TREATMENT Meghan Fraley, PhD Skyline College, Summer 2015

Psychotherapy  Outcome  Research  

¨  Eysenk,  1950,  no  impact  ¨  Meta-­‐analysis:  review  literature  and  find  effect  size  (Smith)    

¨  Effect  size:    ¤ Measure  of  standard  deviaHon  units  of  difference  between  treated  and  untreated  

Average effect size of .85

50% improved by 8th session

75% imporved after 6 months

People do well, women more likely to seek treatment

Research Overview META-ANALYSIS •  Smith, Glass and Miller

Effect Size Meta-Analysis •  Eysneck said untreated

people did better than treated people

•  What’s the criticism of meta-analysis?

•  You end up crunching numbers, and can’t control for the quality of the research

RESULTS: •  50% of clients showed

marked improvement after 8 sessions.

• Dose dependent effect • Howard et al. (1986): •  The bigger the does, the

better the outcome •  75% at 26 sessions, and

85% at 52 sessions, 2 years, a little more!

How Much Does Therapy Help?

Average effect size of .85

50% improved by 8th session

75% improved after 6 months

Effects of Treatment Length

Remoralization

Remediation

Rehabilitation

Phase Model

Dose dependent effect • Howard et al. (1986): • The bigger the does, the better the outcome • 75% at 26 sessions, and 85% at 52 sessions, 2 years, a little more!

Therapy  Variables  

¨  Client:    ¤  Largest  contribuHon  to  outcome  

¤  Lower  SES  and  educaHon,  drop  out  earlier  and  more  frequently  (but  doesn’t  effect  outcome  if  you  stay)  

¤  Individual  and  Group  similar  ¤  Individuals  over  65  less  problems  (except  demenHa)  

¤ Highest  rates  25-­‐44  

Therapy Variables: Therapist and Relationship

Therapy relationship

alliance,

cohesion,

empathy,

collecting feedback

Therapist:

Non-technical aspects most important, little difference in outcome

If matched ethnicity, therapist factors account for 30% of outcome variance

Behavioral  Therapies:

1) Classical Conditioning

2) Operant conditioning

3) Social Learning Theory

IntervenHons  Based  on  Behaviorism

¨  Behaviorists  believe  behavior  is  generated  and  maintained  by  factors  external  to  the  person  

Systematic Desensitization

Systematic desensitization is a

specific technique that breaks the link

between the anxiety-provoking stimulus and the anxiety response.

This treatment requires the patient to gradually confront the

object of fear.

OPERANT  CONDITIONING:  Aversive  Control  of  Behavior  

Punishment

¨  Influences on punishment: ¤  Immediacy ¤ Consistency ¤  Intensity ¤ Verbal clarification ¤ Removal of All Positive

Reinforcement ¤ Reinforcement for

Alternative of Behaviors

Beck’s Cognitive Therapy

¨  AutomaHc  thoughts:  maladapHve  lead  to  symptoms  

¨  Cognitive targets of CT: ¤ Cognitive Schemas ¤ Automatic Thoughts ¤ Cognitive Distortion ¤ Cognitive Profile

Beck’s  Cogni4ve  Profiles

Negative View of Self

Negative View of World

Negative View of Future

Beck’s  CogniHve  Profile  of  Depression Beck’s  CogniHve  Profile  of  Anxiety

Excessive Form of Normal Survival Mechanisms •  Unrealistic Fears about

Physical Threats •  Unrealistic Fears about

Psychological Threats

Basic Cognitive Therapy Techniques. • Usually takes about 12 - 20 weeks. • The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations. Treatment

• First, the patient must learn how to recognize anxious reactions and thoughts as they occur. • One way of accomplishing this is by keeping a daily diary that reports the occurrences of anxiety attacks and any thoughts and events associated with them. A patient with OCD, for instance, may record repetitive thoughts. Recognize Reactions

• These entrenched and automatic reactions and thoughts must be challenged and understood. • Again, using the OCD example, one approach is to record and play back the words of the repetitive thoughts, over exposing the patient to the thoughts and reducing their effect. One effective approach for patients with generalized anxiety disorder targets their intolerance of uncertainty and helps them develop methods to cope with it.

Understand and Challenge

• Patients are usually given behavioral homework assignments to help them change their behavior. • For example, a person with generalized social phobia may be asked to buy an item and then return it the next day. As the patient performs this action, they observe any unrealistic fears and thoughts triggered by such an event. Homework

• As the patient continues with self-observation, they begin to perceive the false assumptions that underlie the anxiety. •  For example, patients with OCD may learn to recognize that their heightened sense of responsibility for preventing harm in non-threatening situations is not necessary or even useful.

Perceive false assumptions

• At that point, the patient can begin substituting new ways of coping with the feared objects and situations. New Ways of Coping

Linehan’s  DialecHcal  Behavioral  Therapy  

¨  OutpaHent  for  borderline  ¨  DialecHc:  Acceptance  and  Change  

¨  Focus  on  present  ¨  Four  requirements:    

¤ commit  to  period  of  Tx  &  a^end  all  sessions,    

¤  reduce  suicidal  behavior,    ¤ work  on  behaviors  that  interfere  with  therapy,    

¤ a^end  skills  training  

Psychodynamic Therapies

¨  Insight oriented ¨  Past determines the

present: ¤  Transference (Past will

determine present relationships through projection).

¨  General principles apply to everyone ¤  Defense mechanisms,

Dr. Freud said every one of us must use them to allay fears

¨  Conflicts affect personality development

Classical  Psychoanalysis  • Primitive • Ruled by Instinct •  Libido • Aggression •  Immediate Pleasure

Id

• Operates on reality principe • Defer immediate gratification •  Executive functioning • Manage Id impulses •  Social Acceptable

Ego

• Conscious • Moral code •  Standards internalized from

parents and society •  Right and Wrong: GUILT

Superego

Deterministic: irrational forces, unconscious

motivations, bio drives, and psychosexual events up to age 6 determine behavior

Anxiety  and  the  Defense  Mechanisms  

Repression

Regression

Projection

Displacement

•  Behaviors exactly opposite of what we are feeling

Reaction Formation

•  Cut off from affect

Intellectualization

Rationalization

•  Normal and desirable •  Channel into something else

Sublimation

We get anxious when Id impulses get too

strong and start moving into

consciousness. Prevent us from becoming

aware of forbidden id impulses

Freudian Psychoanalysis Psychopathology results from unconscious, unresolved conscious from childhood

Defense Mechanisms: Include repression, reaction formation, and displacement

Therapy goal: Reduce maladaptive behavior by bringing unconscious material into conscious awareness

Therapy process: •  Clarification, confrontation, interpretation, and working through

PsychoanalyHc  Treatment  and  Techniques  ¨  Make  conscious  the  unconscious  ¨  Bring  to  the  light  id  conflicts  ¨  Free  associaHon  ¨  Treatment  includes:  

¤ ClarificaHon  ¤ ConfrontaHon  ¤  InterpretaHon  ¤ Working  Through  

¨  Transference  and  Countertransference  

Freudian Therapy process:

Clarification

Confrontation: •  Bring up something below the surface

Interpretation

Working through

Jung’s Analytic Psychology Stood alone for decades

Personality is not shaped by age 5 or 6, it is a life long continuum

Focus is on adulthood. Personality changes are made mid-life, they don’t necessarily, but they can

Components of the Unconscious: the personal unconscious consists of personal experiences and the collective unconscious consists of collective epeirneces of the human race (archetypes).

Personality Theory: Development continues throughout the lifespan. Individuation is a key task of the second half of life and involves developing a unique, integrated identity

Jungian Concepts:

Collective Unconscious •  We humans share a collective

unconscious. Two unconscious layers personal and collective. There from beginning of time.

Archetypes •  Primordial images that exist in the

collective unconscious.

Archetypes  

¨  Universal  and  Pa^erns  of  experience  passé  dhtrough  generaHons  (art,  literature,  dreams)  

¨  Neurosis  is  a^empt  to  free  ourselves  from  our  archetypes,  they  are  prevenHng  us  from  fulfiling  our  potenHal.  Part  of  process  on  way  to  individuaHon.  

Therapies  and  IntervenHons  Based  on  Humanism/ExistenHalism  

Emphasize subjective experience

Phenomenlogical approach: •  Enter client’s

subjective world

Trust clients’ capacity

Focus on freedom, choice,

autonomy, purpose,

meaning, focuse on present

Humanists: Move toward

actualization if nurture

Existentialists: NO internal

nature, world lacks intrinsic meaning, we must make sense of

meaninglessness

Rogers:  Client/Person  Centered  Therapy  

Inborn capacity for purposive, goal-directed behavior

Faulty learning leads to hateful, self-

centered, ineffective, antagonistic approaches

Therapy: expand awarnes and liking of

self

Key characteristics of treatment: • Empathy • Warmth • Genuiness

Unconditional Positive Regard!

Gestalt  Boundary  Disturbances  • Taking information in whole

without crtical examination • Become overly compliant

Introjection

• Put out our feelings on to others

• Leads to Paranoia Projection

• Turn onto you what you would like to do to someone else

Retroflection

• Distancing from your feelings and others. Excessive humor.

• Asking a lot of questions Deflection

• Lack of awareness of how you and someone else are actually two different people

Confluence

Boundary Disturbances: When you engage, you don’t have true

contact

Existential Therapy Overview

•  Personal choice and responsibility for developing meaningful life •  We are evolving and becoming

•  Inability to cope authentically with concerns of existence •  Existential versus neurotic anxiety

•  Live more committed, self-aware and authentic life

•  Here and now •  Therapeutic relationship

Hypnotherapy  

Hypnosis

•  State or condition in which person can respond to suggestions by experiencing alternations in perceptions, memory, or mood

Can lead to altered or dissociated state

Used for:

•  Pain, asthma, conversion, substance use, Acute stress and other anxiety, Obesity, insomnia

Aid memory, but can create false memories (and exagerrate comnfidence in them)

True memory or not, reflects relevant treatment issues

Ekricksonian involves techinques that rely on psycholinguistic nuance

Consequences of Oppression

¨  Internalized Oppression ¨  Conceptual Incarceration

¤  Adopt White worldview/lifestyle

¨  Split-self syndrome ¤  Polarizing self into good

and bad (bad represent one’s African American identity)

¨  Survival Mechanisms ¤  Playing it cool ¤  Happy-go-lucky

Cultural versus Functional Paranoia

Cultural Paranoia •  Lack of disclosure due to experiences

of prejudice in past • Healthy response • When meaning of paranoia is

discussed, client encouraged when it is desirable or not to disclose

Functional Paranoia •  Pathology, won’t disclose to anyone,

general distrust

Intercultural Nonparanoiac Discloser •  Low functional, low cultural •  Willing to disclose

Functional Paranoiac •  High Fucntional, low cultural •  Generally nondisclosive •  Primarily pathology •  Therapist competence rather than race

or culture •  Alleviate pathology

Healthy Cultural Paranoiac •  Low functional, high cultural •  Reluctant with Anglo therapists •  Explore meaning, make conscious,

therapist disclosure •  Disclosure flexibility

Confluent Paranoiac •  High fucntional, high cultural •  Combination of pathology and effects

of racism •  Combine approaches •  Likely therapist from same racial/ethnic

group

Ridley’s Paranoia and Disclosure

Model