objects

that create fear (snakes, spiders), and situations that create fear (heights), in a very safe effective manner.

Implosion Therapy

Other Techniques in Behavior Therapy

Aversion Therapy •  Conditioning negative reactions to serious maladaptive

behavior or to inappropriate stimuli. •  Punishment

Unlike other therapies, behavior therapy does not require insight into one’s problems or client’s cooperation. This means people can be given “therapy” against their will.

12/6/11

5

Extinction of Self Destructive Behavior Aversion Therapy

Aversion therapy associates a punisher with the behavior that is to be avoided or suppressed.

Token Economy Method: •  Therapist Targets Behaviors or Actions they seek to

change. •  Patients get tokens (poker chips, gold stars, or stamps)

for engaging in socially desirable or productive behaviors. Tokens taken away for undesirable behaviors.

•  Tokens can be used to immediately reinforce behaviors, and exchange them later for tangible rewards.

•  Work well in psychiatric hospitals and sheltered care facilities

•  Lack of generalizability to real world is a problem. Where will tokens come from?

Techniques in Behavioral Therapy Enforcing Treatment

Example: 47 year old chronic Schizophrenic. Three behaviors were a problem. •  Stealing food •  Wearing excessive clothing (25 pounds) •  Hoarding towels.

Procedures: •  Timeout. Removed from the dining room. Eliminated in 2 weeks. Weight down

to 180 in fourteen months. •  Excessive Clothing. Had to meet predetermined weight in order to receive meal.

23 lbs at first. Then decreased two per week. Got to 3 lbs in 11 weeks. •  Towel hoarding. Kept 19-29 towels in her room. Tried to make it aversive.

Given 7 per day first week. Then by 3rd week raised to 60. At 624 towels she started removing towels, until she got down to 1.5 and maintained.

–  First week: "Oh you found it for me thank you“ –  Second: "Don't give me no more towels I have enough“ –  Third: "Take them towels away, I can't sit here all night and fold towels.“ –  Fourth: Get these dirty towels out of here. –  Fifth: "I can't drag anymore of these towels, I just can't do it.

Cognitive Therapies

Cognitive therapies focus on person’s ingrained thoughts and beliefs that create maladaptive negative feelings.

Cognitive therapy-Aaron Beck •  seeks to improve people’s functioning by changing how

they think and believe about situations that affect them negatively.

Aaron Beck’s Cognitive Errors All or none thinking

•  If a situation is less than perfect you see it as a total failure. Overgeneralization

•  You see a single event as a never ending pattern of defeat by using the words ALWAYS or NEVER.

Mental filter •  You pick out a single negative detail and dwell on it exclusively. A word

of criticism erases all the praise you receive. Magnification and minification

•  You exaggerate the importance of your problems and shortcomings and minimize your strengths.

Emotional reasoning •  You assume that your negative emotions accurately reflect reality. “I feel

guilty. I must be a rotten person.” Labeling

•  Instead of saying you made a mistake you attach a negative label to yourself: “I’m a loser.”

Personalization and blame •  You hold yourself personally responsible for events you can’t control. If

it rained for the picnic you planned, it is your fault.

12/6/11

6

Beck: Root of Depression is Negative Thinking Cognitive-Behavioral Therapy

Rational-emotive therapy-Albert Ellis •  Like Beck Ellis emphasizes that thoughts precede

emotions, and that unpleasant feelings are a result of irrational thoughts.

•  Biggest difference is that these therapists tend to have a more “in your face” style of confronting you when you engage in negavitve thinking.

•  More likely to arrange “homework” to ensure changes in your behavior.

Cognitive and Rational-Emotive Therapies

Source of Problem •  Person has developed habitual ways of thinking

negatively about the self that does not match reality, leading to depressive thoughts and feelings.

Both therapies apply learning principles. •  Sets clear goals and procedures for changing behavior.

Therapeutic Techniques: –  Identify negative cognitions and examine them against reality –  Challenge the person to test them, require explanations,

express disbelief and disapproval of irrational beliefs. Confrontive.

–  Replace negative cognitions with more accurate perceptions –  Homework. Both theorists require homework to practice new

ways of dealing with difficult situations.

Cognitive Restructuring Exercise

Situation: •  Having a long difficult assignment due the next day.

Negative Cognition: •  "I'll never get this work done by tomorrow."

Positive alternatives: •  "If I work real hard I may be able to get it all done for

tomorrow." •  "This is going to be tough but it is still possible." •  "It will be a real challenge finishing this assignment for

tomorrow."

Cognitive Restructuring Exercise

Situation: •  Breaking up with a person you love.

Negative: •  "I can't go on. He/she was everything to me.

Positive Alternatives: •  "I really hoped our relationship would work but it is not

the end of the world." •  "Maybe we can get back together sometime in the

future." •  "I'll just have to try to keep myself busy and not let it

bother me." •  "If I met him/her, there is no reason why I won't meet

someone else."

12/6/11

7

Determining If Psychotherapy Works

Evaluating Psychotherapy more complex than it looks.

Can we use a before treatment and after treatment assessment of people in therapy •  Problem of regression to mean. Most people look for

help when they are feeling their worst. The passage by itself is likely to show an improvement.

Comparing people who decide to use Psychotherapy and those who do not. •  Those who decide on psychotherapy are obviously

different why else would they decide on psychotherapy; maybe more motivated to change.

The Effectiveness of Psychotherapy

The use of an Experimental and Control group. Experimental Group

•  Those who receive therapy

Control group •  Those not receiving therapy

Important things to control for •  Random assignment of groups •  Who decides if patient improved?

–  Patient –  Therapist –  Disinterested third person who doesn't’t know who was treated

Effectiveness of Psychotherapy

If we control for things on the previous slide is that enough for us to determine effectiveness?

Experimental •  People who receive therapy

Control group •  People who do not receive therapy

Placebo Control •  People who are not treated but think that they are

Testing Effectiveness of Psychotherapy

In Placebo control, the person has the expectation they are being treated.

Giving a public presentation ________________________________________________ Group Percent “significantly improved” _________________________________________________ Self Report Objective Physiological of anxiety behavior indices Desensitization 100 100 87 Insight 53 60 53 No-Trt control 7 24 28 Placebo control 47 73 47

Creating Placebo Controls

One way to do this has been to have people without any training in psychotherapy counsel students with problems. •  Very difficult problem to solve, but with this in mind

what do you make of the findings that in comparing all the mainstream types of therapy they are pretty much the same?

•  Or that therapists with advanced degrees do not seem to matter,

•  Or that how much experience therapist has had seems to be irrelevant.

This question is getting at whether psychology has special insights into what works in therapy.

12/6/11

8

Choosing a Therapist and Therapy

Even though it has been difficult to determine the effectiveness of therapy we do know that effective therapists •  Are seen by their clients as genuine, warm, and caring. •  Are considered to be people the client trusts and can

work with

Effective Therapies •  Behavior therapies seem to be more effective in curing

phobias •  Cognitive therapies most effective in curing anxiety and

depressive disorders.