CHP Notes: Foundations of Clinical Psychology

CLINICAL & HEALTH PSYCHOLOGY L01-02: Foundations of Clinical Psychology COURSE OVERVIEW -​ 2 separate modules: Clinical and Health Psych -​ Exam -​ 2 assignments: 1.​ CASE STUDY, In pairs: provided a case study, asked to evaluate whether a person in t...

CLINICAL & HEALTH PSYCHOLOGY L01-02: Foundations of Clinical Psychology COURSE OVERVIEW -​ 2 separate modules: Clinical and Health Psych -​ Exam -​ 2 assignments: 1.​ CASE STUDY, In pairs: provided a case study, asked to evaluate whether a person in the case meets criteria for pathology, according to 1 theory, decide what type of psych help this person requires. [beginnning of december]​ Be able to distinguish psych problems, everyday problems, other problems 2.​ Health psych. Focus on stress. Prevention (self esteem, assertiveness) In groups of 4. Devise plan of prevention program (eg smoking cigarettes, stds, depression -​ NO Additional literature for workshops. Same ones as for the lectures​ + additional tasks (not always reading)​ -​ Prof’s focus on schizophrenia and personality disorders -​ Onsite consultations on Tuesday -​ Possibility of online meetings on Monday, Wednesday, Friday LECTURE OVERVIEW: Foundations of CLINICAL PSYCHOLOGY​ ​ historical overview (literature) ​ ways of defining, area of interest, tasks ​ relations of clinical psychology with other disciplines (literature) ​ empirical basis of psychological practice ​ the scientist-practitioner model WHAT IS CLINICAL PSYCHOLOGY? Most people wrongly think it is psychotherapy. NO. Two separate things. Only some clin psys become psychotherapists. CPs try to integrate 3 branches of functioning.​ 1. Science: importance of doing research. A lot of bs around. Most of self-help books do not work. Most people with mental breakdowns feel even worse after reading those. See Bert Hellinger: a lot of people in PL undergo his sessions (trauma-related) – a lot of them end up in psych wards. Depression naturally fades after 6 months. Often attributed to psychotherapy, altho it should help much earlier (3rd month). 2. Theory. Often hard to check. E.g. based on unconscious processes. Rather say that we talk about MODELS. None of the ones we are going to talk about are perfect. 3. PRACTICE​ which cannot happen without the previous 2. Positivity of therapist is important at the beg of the session; but by the end is attuning to them (speech, cadence, tone) – otherwise they will resign. Attention ON THE CLIENT is always important. Not all psychotherapies work for everybody. E.g. CBT is not ok for ALL depressions. Yes for the ones rooted in rumination. Others are more biologically rooted, e.g. postpartum => CBT not needed; migration-related = reactive depr for adaptation => help them adapt, no CBT. So the main activity at the beginning is to UNDERSTAND the client and their problem. Cognitive thinking, psychodynamic, humanistic are needed depending on the person & situation. Understanding is key, then comes the intervention. ​ The field of clinical psychology integrates science, theory, and practice to understand, predict, and alleviate maladjustment, disability, and discomfort as well as to promote human adaptation, adjustment, and personal development. PREDICTION: all Dxs are a form of prediction. Esp clinical psych’s who work in a forensic setting. ALLEVIATE MALADJUSTMENT: e.g. neurodevelopmental problems. Increased incidence than in the past. Children and adolescents with such problems – huge need nowadays. DISABILITIES: Often come together with strengths. E.g. Temple Grandin​ => So many psychologists do not only try to address the problem but also work to increase the strengths. HUMAN ADAPTATION PERSONAL DEVELOPMENT: esp. we, not so much about becoming better, will have more awareness of our good and bad sides. According to Jung, only by acceptance of unwanted aspects of ourselves we can control them better. ​ Lightner Witmer (1907) defined clinical psychology as „the study of individuals, by observation or experimentation, with the intention of promoting change”​ Bit of a different definition. Focus on the individual and making a better change for him/her.​ Some pts cannot become healthier (see palliative care) but can be better. ​ Clinicians combine knowledge from research on human responses and mental processes with assessment in order to understand and treat the individual. ​ to understand disorders of emotions/cognition/social interaction, we need to understand what is typical. Complex emotions require higher cognition. Not everybody is able to experience them (autism, psychopathy– inability to experience guilt, shame, remorse [kind of disability]. Same for cognition: importance of schemas in depression and anxiety ​ Clinical psychology is a subfield of psychology that examines the study and treatment of human behavior and mental processes. ​ Two aspects: BEHAVIOR (behav therapy- operant conditioning: very effective on clients esp. with neurodevelopmental issues). Behavioral activation is one of the best treatments for depression: small steps to become active – based on acting better to feel better.​ And MENTAL PROCESSES The focus in on examining human behavior, personality characteristics (e.g. level of neuroticism, openness – influence on choice of therapy), and psychopathology. Each of us have different predispositions (e.g. genes for psychosis vs for anxiety in family) ​ Clinical psychology focuses on the cognitive [bases of cognition play key role in mental health problems], Emotional [mood (no reason for their experience- mood disorders, BPD) vs affect], social [e.g. autism, bpd, npd + consequences of how disorder and people around interact], behavioral [e.g. if depressed and eat a lot of sugar – research on Nutritional Psychiatry (getting rid of carbs prevents severe depression) and biological contributors [genetic, body] to human functioning across the life span [to make things more difficult. E.g. more emotionally unstable in early 20s. BPD should be dxed more carefully in young people than elder], in varying cultures [e.g. in pl schools the best child is the quietest one; in Norway activity is encouraged], and at all socioeconomic levels [e.g. very hard to find someone with eating disorders in low SES levels; Wealth brings its own problems]. ​ Increasing interdisciplinary and collaborative nature to the science.​ ​ Clinicians differ from other psychologists in their approach to human beings. INTRO TO CLINICAL PSYCHOLOGY ​ There are different theoretical orientations used in clinical psychology​ ​ Different approaches have different ideas about what causes psychological disorders to develop.​ ​ NO one is best ​ Most psychological disorders are caused by multiple factors - Bio-psycho-social model​ Cannot understand depression only by thinking of one’s childhood/parents.​ We today have an unfavorable social context (pressures, comparisons, being unique) ​ Treatment is shaped by one’s understanding of the causes of the problem ​ Eclectic approaches combine ideas from the different approaches within psychology PLACE OF CLIN PSY AMONG OTHER MENTAL HEALTH DOMAINS Clinical Psychology vs. Psychiatry Clinical Psychologists... Psychiatrists.... ​ Learn to think as researchers ​ Are physicians ​ To evaluate findings ​ Learn facts and use this knowledge to ​ To defend their views by citing data understand and treat patients ​ View the nature of client’s problems in a ​ Focus on biological aspects of client’s multivariate way problem [some pts are in such a bad condition that they’d best undergo psychiatric therapy before starting psychother] ​ They cannot assess cognitive abilities (did not have psychometrics: do not know how to use diagnostic measures) Both… ​ Diagnose? Only psychiatrists can do the formal, final diagnose mental disorders​ [e.g. BPD can be really a thyroid problem]. We can diagnose other things (e.g. personality disorders, extremes in traits, cognitive distortions) ​ Treat using therapy (although training in psychotherapy is more heavily emphasized for clinical psychologists) DISTINGUISHING CLIN PSYCH FROM RELATED PROFESSIONS Counseling Psychology ​ Most similar to clinical psychology ​ Training about the same ​ Counseling psychologists tend to deal with problems of adjustment in healthy individuals ​ Historically counseling psychologists worked within university counseling centers ​ In last few decades, they have expanded their work setting to include private practice​ Deal with Psychological problems but NOT mental health problems -​ Eg grief, relationship problems, adaptation problems, assertiveness, self esteem​ [Generally much higher motivation to get better than mentally ill] A lot of overlap with CP though. Same techniques. Different clients population. Psychotherapy, Coaching ​ In contrast to clinical psychology, both are unregulated titles (anyone can offer services suing them)​ ​ Different training – for psychotherapy and coaching there are no educational requirements, only licensing.​ ​ Only Clinical psychologist can conduct psychological assessment.​ ​ Provide psychological help in a form of psychotherapy or personality development to people with mental health/well-being problems Social Work ​ M.S.W. (2 years of post B.A. training) emphasizing clinical work [masters in social work] – in the US​ ​ Typically focus on working with the poor and disenfranchised segments of the population​ ​ Work in settings dealing with many aspects of a patient’s life and care such as social security, housing, food stamps, Medicare, arrangements for nursing homes, and foster care placement​ ​ Emphasis on therapy, but not diagnostic training or emphasis on research CLINICAL PSYCHOLOGY SPECIALISATIONS ​ Adult disorders - Diagnosis - Psychotherapy - Rehabilitation - Substance abuse ​ Child and adolescents -​ Health psychology (e.g. oncopsychology) -​ Neuropsychology -​ Geropsychology -​ Community Psychology -​ Forensic Psychology ( a lot of CPs sometimes do dxs for the court) -​ Psychoanalysis: very orthodox method (vs psychodynamic treatment WHAT DO CLINICAL PSYCHOLOGISTS DO? ​ Conduct Research on human behavior and mental processes​ More needed than eg research on social psy ​ Make Psychological Assessments Exactly what they do, as opposed to all other professions. We need psy degrees to be able to buy diagnostic tests A lot of jobs ​ Use therapy to treat mental problems & disorders  Therapy has many different forms (teaching skills, psychotherapy, other interventions)​ ​ Teach as Faculty​ ​ Provide consultation: eg schools ask for a CP from the outside, or gvmt, or other organizations​ ​ Work in administration: very few people. But more are needed to make their voices heard; regulate the job better. There is a much stronger psychiatric lobby than psychological. Insurance company right now will only pay for CBT.​ ​ Develop/engage in/direct health promotion programs​ ​ Develop/engage in/direct prevention programs SIGNIFICANCE OF RESEARCH ​ Psychology hasn’t always been acknowledged as a purely scientific discipline.​ ​ Especially its clinical branch has been frequently referred to as a kind of art [importance of the relationship with the client].​ -/-> that’s not all​ ​ Although recently psychology has become increasingly associated with cognitive sciences and scientific methods of research became prevalent, not all psychologists appreciate its scientific part, adopting a more humanistic approach.​ ​ Thus, it is still considered by many as a ‘soft’ science.​ ​ Conflict between researchers and practicing clinicians. Why to consider the notion of Pseudoscience in the context of psychology? Many misconceptions in lay knowledge ​ As psychology has been applied to various occupations and fields, many of psychological concepts and theories have been not properly used and abused not only by professionals outside the field, but also among psychologists themselves.​ ​ As a result, the field is full of assessment methods and interventions that deserve a status of pseudoscientific.​ ​ Thus it is frequently hard to differentiate psychological methods from pseudo-psychological ones and so-called pop psychology, especially if one is a layman. Significance of Research ​ Psychological disorders are real problems that affect real people.​ Big impact of what we know and do​ ​ Research into the causes and treatment of psychological disorders is critically important.​ There’s a lot we don’t understand. 1 billion people estimated to have mental health problems. Most of these could be prevented if we knew everything​ ​ Need to distinguish science from pseudoscience.​ Many popular books and websites claim that adult children of alcoholics have a distinct personality profile (low self-esteem, feelings of powerlessness, difficulties with intimacy.) -> research showed that adult children of alcoholics are no more likely to have these problems than anybody else (Lilienfeld et al., 2010). In PL, NFZ funds treatment for people who had alcoholic parents [based on falsity] Also, sensory integration was funded for children with neurodevelopmental disorders [also not based on research. Behavioral therapy would be much more helpful] What can we say about one’s Personality based on Handwriting? ​ ​ Handwriting analysis or graphology is sometimes claimed to be a psychological assessment technique.​ ​ However, actually it is not. There is no evidence for its validity (Eysenck & Gudjonsson, 1986; Greasley, 2000). Significance of Research ​ The use of psychiatric medication has increased dramatically relative to the provision of psychological interventions. Psychiatric industry >>> psychological industry​ ​ Building evidence for insurance companies and policy makers that particular psychological interventions are effective.​ ​ Cathartic technique in psychological practice (Trzebińska & Gabińska, 2015) -​ Catharsis – releasing emotions, venting anger [one of main tenets of psychodynamic approach] -​ Many mental health professionals consider it as a core technique to achieve positive therapeutic change.  -​ But growing evidence that intensified expression of negative emotions may be harmful because, paradoxically, it causes an intensification of these feelings (Lohr, Olatunji, Baumeister, & Bushman, 2007). Limitations of Cathartic Technique (In which cases it won’t work) ​ People having personality dispositions to experience negative emotional states – narcissistic pd ​ Expressing anger – when people already express it ​ Bereavement – not true that the most important thing is to talk about it. Being quiet with their sadness until ready is best ​ Debriefing which takes place immediately after the traumatic event – e.g. policemen involved in shooting, catastrophes. Actually, this increases the possibility of trauma - for victims of sudden violence - victims of burns and car crashes Interested? Read more here: Trzebińska & Gabińska (2015) Correcting emotions in psycotherapy in Roczniki Psychologiczne https://www.researchgate.net/publication/299465157_Correcting_emotions_in_psychotherapy THE SCIENTIST-PRACTITIONER ​ Call for clinical psychologists to be scientists goes back to the earliest days of the field.​ Witmer (1907) argued that the pure and applied sciences advance as one – what retards or fosters progress in one, retards or fosters progress in the other.​ ​ The Boulder Conference (1949)​ Formulated the “Boulder Model”​ Scientist-Practitioner Model Main Reason for “Joint” Training as Scientists and Practitioners So students could develop interests in both research and practice, despite the fact that most would concentrate on one or the other in their careers. ​ Underlying assumptions: -​ Specialization in either research or practice was seen as likely to contribute to narrowness of thinking and rigidity of action.  -​ Direct involvement in clinical work by researchers would foster their knowledge of important clinical issues so they would be more likely to study them. Why are clinical psychologists required to engage in research to earn their degrees? ​ Clinical psychologists need to be trained to critically evaluate published research on assessment methods and treatment options to determine which have been validated.​ ​ Research training will help clinicians objectively evaluate their own treatment methods.​ ​ A strong research background will aid clinicians who work with community mental health centers in assessing the effectiveness of the agency’s programs.​ ​ Clinical psychologists who work as faculty members at a university need to supervise and mentor students in research programs. What are Evidence-Based Practices? ​ Interventions that show consistent scientific evidence of being related to preferred client outcomes. ​ CBT has a lot of backing. Mindfulness not that much ​ Are an alternative to authority-based practice: Appeals to: -​ A famous person. “If Freud said it, it must be true.” -​ Popularity. “Eighty percent of social workers use...I’m going to use it too.” -​ Tradition “That’s the way we have always done it.” -​ Consensus “We all believe that ____” ​ EBP = Evidence Based Practice → practice based on empirical research​ ​ EBM = Evidence Based Medicine → medicine based on empirical research​ ​ EBPP = Evidence-Based Practice in Psychology → psychological practice based on empirical research​ ​ EBA = Evidence Based Assessment → diagnosis based on empirical research APA Policy Statement adopted in August 2005 ​ “Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”​ Eg CBT will be much better for elderly men, who do not speak often about their emotions, rather than humanistic or pdynamic ​ To provide a rational basis for deciding which treatments to fund (e.g. which medications to prescribe). The EBP Model – Best Available Research Evidence ​ Adopt a scientific view of clinical psychology ​ Knowledge of clinical research design and methods ​ Strategies for accessing best available research ​ Ability to evaluate relevant evidence MULTIPLE TYPES OF RESEARCH EVIDENCE Clinical observation Qualitative research (eg reading accounts of people with x condition) Systematic case studies (article with case + intervention – good food for thought, but not enough…​ need metanalysis) Single-case experimental designs Public health and ethnographic research Process-outcome studies Effectiveness research in naturalistic settings RCTs and their logical equivalents Meta-analysis  L03: The concept of Health and Disease in Clin. Psy. LECTURE OVERVIEW: ​ The notion of psychological health​ ​ Different criteria in assessing mental health and disorders (ie. statistical, socio-cultural, theoretical)​ ​ The notion of diagnosis and classification of psychological problems SPECIFICITY OF PSYCHOLOGICAL NORM There is a difficulty in distinguishing healthy from unhealthy. Norms are not concrete numbers, as in medicine ​ Norm – ideal or real pattern of characteristics (i.e. behavior, personality or development)​ ​ Primacy of negativity – norm as a lack of pathology​ For a long time, this was the used rule. Not anymore​ ​ Terms “psychological norm” and „health” used interchangeably Statistical model When we talk about something countable. Good for medical science ​ Normal or healthy = mediocre, average, or present in most people​ Eg trait opennes. If someone is very low in it, this is not adaptive to function in society; But also being super high is not (extreme disinhibition)​ Level of Intelligence. 100 is the median. It is also very hard to live in society with 130-140. According to this model, their functioning will be different.​ ​ Refers to the normal distribution of certain features - normal is what is in the area of central tendency (the area defined by the acceptable standard deviations) -​ Changes in time ​ Pathological phenomena due to the prevalence may be considered as norm​ ​ And people deviating positively? Socio-cultural Model ​ We are used to particular patterns of behaving,thinking, feeling. What deviates too much is abnormal. The same behav if abnormal in one culture can be ok in another. Even among families (eg yelling when communicating) ​ Normal is something that is recognized as common, typical for a particular culture –behavior consistent with commons and conventions​ ​ Normal individual – typical for a particular group or culture.​ ​ Related to the cultural heritage, values and social roles.​ ​ An indicator of optimal functioning – the ability to meet own important needs in a manner consistent with social norms Importance of finding a balance between own needs and social norms​ ​ Abnormal individual – a person who does not meet the common social-cultural, ethical (eg cheating, lying, manipulating) and legal norms of a society in culture (abnormal in a sense that he/she violates the social order and jeopardizes the functioning of society and personal development).​ ​ Disorder (social maladjustment) as a violation of socio-cultural norms (also ethical, legal etc.) Entails social sanctions ​ The most relativized model, charged with evaluation​ ​ In periods of social change, breakthroughs and sudden shifts in the systems of values the phenomena considered abnormal intensify Theoretical Model Theories sometime they will apply to the individual, sometimes they won’t ​ Norm is determined by reference to theoretical models E.g. Freud theorized that a healthy person should be able to work and be in a committed relationship. To do so they must prevent their defense mechanisms from being too prevalent Rogers: Health = congruence between real self and ideal self [Each psychologist was able to grasp sth important] ​ Norm comes from scientific claims, reasonable concepts or empirically proven relationship​ ​ Models within the paradigms: psychoanalytic, cognitive-behavioral, humanistic, systemic​ ​ Theoretical norm became a standard, to which the individual data are referred How to Define Abnormality? The Three/Four Ds ​ Distress Not always in the person who has those abnormal behaviors. E.g. psychopathy. egosyntonic vs egodystonic symptoms. All forms of personality disorders, sometimes in autism. people that have egosyntonic symptoms are not able to change their perspectives. ​ Deviance: the behavior must be significantly different from what society deems acceptable​ Violating some socio-cultural norms. Today they are getting wider and wider, we​ accept more and more behaviors. Altho there are more limits in psychology​ ​ Dysfunction (aka Maladaptive behavior): the behavior interferes with the person’s ability to function e.g. wearing a swimsuit in winter is deviant and also dysfunctional. ​ (Dangerousness). Probably recently excluded to not exclude people/minorities. But worth including. E.g. eating disorders, psychosis => danger for themselves (e.g. believing in miracle cures) ​ Meeting only one criterion is many times symptomatic of a mental disorder. ​ The criteria of mental disorders are indeed value-related. Concepts of Normality and Abnormality ​ Rosenhan and Seligman suggested that there are seven criteria that could be used to decide whether a person or a behavior is normal or not.​ ​ Not used as frequently as the 3D criteria. But better to differentiate abnormal from strange but normal bc they are much more detailed 1.​ Suffering – does the person experience distress or discomfort? Maybe the clinically significant suffering is experienced by people around the person? - Very similar to Distress. - Some people may have all symptoms of a disease but no suffering. E.g. prof’s patient with adhd, learned to use it positively 2.​ Maladaptation – does the person engage in behaviors that make life difficult for him or her rather than being helpful, also in the long run? Does the person fulfill the roles and tasks which are characteristic for his/her developmental stage? - much broader than in 3D (dysfunction) - very dependent on developmental stage. - E.g. a 7y-o. child should be able to make friends (engage in some form of social relations) ​ and have good enough relationship with parents, able to engage in school activities. - In a uni student, enrolling in courses, passing exams, taking care of themselves and their ​ house We expect people to engage in different (more and more difficult) social roles. Fulfill the​ roles that are congruent to their developmental ages. At least until old age​ 3.​ Violation of moral or ideal standards – does the person habitually break the accepted ethical and moral standards of the culture? ​  - We refer to habitual violation… Either antisociality or just no understanding​ 4.​ Irrationality – does the person behavior/thoughts follow the rules of logic? Are they based on a realistic perception of the world? is the person incomprehensible or unable to communicate in a reasonable manner? -​ Often abnormal behaviors are irrational. Somebody does sth assuming that will bring consequences that are irrational for us (eg compulsions). From the pov of the individual, there is a logical reasoning (anorexia to change the image in the mirror), but is unreasonable for the rest of us [observer pov] => symptoms are assessed from our pov 5.​ Unpredictability – does the person act in ways that are unexpected by himself, herself or other people? Does the person have control over his/her thoughts/emotions and/or behaviors?​ - more about control of behav. Someone with ADHD cannot control their minds. Impulsivity in BPD​ 6.​ Vividness and Unconventionality – does the person experience things that are different from most people?​ - Unconventionality is not a criterion which alone allows us to dx abnormality. Eg artists. Not all experience mental health problems. Or believing in the power of some “magical tools”​ 7.​ Observer discomfort – is this person acting in a way that is difficult to watch or that makes other people embarrassed? -​ Even someone always finding sth wrong about sbdy else (“I’m just sincere”). Everybody felt uncomfortable. Another case in which the criterion is outside. Big responsibility on the psychologist. We need to take the overall standards of the society, not our individual ones. Not necessarily all criteria be present to dx a person. Many pts are not unconventional, but they are irrational (depression, “my life is worthless”). Suffering always. In worst cases all can be present Difference between counselling and clinical psych. A lot of people nowadays go to CPs not with mental health issues, but with psychological problems. We need to determine what is healthy or unhealthy. Strongly dependent on developmental stage, social functioning… How to Define Abnormality? ​ Quantitative criteria:​ Abnormal is something that significantly differs from the average, defined for a given feature -​ E.g. some sadness during autumn is normal. Same symptoms, different intensity and frequency for Depression (eg that thought everyday for 3 months) -​ It is not bad to have a good self-esteem and self-efficacy vs narcissistic pd ​ Qualitative criteria:​ Abnormal functioning is of different quality than healthy​ People experiencing sth that most don’t experience at all ​ Criteria of coexisting combinations of traits:  -​ Abnormality when few symptoms exist together​ Eg sadness + weight loss + insomnia … Psychopathological Symptom Sth the clinician can declare, observe ​ Disruption, disorder of the smallest manifestations of mental life​ ​ Examples: Single experiences of anxiety, hallucination, depressed mood, lack of initiative -​ They tell us which function is not working properly (affective-sadness, cognitive-hallucinations, motivational-not energy) ​ A sign of abnormality in one of the mental functions: -​ Cognitive -​ Emotional -​ Impulses -​ Motivational -​ Volitional -​ integrating mental activities Psychopathological Syndrome ​ A pattern of coexisting symptoms indicative of some disease​ ​ Several symptoms coming from different psychological functions occurring together​ ​ A set of symptoms and signs that are usually due to a single cause (or set of related causes) and together indicate a particular physical or mental disease or disorder. Also called symptom complex.​ ​ Example: manic syndrome -​ Mood changes -​ Sudden changes in energy and activity -​ Speech disruptions -​ Impaired judgment -​ Changes in thought patterns Mental Disorder ​ A pattern of symptoms with characteristic beginning, course and final, conditioned with specific disease factor​ ​ A set of symptoms which follow a characteristic pattern and develop in a specific way. It’s process it goes through different phases.​ ​ Example: bipolar disorder ​ - symptom can be lower mood, lack of appetite, insomnia​ => depressive syndrome​ which is NOT depression.​ Because if there is also Manic Syndrome ⇨​ Bipolar Disorder Models of Classification ​ Categorical approach – there are separate classes, clusters of disorders of high consistency, different from other classes​ ​ Dimensional approach – health and disorder differ only in the severity or intensity​ ​ Prototypical approach -​ Prototype – the most representative; disease entity, that has the typical qualities; the reference point -​ In the current classifications CLASSIFICATIONS OF MENTAL DISORDERS ​ ICD-11 (International Classification of Diseases and Related Health Problems, 2019)​ ​ DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, 2022); (DSM-5: 2013)​ ​ CCMD-3 (The Chinese Classification of Mental Disorders)​ ​ Some of the wordings of the diagnosis are different: - borderline personality disorder in the DSM, - emotionally unstable personality disorder (borderline type) in the ICD, - impulsive personality disorder in the CCMD. The DSM-5-TR definition of mental disorder (APA, 2022, p.14): ​ „a syndrome characterized by clinically significant disturbance ​ in an individual’s cognition, emotion regulation, or behavior ​ that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.​ ​ Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.​ ​ An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above”. (p.14) The complete state model of mental health and illness ​ (Keyes & Lopez, 2007)  L04: Between Clinical Assessment and Clinical Diagnosis LECTURE OVERVIEW: ​ different assessment tools used by clinical psychologists (literature) ​ the role of intelligence, personality and behavioral assessment in clinical psychology (literature) ​ clinical judgment ​ CPs do not dx mental disorders. They assist psychiatrists in it. Clinical Diagnosis: Classifications of Mental Disorders ​ ICD-11 (International Classification of Diseases and Related Health Problems, 2019) Majority of people in Europe use this ​ DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, 2022) Only used in US and Canada ​ CCMD-3 (The Chinese Classification of Mental Disorders Reflects cultural differences in what is considered pathological All these are typically medical books. So what do CPs diagnose? Today’s lecture is all about this. Focus: distinguishing what is normal from abnormal Between Clinical Assessment and Clinical Diagnosis ​ If someone is depressed, we a psychiatrist may, in a particular case, diagnose for instance with the full DSM-IV nosology of: -​ Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features, With Melancholic Features, With Full Interepisode Recovery, Superimposed on Dysthymic Disorder. ​ But what does it tell us?​ ​ A psychiatrists might say, “OK. It’s major depression, let’s try an antidepressant medication.”​ ​ (Fair enough. After all, if someone breaks his leg the treatment doesn’t hinge on why he broke his leg.)​ ​ But as a psychologist, we need to know much more:​ A psychologist has to ask why. “Yes, but why is he depressed?” And in answer to this question  the DSM diagnosis tells us nothing. If it is a reaction to loss of everything after a catastrophe, or reaction to a breakup- it is very different.​ ​ Different psycho treatments work on different people Aim of the Clinical Psychological Assessment ​ Understanding the person’s problem: 1.​ Description of a problem (what is it specifically?) 2.​ Analysis of the causes of a problem (how it started?)​ What was the reason: loss of hope in future, loss of sources of motivation to live on, loss of resources to live on – 3 different reasons) 3.​ Analysis of psychopathological mechanism (how it is maintained?)​ Intense sadness as a normal reaction to loss. There must be sth that maintains this sitch in order for it to become depression: isolating, neurotransmitter problem, rewarded for being depressed, rumination ​ Underlying assumption: Symptoms manifest and indicate the pathological process.​ ​ Psychological assessment is most useful in the understanding and evaluation of personality and problems of living. Eg neuroticism predisposes people to rather experience negative emotions than positive; low level of openness: pharmacotherapy is best. This is far more important than just the symptoms. Behavioral analysis is often independent of the diagnosis => individually tailored treatment What is the Clinical Psychological Assessment ​ A broader psychological assessment to more accurately diagnose a person's psychological condition. Not just administering NEO-PI​ ​ Based on information from multiple sources: -​ psychological tests -​ personal interview, family interview -​ observation -​ job history records -​ reports and records from other physicians, therapists, and counselors. ​ „Getting to know the whole story” - a person’s inner and outer life, past and present life situations, psychological state and behaviors. Why to assess? ​ In cooperation with a psychiatrist to make a psychiatric diagnosis​ ​ To understand psychological difficulties and problems reported by a person and determine the likely causes and the best ways to deal with these issues​ ​ To assess the weaknesses and strengths of functioning. Eg for children, when deciding what kind of schooling is best for them ​ Based on assessments, psychologists develop and apply effective therapeutic treatment plans and interventions. Psychological Assessment We need to have knowledge of tests ​ Process that involves the integration of information from multiple sources, such as psychological tests, observation, interviews, analysis of personal history, description of current symptoms and problems by either self or others, and collateral information.​ There are very different forms of observation (systematic, functional)​ Diff types of interviews (intake interview at hospital admission, case history int, birth record history: apgar score, birth circumstances; family interview)​ We need to decide what kinds of tool to use. Why we need psychometrics. Some tools work better​ ​ Comprehensive psychological evaluation consisting of selection, administration (NEO-PI is easy; Wechsler or Raven is much more complicated: a lot depends on what you do and say; projective tests are hard to analyse), evaluation, interpretation of various assessment instruments and integration of results into a coherent report (in case of clinical assessment often including guidelines for treatment planning) How do I know which Psychological Tools to use? Sometimes it is very easy. Esp in hospitals; people come with dx, there is a battery of available tests ​ The type of tools used in the clinical psychological assessment depends on the purpose of the diagnosis.​ ​ Sometimes the purpose is clear from the beginning: -​ A psychiatrist asks for help in differentiation between two specific disorders; -​ The child is sent to the psychologist with suspected ADHD,​ check also IQ: is it adhd or learning difficulty? Children who are highly intelligent and temperamentally ? will present adhd symptoms, but they are just bored + entitled to move around as kids are these days. Treatment has to be tailored to intelligence -​ A client wants to know his IQ, etc. Emotional Intelligence: two guys have problems in relationships, go to psychiatrist are dxd with panic disorders. One guy has very low EI, the other very high. One will first have to be taught about emotions, the other can already start working on triggers. Just applying CBT to both without assessing EI will be ok only for the high EI guy (in CBT we assume that a person is already able to distinguish emotions). Attachment. Same two guys. One is securely attached, the other is not. In the second case, building therapeutic attachment will be much harder. If no time, do behavioral treatment (just teach how to cope) ​ In determining the purpose of the diagnosis, a personal interview with the patient/client is necessary. Sometimes just 15 minutes. Need to add the right discriminating questions to have some ideas of what to additionally assess.​ ​ Even when the purpose of assessment is clear from the beginning (eg a person coming saying they have adhd bc they did a screening test online), the interview is necessary to determine possible contraindications to the use of specific psychological tools (problems with eyesight, hearing, hand motility, language barrier, cultural barrier, etc.), or find the right dx. DIFFERENT ASSESSMENT TOOLS USED BY CLINICAL PSYCHOLOGISTS Methods, techniques, tests: Nomothetic vs. idiographic ​ allows to compare this particular person ​ We don’t compare person to others. We to other people. Eg NEO-PI: can know only listen to the person’s story. Both N level of neuroticism only by comparing to and I are needed. Kid with adhd. Compare others to other kids. Maybe they are just used to be more straightforward to adults. ​ standardized ​ „free”​ ​ quantitative ​ Qualitative​ ​ objective ​ projective, subjective. Most clinical dxs conclusions are wrong. It is hard to distance ourselves from our ideas, memories. Importance of recipathy (if I have a feeling about a pt, that’s probably what other people feel towards him as well, so it is diagnostic too)​ ​ psychometric ​ interpretative​ ​ PERSONALITY INVENTORY ​ INTERVIEW ​ INTELIGENCE TEST ​ PROJECTIVE TEST ​ BEHAVIORAL ASSESSMENT ​ Interviews  -​ Generally idiographic -​ Structured interviews for different DSM disorders -​ The intake-admission interview -​ The case-history interview -​ The mental status examination interview ​ Observation (structured vs. Unstructured)​ ​ Questionnaires: 3 main classes -​ The broad screening measures (SCL-90-R) -​ Symptoms checklists (BDI) -​ Personality Inventories (MMPI, NEO-PI-R) ​ Projective tests (TAT or RISB)​ generally considered to be an indirect way to assess personality but defined in a different way than big 5. In short, Rorschach should not be used for dx, maybe just to know more about pt. You can learn about people’s relationships without directly asking them about it. E.g. someone is a control freak in relationships. In projection, they will talk about control, dominance. Manifestation of our cognitive schemas, with which we organize reality [people don’t need to know that we are assessing them]​ ​ Sample Task Performance Techniques -​ Intelligence testing (WAIS-IV. Stanford-Binet-5th Edition) ​ Behavioral assessment (functional analysis) CLINICAL JUDGEMENT DIAGNOSTIC INFERENCE Aim: to create an accurate description of the client/patient. How to derive a proper diagnose, avoid misdiagnosis? 1.​ Development of an optimum level of rapport → increases the likelihood of client’s optimum level of performance. 2.​ Impact of various situational variables (transient conditions, assessment context). E.g. if someone is on antibiotics, they won’t do well on intelligence test ​ Clinician's objectivity may be biased by: -​ first impression (primacy effect) -​ self-fulfilling prophecies, confirmatory bias – especially in a hypothesis-testing situation. -​ clinician’s professional and personal experience (personal and cultural bias). ​ Accurate person perception is positively associated with: -​ Intelligence -​ good emotional adjustment -​ similarity in race and cultural backgrounds ​ Accuracy of clinical judgments also heavily relies on: -​ the level of knowledge and experience of the diagnostician -​ the kind of sources used to create client’s description ​ Acknowledging the role of chance That our predictions will be less than 100% accurate -​ Not only relying on intuition, but also actuarial (=we don’t use informal subjective methods aka tests) prediction = nomothetic techniques Clinical and Mechanical (Actuarial, Statistical) Diagnosis (Meehl, 1954) Clinical judgment refers to the typical procedure long used by clinical and applied psychologists and physicians, in which the judge puts the data together using informal, subjective methods => Rule-of-the-thumb (Meehl, 1956,p. 264) Psychologists, who base their work on clinical prediction, believe that their experience gives them a „clinical insight”, which allows them to make better predictions than those derived from research. Clinicians differ in how they do this: the very nature of the process tends to preclude precise specification (Grove et al., 2000), but all value the use of personal interviews. Meehl suggested that such diagnosis should be replaced by mechanical diagnosis, so that there are: -​ explicit, well-defined rules -​ leading to reproducible results -​ regardless of the circumstances of diagnosis Problems with Diagnosis of Mental Disorders in Children and Adolescents​ (Metanalysis by Merten et al., 2017) Significant differences are observed between clinical and epidemiological data in mental disorders -> overdiagnosis -​ especially in case of ADHD A number of studies suggest that misdiagnosis does occur -> diagnosticians are prone to making mistakes in the decision-making process. Research by Bruchmüller and colleagues (2012) suggest that diagnosticians make more false-positive than false-negative diagnoses, which can be seen as proof of overdiagnosis of ADHD. -​ 16.7% of psychotherapists diagnosed ADHD although diagnostic criteria were not fulfilled. -​ Only 7% gave no diagnosis, although the case vignette fulfilled diagnostic criteria for ADHD. L05: Main Models of Human Functioning and Approaches Used in Clinical Psychology. Part 1 LECTURE OVERVIEW: one-dimension model and multipath models diathesis-stress model psychodynamic approach humanistic [no one model is better than the other overall; they shed light on sth different. Some are better to understand an individual than the other. They have different research support: cbt, behavioral therapy is the most researched.​ All such models are generalizations based on the cognitive distortions of their authors]​ PATHOGENIC APPROACH Metamodels: models about models. Most important in clinical psychology Pathogenic: we are looking at different ways to understand the cause of a pathology​ ​ One-dimension models of mental disorders:  explain disorders in terms of a single cause  predominantly linear explanation  considered to be overly simplistic.​ [eg autism is caused by vaccination; sb’s disorder is caused by trauma. Very simplistic. We know to be false] Multipath models of mental disorders:  explain disorders in more (psychologically) holistic and interactive terms.  system of different reciprocal influences (biological, psychological, social and sociocultural) interact in complex ways to yield the major etiological and maintaining processes responsible for mental disorders. Importance of predispositions (some people will not experience anxiety, but will eg drink too​ much). A lot of panic attacks can happen after drinking energetics i.e. Biopsychosocial model. NO matter what interest in psychology, it is now undisputable The Interaction of Genes and Environment (Barlow & Durand, 2015) Genetic factors contribute to all disorders (but explain less than 50%) -> there must be an environmental trigger for a disorder to occur.​ [if we have genetic predisp, we should be a bit more careful of the environment] Diathesis-stress model – one inherits a predisposition for a certain behavior or trait (diathesis), which can be activated in a particular conditions of stress. ​ Diathesis or Vulnerability, is genetically determined and makes a person prone to develop a disorder ​ Stress is environmental E.g. most psychotic disorders manifest in early 20s (brain development, drugs, moving out aka handling independence, formation of adult identity The bigger the vulnerability, the smaller the life stress required to produce the disorder. PSYCHODYNAMIC MODEL Sigmund Freud was the first to challenge the view that mental disorders were caused by physical illness. Instead, he proposed that psychological factors were responsible. The essence of the psychodynamic approach is to explain behavior in terms of its dynamics, i.e. the forces that drives it. 1. Personality structure 2. Level of awareness 3. Psychosexual stages 4. Defense mechanisms We no longer think of layers processes that run with or without our awareness From the tutorials: PSYCHODYNAMIC THEORY Much of mental life is unconscious. ◼ Childhood experiences together with genetic factors shape the adult. ◼ Symptoms and behaviors serve multiple functions and are determined by complex and often unconscious forces.​ DEFENSE MECHANISMS May be both adaptive and maladaptive ◼ By Freud seen as preventing awareness of unconscious sexual or aggressive wishes, but in the contemporary psychodynamic thinking – they preserve a sense of self-esteem, ensure a sense of safety by helping the individual to cope with anxiety. Situations in which a defense mechanism may turn on… ​ A person who believes that stealing is wrong just walked out of a store without paying for a candy bar. ​ A person who is married is attracted to his next-door neighbor. ​ A student who sees herself as honest just cheated on a math test. ​ A person who is trying to lose weight just ate a large ice cream sundae. -​ Rationalization: The person thinks, well, it was a special occasion, so it doesn’t really count. Plus there were peanuts on the sundae, and nuts are healthy. Chocolate is good for you also because it has special nutrients. -​ Repression: In recording her food log for the day, she “forgets” to include the ice cream. -​ Projection: She looks at her friend and thinks that he eats too much and should really lose some weight; he makes poor food decisions. -​ Displacement: Rather than feeling guilty or anxious about eating ice cream, she starts to worry about whether she should have donated more money to a charity that contacted her last week. -​ Reaction formation: The next day she denies eating the whole ice cream sundae, instead saying that she really only ate a few bites and was disgusted with it and refused to eat the rest. -​ Regression: Feeling bad about eating the large ice cream sundae, she resorts to comforting herself by watching a DVD of her favorite childhood cartoons. -​ Identification: The lapsed dieter begins to admire her thin friend and decides to copy some of her eating and exercise habits. Personality Structure Adult personality is structured into three parts - id, ego and superego - that develop at different stages in our lives.  According to Freud, the key to a healthy personality is a balance between the id, the ego and the superego. People differ in terms of the extent to which their personality is dominated by the id, ego or superego. For example, a person with a personality dominated by id will tend to be pleasure seeking and antisocial, lacking concern for others.​ ​ Eg “children-like” behaving individuals have a dominating id. Psychopathy = no superego. In many cases a structure does not exist we cannot assume we can teach them sth that pertains to that structure (eg no guilt if no superego). Psychosis = loss of ability to use ego => we cannot process reality. But the ego is there, there was no psychosis earlier. So we can train ego. But, in psychopathy we need to come up with strategies to treat others well without assuming guilt. Id-dominated people are very impulsive The Id The impulsive and unconscious part of our personality, present at birth (instinctual).  gaining pleasure;  immediate satisfaction at any cost People getting very angry when they don’t get what they want (see case of Antonio).​ Adulthood is about managing frustration. Freud said women were very sexually frustrated. He​ meant sexual as in everything positive we may want (as opposed to destruction). In preschool​ we learn that given things are given at given times = learning gratification delay.  no regard for social norms Antonio; making easy money in illegal ways. In a lot of people with personality disorders, their​ functioning is dominated by id -​ People who don’t have access to their id cannot enjoy sex nor other pleasures. People with OCD, OCPD Guided by pleasure principle  Id seeks gratification of instinct in action (eating) or fantasy (visualizing food, sex). The Ego  The conscious, and rational part of the mind, acting in the external world.  Develops around the age of two years, but changes with time.  It’s aim is to work out realistic ways of balancing the demands of the id in a socially acceptable way: -​ gratification delay is possible. Youngesters cannot do It bc their ego is very weak​ [But, another functino of the ego is to] Able to separate wish from fantasy, tolerates tension, able to compromise.​ Many people think they can be ideal, this is Id (?)​ Perfectionism is a very weak Id, but dominant Superego, altho there’s also a lot of pleasure in being thought of as perfect… The Superego Forms at around the age of four years, is a learned aspect of self. Includes (1) ego ideal and (2) conscience (individual’s morality: what we should do for other people). Psychopaths don’t have this aspect of conscience, tho they have ego ideal. Conscience development is a process. As children, we don’t do bad things to avoid punishment, as adults, bc it is not right Seeks to perfect and civilize our behavior. [Perfectionism today is not a disorder, but a psychological problem most people have nowadays] Learned through identification with one’s parents and others (the values that other people have Black-white judgments – no ability to compromise. [no reality testing in superego]​ CBT tries to engage people’s ego, teach them to use it. Freud thought that before we can strengthen ego, we should understand id and superego Levels of Awareness Freud’s most enduring insight was his recognition that unconscious forces can influence behavior. [Some people are more aware of their thoughts & inner processes. Bad combo if one is reflective and neurotic]  Conscious – a logical mind  Unconscious – ruled by pleasure-principle  Psychic energy is used to find acceptable ways to express unconscious ideas and wishes or to keep them repressed Freud’s Model of Personality Structure ​ Today we don’t say those processes are unconscious, but that we don’t pay attention to them. Attachment, cognitive schemas can be accessed thru psychotherapeutic work, meditation. When our lives go fine, there is no need to investigate unconscious processes, altho they are still running. But eg if we end up over and over in bad relationships, or never holding a job even tho abilities are present, psychotherapy is needed Psychosexual Stages Not much research on it. Very questionable. Altho in some cases some people are clearly “oral character” or “anal character”. But when it comes to oedipus complex, majority of people seem to not go through it. Sexual = everything that brings pleasure thru the body -​ children put everything in the mouth -​ potty training learning control Freud used the term ‘sexual’ to mean sensual or physical. At each stage, a person’s life force is attached to an organ of the body. Focuses on the development of the instincts, therefore rooted in biology He theorized that the ways in which children deal with immature sexual urges during different stages of psychosexual development shape personality. Freud predicted that experiences during these key stages would result in distinct adult personality types. Such effects are due either to frustration or overindulgence during any psychosexual stage – both of which lead to a fixation on the stage and characteristic kinds of behavior. ORAL:  -​ a lot of research shows that if people are neglected in 1st year of life insecure attachment. -​ Way too much attention become overdependent on others -​ Smoke, eat too much => oversimplistic -​ More evidence about the traits. Insecure attachment is proved to be related to dependence. ANAL: -​ Defense Mechanisms WHAT ENTERED MAINSTREAM PSYCHOLOGY Not necessarily pathological; can also be adaptive (good to repress sexual urges in public), but becomes maladaptive when they are very frequent: losing contact with Id. People who overuse them begin to have different symptoms. OCD: compulsions entered not to experience anger, anxiety (easier to go wash hands instead of thinking about how much you hate sth…) The ego attempts to keep conflicts and their discomfort from reaching consciousness by employing a variety of defense mechanisms that distort reality, usually at an unconscious level.  Help the individual cope with anxiety and prevent the Ego from being overwhelmed.  Have adaptive value if they are mature and do not become a style of life to avoid facing reality.  MECHANISMS OF DEFENSE that help the Ego deal with the anxiety  Overusing defense mechanisms, results in SYMPTOMS formation - disguised expression of repressed emotions and impulses AIM: to get rid of impulses, OR be able to confront them in a socially accepted way (eg sublimation: humor)  Displacement (transfer of impulses from one person or object to another).  Projection (undesirable thoughts are attributed to someone else).  Jung made it the most important mechanism Evidence that all of us project.  Denial (refusing to accept reality)  Sublimation (negative emotions are transformed to positive, socially acceptable behaviors or emotions)  Suppression aka Repression (pushing uncomfortable thoughts into the preconscious so they can be accessed later). Repression: of things that happened internally eg trauma, abuse, the case of Antonio (“I don’t remember”) PROBLEM OF DEFENSE MECHANISMS = OVERUSING THEM HUMANISTIC MODEL This model appeared later on. During the hippy movement. Emphasis on people as friendly, cooperative and constructive; Humanity is basically good, forward-moving, and trustworthy Sometimes you will see people suffering (e.g. Paul, who just cannot be happy) focus on drive to self-actualization the drive to better [not ideal] self: we have the ability to become what we want and to fulfill our capacities people are motivated by the actualizing tendency to enhance the self. Reality: the product of our unique experiences and perceptions of the world; subjective universe is more important than the events themselves. Example of whether the early lecture is good or not. Depends on the person Rogers’ Humanistic Theory R also believed parents have a strong impact on our personality, but not just in the first years of life. Unconditional positive regard should be given longer. Conditions of worth are the most detrimental to us Development of abnormal behavior occurs when society imposes conditions of worth on people so that their self-concept and actualizing tendency become incongruent. Such incongruence produces behavior disorders.​ even eg being expected to become a lawyer bc everyone in the family was Unconditional positive regard: Value and respect a person, separate from one’s actions eg always receiving hug no matter what Abnormal behavior results from disharmony between a person’s potential and self- concept. ​ Can do 3 things: 1.​ Rebel against parents and risk losing love 2.​ Ignore inner wishes and feelings depression, anxiety 3.​ Stay in the conflict. On the fence, find compromising aspects. With nonjudgemental approach, the incongruence decreases. Incongruence on Self-concept by Roger’s - Incongruence of self-concept: one’s self-concept may not go along with the realities of one’s actual experience. - Different people have varied amounts of incongruence between their self- concept and reality. -In case of conditional affection, these conditions are different for different people. Abraham Maslow The pyramid was not supposed to be a pyramid. More of a ladder The higher the need, the stronger the search for psychotherapy. Actualizing tendency: People are motivated to satisfy not only biological needs, but also the self. Self-actualization: Inherent tendency to strive toward realization of one’s full potential L06: Main Models of Human Functioning and Approaches Used in Clinical Psychology. Part 2 LECTURE OVERVIEW behavioral cognitive approach BEHAVIORAL MODEL All behavior is learned.  The reason you tend to be aggressive or loving or good at exams or suffer from a mental disorder can all be explained in terms of the experiences you have had as opposed to any inherited dispositions. Like psychodynamic theorists, behavioral theorists believe that our actions are determined largely by our experiences in life.  People are born as a ‘blank slate’. Behavior is all that should concern psychologists – there is no need to search for the mind or analyze thoughts and feelings. Personality is as a collection of response tendencies that are tied to various stimulus situations Focus on symptoms not causes Normality equaled with the possession of an adequately large repertoire of learned responses Focus on FLEXIBILITY of behavior:​ People with mental health disorders have. A very limited repertoire of coping behaviors: e.g. cleaning in ocd, seeking other’s attention in narcissism and bpd A major cause for abnormal behavior [not mental disorders] is a learned maladaptive responses  acquisition of emotional responses, e.g. anxiety No distinction between symptoms and behavior disorder Everything is a behavioral problem  “Mental illness”/“Mental disorder” are not Meaningful WE LEARN MAINLY THROUGH 3 MODELS: 1. Classical Conditioning Learning by temporal association When two events repeatedly occur close together in time, they become fused in a person’s mind; before long, the person responds in the same way to both events. If a man experiences chest pains which result in anxiety while shopping in a department store, he may develop a fear of department stores and begin to avoid them because he associates them with anxiety. [Easy cause => easy, short treatment] Eg HR incre, sweaty, chest pain => anxiety (UCS->UCR) But if chest pain happens in a shopping mall => very quick conditioning​ [same for positive feelings, tho slower, more repetitions needed. To develop a panic disorder, 1 is enough] Prerequisites to condition classically: physiological reaction, temporal association 2. Operant Conditioning Humans learn to behave in certain ways as a result of receiving rewards whenever they do so. Positive reinforcement- increasing a behavior by providing a positive reinforcer when the behavior occurs. Different for each of us!!! For some people, eg difficult children, a teacher’s attention – even if angered – is a positive reinforcer Works well for people that are internally motivated​ Negative reinforcement- increasing a behavior by removing a negative reinforcer when the behavior occurs. Eg stopping electric shocks when a person starts behaving right; beeping in car until you put your seatbelt on EXAM Q Very important for teaching social skills in people with neurodevelopmental disorders eg adhd, where PR would not be enough​ Punishment- decreasing a behavior by providing a negative consequence when the behavior occurs. Eg providing electric shocks when a person starts behaving wrong Both NR and P work Extinction (omission training)- decreasing a behavior by removing a positive reinforcer when the behavior occurs. Operant conditioning explains eating disorders well It is much easier to engage into a new positive habit than change a negative habit ​ [survival, evolutionary reasons] If a young woman begins to lose weight and her friends and family praise her for doing so, she may continue to lose weight, even if it means starving herself. Her restricted eating behavior will continue because she now associates a reduction in her diet with the praise and acceptance of others. 3. Observational Learning: Social Learning Theory by A. Bandura More and more important for younger generations. It’s enough to see sth on the internet to change behavior. Acquisition of new behaviors does not only rely on personal experiences. Responses are learned indirectly by observing and repeating behavior of others, there is no direct reinforcement. Explanation of how some people become aggressive, addicted (looking at family members typical behavior) Individuals observe role models (people with whom they identify) and learn about the consequences of behavior through indirect reinforcement. These consequences are represented as expectancies of future outcomes and stored as internal mental representations. Important to find good role models: importance of the friends teenagers hang out with Often clients in counselling just need to be shown a good role model Importance in BT to understand which mechanism is at the basis of a learned behavior and then change it. BT is good for people with lower literacy level Application in many different settings (sports, personal life, motivation) -​ Working eg with obese people, it is important to weaken the strength of eating as a reinforcer, introducing others COGNITIVE MODEL Looks at people not like animals (BT), but as a little bit more of computers Based in information processing viewpoint. Cognition involves the mental processes of perceiving, recognizing, judging and reasoning. Nothing is positive or negative in itself. But how we evaluate it The therapist has to understand how a person subjectively evaluates various things​ [not how they learned it as in BT] Schemas: a set of underlying assumptions rooted in experiences, values and perceived capabilities (beliefs, attributions, expectancies). The most influential ones in our lives are the ones created earlier in life Eg attachment (people can/cannot be trusted) Irrational and maladaptive assumptions and Thoughts, fueled by maladaptive schemas (the “glasses” we look from) Cognitive distortions Ellis Not used as frequently nowadays, but at the basis of all Ellis believed that everyone’s thoughts were rational at times and irrational at other times. -​ Eg “ I need to be perfect” is irrational bc it is not possible When we think rationally, we behave rationally and we feel happy, competent and efficient. When we think irrationally we can develop negative or disturbed habits in our thinking which can lead to psychological disturbance (i.e. depression, anxiety) dysfunctional thought patterns​ aim of therapist is to discover them, show them to us and help us change them pathology results when persons adopt illogic in response to life situations Every B starts with an A. Eg I get a ticket for parking my car I’m stupid, I am a bad driver, policeman’s fault ⇨​ We can act on Bs: make them less intense, change them ⇨​ CT is about distancing oneself from one’s emotions. -​ Will not work with low literacy people -​ Will not work with people with intense emotions​ What are Automatic Thoughts?​ What was going through your mind? Happen spontaneously in response to situation  Occur in shorthand: words or images  Do not arise from reasoning  No logical sequence  Hard to turn off  May be hard to articulate Core Beliefs Core beliefs underlie and produce automatic thoughts. These assumptions influence information processing and organize understanding about ourselves, others, and the future. These core beliefs remain dormant until activated by stress or negative life events. Categories of core beliefs (helpless, worthless, unlovable) Hard to change, but at least can teach to distance from them CT: show the client that he is processing thoughts in a bad way Examples of Core Beliefs Helpless core beliefs  I am inadequate,  I am powerless,  I am vulnerable  I am a failure very easy to get depressed Unlovable core beliefs  I will be rejected or abandoned,  I am ugly,  I am different, Worthless core beliefs  I am worthless,  I am hurtful,  I don’t deserve to live Cognitive Conceptualization Compensatory Strategies: Eg people who believe they are failures will try hard to show everybody that they are not (eg people pleasing) ⇨​ This is the most popular model nowadays, bc it fits our era very well- we are a lot up in our heads ⇨​ Works better for many disorders (eg many cases of Depr) ⇨​ Not enough for psychosis, eating disorders Cognitive Distortions Here we analyze the process (vs schemas the content) Some tend to make consistent errors in their thinking. Which makes the situation worse Often, there is a systematic negative bias in the cognitive processing of patients suffering from psychiatric disorders Selective abstraction - conceptualizing based on a detail Somebody who has depression. They receive praise + one small criticism they will only focus on that. Happens in many contexts: eg researchers focusing only on the results they want Overgeneralization - creating a rule based on only one (or few) incidents Incorrect assessment of danger versus safety - sensing risk as dangerously high Eg fear of flying Dichotomous (polarized) thinking - Interpreting in terms of extremes Very common to be brought up in families in which perfection was a model All-or-nothing thinking - all good or all bad Emotional reasoning - feelings are facts in psychosis, people are afraid of feelings. They believe that their emotions are real. We have to educate them on the fact that they are mental phenomena. So they pass. Magnification Minimization Eg people in manic state L07: Characteristic features of psychological help and psychological interventions used in clinical psychology. LECTURE OVERVIEW helping relationship - its elements and determinants (stages of change, ethics) common factors of psychotherapy associated with positive outcome the role of clinical assessment in providing effective psychological help We will be able to provide PSYCHOLOGICAL HELP (evidence-based), not just psychotherapy (in PL anyone can provide it) Who is Helping? friends  family members  role model  priest  couch  fortune-teller  psychiatrist  psychologist Psychological Helping Relationship - Elements and Determinants 1.​ Taking into account social and cultural criteria ​ in the assessment of mental health/disorders​ [already covered] Concepts: norm, moral misconduct, maladaptive functioning vs. mental disorder vs. mental "illness". Not everybody coming will have a mental disorder, or abnormality (think artists), some are just unique Up to us to assess whether they have a mental disorder other example: mother neglecting children = low in psychopathology ,low in wellbeing => maladaptation, but not mental disorder. Can benefit from social skills training 2.​ Recognizing psychological disturbances for the purposes of receiving specialized help When we do assessment, we also consider their resources and context. Can they use psychotherapy?​ 3.​ Understanding human behavior instead of judging it morally. Concepts: empathy [think how hard it is to be empathic towards a narcissist], unconditional acceptance, "being on the client's side", psychopathological symptom, its function and psychological mechanism.​ [Unconditional positive regard as a basis for all types of psych help] But report to police if there is a direct threat (eg mass murderer) 4.​ Treating difficulties as a problem to be solved and a starting point for a beneficial life change. Concepts: post-traumatic growth, personal development, personality and social resources, mental strength, social support. There is always a possibility fro change, even if not for cure (eg improve thinking, feeling) 5.​ Restraint towards atypical behaviors, deviating from common patterns of functioning. Concepts: individual autonomy, client's good and rights, therapeutic contract. 6.​ Following the code of ethics and following the rules of mental hygiene. (eg what to do with a client who sells heroine to a lot of people) https://www.apa.org/ethics/code Ethical Essentials Confidentiality (Vegas rule, unless you do supervision with a supervisor + serious life threat to client or others) and informed consent  Multiple roles (AVOID. Clients should only be clients: no friends, relatives… we should only assess what is in the office. Any type of emotional contact typically disrupts the therapeutic alliance)  Client harm: sexual abuse of therapy clients. [you become center of attention. Easily target of romantic emotions]. 2-5 years (APA) of no contact before entering a relationship with patient, otherwise it is sexual abuse no matter what happens.  Competence Additional ethical issues in 10-15 years we will have to update a lot our knowledge CRITERIA FOR RECEIVING PSYCHOLOGICAL HELP Often people do not get better bc they shouldn’t have received it. They are not suitable (eg not ready) a. Subjective experience of the problem b. Psychological nature of the problem c. The right motivation d. No contraindications to receive psychological help (e.g. no intoxication) A) Subjective Experience of the Problem 4 criteria must be meet, in order to provide therapy: 1.​ The client must express concern about his own or others' behavior, feelings or thoughts. eg often problem with addiction: people don’t see it as a problem => we can’t help them OFTEN THE PROBLEM THAT CLIENTS SEE IS NOT THE ONE WE WILL WORK ON 2.​ The client's behavior, thoughts or feelings must be described as: disturbed (unusual, inappropriate, abnormal) or not safe (causing suffering) or harmful (potentially or directly) to the client or others who display them. “there is something wrong with… /something within me”​ 3.​ The client must admit that he made an intentional effort to change or inhibit a given behavior, thoughts or feelings, but it did not bring the expected effect. Even talking. Some therapists don’t talk until the client makes the decision to. ​ See good will hunting (humanistic approach) 4.​ As a result of the lack of positive results of own efforts aimed at overcoming the undesirable behavior, the client asks for help. B) Psychological Nature of the Problem The problem needs to be psychological Often a non-psychological problem causes psychological disturbances. Can be a medical problem (eg thyroid hormones), or a social one The problem concerns the client or people directly related to him (not, for example, the president or prime minister, but client’s brother or partner). The client has some influence on the problem (e.g. heavy autism – no ability to make changes, sometimes only the parents can be helped; his difficulty in managing home budget but not the tax system in Poland) The problem lies in the competences of a psychologist ​ (giving support in finding yourself in a new life situation but not cancer treatment) C) The Right Motivation Internal or external motivation  Why did the person decide to come?  Why the person is coming right now? Internally motivated people will get better quicker We should help exterjnally motivated patients find an internal motivation and change to it How severe the problem is?  Severity in terms of: how annoying/worrisome/troublesome it is? Eg someone addicted to cocaine for years. Will probably not be able to overcome it alone In cases like this we offer treatment in institutions/facilities. Who is affected by the problem? Quite important: very rarely we see someon with a personality D will come wanting to get better. But if they are parents of eg suicidal children, they would be motivated to work on themselves to help children. D) Contraindications to Receive Psychological Help  "Suicidal" thoughts and /or tendencies  Is somebody is really suicidal, this is not the moment for therapy, but for facility.  Possibility of neurological disorders Eg depression as a symptom of Parkinsons, or side effect of drugs need to have basic knowledge not only of cli psych  Disturbances of consciousness acute psychosis, intoxication. Wait or give pharmacotherapy  Strong psychopathological symptoms [eg some people are so stressed they cannot think about their thoughts] Start with pharmacotherapy.  Physical exhaustion/cachexia  Low level of intellectual functioning Behavioral intervation on things aroud them, not within them. Or pharmachotherapy STAGES OF CHANGE Remember this model. Very useful in psychology, not only clinical Stages in our mind that produce change Precontemplation (Denial)  “What problem? I’m not thinking about it.” [not freudian: I see the problem, but it is not mine]​ Impossible to help people in this phase​ Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not ready to decide anything yet.” We don’t know if treatment will be helpful in this stage. Preparation / Determination (Admission)  “I have a problem.” Best stage to start treatment. People need to be ready for change Action (Taking steps / Making changes)  “I have a problem and I’m ready to do something about it.” High possibility to help Maintenance (Continuing what works)  “I’m stabilized and doing well. How can I support my ongoing recovery?” Relapse / Recycle (Trying again)  “I’m stabilized but have relapsed. How can I get back into active recovery?” LEVEL OF READINESS. Openness is positively associated with readiness for psychotherapy They are able to learn new ways of behavior. Perseverance => same ability to cope with levels of dissatisfaction Some people who are very susceptible to get max stressed out ​ Teach slowly how to tolerate distress. Eg DBT for people with BPD.. Disinterest => negatively associated People who are not mindful, or not have a theory of mind (only see behaaviors, not thoughts, including all the psychologist says). Distress => best if high but not severe WHAT WORKS IN THERAPY? In one of a number of major reviews, Wampold identifies the following factors that affect outcomes:  General effects - common factors that underlie all psychotherapies: 70 per cent  Specific effects – that is particular aspects linked to a specific model: 8 per cent. In other words, the model practised counts for only 8% towards positive outcome in therapy.  Unexplained variability – most likely linked to client differences: 22 per cent. Wampold BE. (2001). The great psychotherapy debate. New Jersey: Lawrence Erlbaum “The relationship is the most significant in- therapy factor as related to positive outcomes.” Paul, S and Haugh S (2008) The Relationship not the Therapy? In S Haugh and S Paul, The Therapeutic Relationship: Perspectives and Themes Ross-on-Wye: PCCS Books. Common Factors in Psychotherapy Associated with Positive Outcome Common factors: shared, fundamental elements of therapy (rather than specific techniques) are “active ingredients”  therapeutic relationship/alliance,  instillation of hope,  attention  corrective experience,  opportunity for catharsis,  practicing new behaviors Three-stage sequential model of common factors: ​ support, learning, action factors (in that sequence)  Support factors: a strong therapist-client relationship, therapist warmth and acceptance, trust  Learning factors: changing expectations about oneself, changes in thought patterns, corrective emotional experiences, new insights Action factors: taking risks, facing fears, practicing and mastering new behaviors, working through problems Therapeutic Factors in Group Therapy Instillation of hope  Universality  Imparting information  Altruism  Corrective recapitulation of the primary family group  Development of socializing techniques  Imitative behavior  Interpersonal learning  Group cohesiveness  Catharsis  Existential factors L08-09: Types of psychological help available in solving various psychological and health problems. LECTURE OVERVIEW Variety of professional activities of clinical psychologist due to the purpose of help (psychoeducation, prevention, promotion, counselling, crisis intervention, psychotherapy) psychotherapy theories and approaches (readings). Psychotherapy is just one way in which psychologists work TYPES OF PSYCHOLOGICAL HELP Prevention  Promotion  Psychoeducation  Counseling  Psychotherapy  Crisis intervention Often all these are not included in textbooks. You can specialize in any of these Starting with psychoeducation is the best before becoming a clinpsych. Can start even after BA. Different types of psychological help in health care system 1.​ Health promotion – what we should ideally start with: emotional int, resilience, work-life balance (think youtubers, influencers). NO concern with risks, pathologies 2.​ Prevention – we do not only focus on how to improve people’s wellbeing. Some groups of people may be exposed to risk factors 3.​ Treatment 4.​ Aftertreatment procedures (relapse`s prevention) – very important when working with people with addictions. Relapse is a part of addiction – we try to make them rarer and shorter HEALTH PROMOTION Aim: improve overall wellbeing; encourage and increase protective mental health factors and healthy behaviors that help prevent the onset of various disorders; Protective mental health factors: resilience (we can teach how to react best when problems appear), emotional intelligence (esp being able to recognize emotions), effective coping strategies We also teach how to create social networks​  ie. creating living conditions and environments that support mental health and allow people to adopt and maintain healthy lifestyles.  Recipients: various groups: may be delivered where people live, work, learn, and thrive. Specific features: school and workplace mental health programs, early childhood interventions, social support and community engagement, women empowerment, anti-discrimination programs PREVENTION Aim: prevent problems (disturbances, dysfunctions, disorders) before they occur. e.g. people who just lost someone, or who are taking care of a sick relative, or parents who don’t have skills or situation to take care of children the best  prevention – conscious action aimed to keep something from happening. (we will talk more about it in the Health Psych section) Recipients: depending of the type of prevention it can be addressed to the whole population, those at risk of developing problems/disorders or those, who already suffer from mental disorders [relapse prevention]. -​ Psych students are considered to be an at risk population: (1) some of them have mental health problems themselves [masha linehan had very severe BPD]; (2) commonly self-diagnose; (3) generally more emotionally sensitive -​ Specific features: requires not only knowledge from clinical psychology but also social psychology (social influence, groups, stereotypes etc.). Makes use of psychoeducation, skills training and raising awareness. Prevention efforts vary also based on the level of intensity and development phase they target. PSYCHOEDUCATION Broad term. Can be intended as part of psychotherapy. In this case, we are referring to PE strict – as a separate activity Aim: providing knowledge, skills and experience in order to improve coping with difficulties, emotions and relationships. -​ Restricted to specific topics (eg sex education, emotional intelligence Recipients: mainly healthy individuals or targeted clinical population. Even e.g. teachers Specific features: used in health promotion, prevention and treatment of patients with mental disorders. Programs for targeted clinical populations -​ improves knowledge about mental illness/coping with stress/healthy behaviors/parental skills (eg tara foundaaìtion in ny - target personality disorders, also with PE for relatives; also psychoeducate patients what to expect from a condition -​ behavioral tailoring improves medication adherence as prescribed: we also teach pts how to take their medicines, avoid withdrawal from treatment protocol -​ relapse prevention reduces rates of symptom relapses and rehospitalizations: eg alcoholics; -​ cognitive-behavioral coping skills training (alone, without psychotherapy) reduces the severity and distress of persistent symptoms -​ Social skills training (SST) for psychotic patients – with an aim of acquisition and utilization of social. Big interest now in Poland esp for autistic + adolescents skills. -​ Improves social functioning  -​ Reduces relapse rates and hospitalization Assertiveness training – not necessary for clinical populations, for all who have trouble expressing their opinions. COUNSELING OR PSYCHOTHERAPY More advanced forms of psych help. Nowadays many say “psychological intervention(?)” instead of pt not to confuse with other professionals offering psych help In PL, as well as in many other european countries, there is no such distinction Clinical psychologists and counseling psychologists both treat wide variety of mental and emotional problems. -​ Counseling psychologists typically focus on individuals whose symptoms are less severe, such as those coping with everyday stresses and adjusting to life’s rollercoaster ride. -​ Clinical psychologists often treat patients with more serious symptoms and disorders. [first choice for people with diagnosed disorders]. In theory, if you don’t have a mental health disorder, it is better to go to counseling. In counseling, we expect people to get well faster. We assume they have good psychological abilities and protective factors. Coaching is not psychology (in theory) E.g. Paul going to a counselor => midlife crisis Adolescent => identity formation problem (coaches don’t know this differences) -​ In both the same techniques may be used, but in each psychologist should have different assumptions about abilities of the client/patient. COUNSELING Aim: facilitating reflection about oneself and one’s problems in order to take the responsibility for one’s lives and effectively manage one’s development. -​ Eg children when parents divorce -​ International students when they struggle to adapt Recipients: healthy individuals in times of developmental crises and experiencing troubles with adjustment. Specific features: the most common form of psychological help, diagnostic consultation, "short-term psychotherapy.” Life/professional coaching - training systems developed in order to support people and organizations in achieve their goals. Form of counseling performed by psychologists PSYCHOTHERAPY Aim: treatment of mental disorders, recognized as specific syndromes. That’s why it was created, not to help people with their everyday problem IN theory, it is a mistake that everyone has their psychotherappist. Healthy people use mature defense mechanisms. Have some incongruence Unhealthy people don’t. Often no congruence at all Recipients: individuals with symptoms of mental disorders. Specific features: primary aka first-choice treatement (eg. in the case of neurotic syndromes eg anxiety, we know we can help them) or complementary (eg. in the case of psychosis) method of treatment for mental disorders. We differentiate:​ Insight therapies (talk therapies) and behavioral therapies (changing overt behavior) browse the readings – questions in exam Therapeutic approaches are related to the main theoretical perspectives and beliefs about root of behavior. Different Kinds of Psychotherapy A lot of them have not been scientifically examined Some are known to be best for specific conditions -​ E.g. DBT is the best for BPD Check this https://div12.org/treatments/ CRISIS INTERVENTION A specific specialization. Intensive programs but short in duration Aim: supporting people so that they regain the ability to independently solve the crisis. Traumatic crises, like erthquakes, car accidents… not midlife crisis Recipients: healthy individuals experiencing severe or profound crisis. People in times of peak emotional tension Specific features: in times of high emotional tension, fear, sense of loss of control and helplessness, and when disorganized behavior and somatic symptoms appear. Debriefing - intervention (partly Psychoeducation on eg how to not get overwhelmed by very intense emotions) oriented to minimize the risk of PTSD as a result of experienced trauma. Understanding the needs of the other person as a basis for effective help factors affecting the current needs of the people: gender, personality, temperament stages of life, life situation, cultural background. E.g. a typical man, to feel that therapy works, they need to learn to use tools that make a practical difference in their lifes. Tasks. Not much interest in the roots of stuff… Behavioral treatemtn is best Typical woman needs support, someone that listens and allows to voice opinions… Humanistic treatment is preferred E.g. Openness to experience Very high more ease to answer questions, investigating. Can try different imaginative techniques Very low Harder to use imaginative techniques; better to use more traditiional approaches. More difficult to change their thinking, will take more time Introversion large groups would be very hard for them to benefit from Temperament: Highly reactive people will be harder to learn and implement better management of emotions. Most of BPD patients are highly reactive from a temperamental pov Very low reactivity easier to regulate their emotions Stages of life: Somethings that are irrelevant for an 18 y.o. can be very important for a 30 y.o. Situation: cannot offer intensive psychotherapy if they don’t have money, even if it would be the best matching the type of support provided to the properties of the individual and the situation he/she is in. the relationship between the desired support and the support delivered. We should ask people what they want. High percentage of dropout in psychotherapy FORMATS OF PSYCHOTHERAPY The most common is Individual Therapy -​ Couples/marital psyther is becoming very important as well. role of mediators, translator very demanded Family (and Couples) Therapy It originated as a therapy for treating mental disorders ​ See mental disorders Aim: ultimate: treatment of mental disorders, dealing with wide variety of psychological problems direct: nurturing change and development in families [where possible] and couples [typically the aim is to improve communication & solve problems], ​ who undergo crisis by improving the communication and solving family problems. Very useful for Eating disorders, anxiety & ocd & depression in adolescents. Shown in research (more limited than for cbt tho)​ THE CONCERN IS NOT ON ANY INDIVIDUAL, but on the PROCESSES, INTERACTIONS. ​ We never advocate for one over the other. Never blame ⇨​ Focus on ROLES in the families Recipients: families of individuals suffering from mental disorders or experiencing psychological problems; couples in crisis. Specific features: effective intervention requires a change of interaction(s) between family members. Mental disorders understood as playing a particular function for the whole family system (identified patient). Family Therapy: The System as the Problem  When the family therapy movement initially arose in the mid-1900s, it was considered revolutionary  Psychological symptoms as a byproduct of dysfunctional families  One individual may exhibit symptoms [“identified patient”], but the problem belongs to the entire system  Circular causality—events influence each other reciprocally ​ As opposed to linear causality, which is endorsed by individual therapists [as seen so far] Can use Miracle Q: ask each family member: if tmr morning all problems disappeared, what would be the first thing you notices (eg mother saying husband would hug her, husband saying she would say he’s doing his best, son saying he would go do sth with father)  Focus on functionalism of symptoms ​ Within family, symptoms may be adaptive ​ Eg child having panic attacks to make parents stop arguing ​ A lot of disorders, esp when developed in anorexia, serve purpose of joining all family members into sth ​ Symptoms that children bear seve the purpose of keeping the family together Family Life Cycle: developmental theory for families, including seven stages​ Every family undergoes them. Most divorces happen in the first 2-3 years. ​ It’s normal: very difficult stage 1.​ Leaving home: young adults. Very difficult moment for parents. They need to renegotiate their relationship 2.​ Joining of families through marriage or union. A lot of problems after the honeymoon experience. Difficult to merge families with different styles of being, communicating. Effort to create common rules  3.​ Families with young children. Often when men have affairs due to receiving diminished attention. Also, new responsibility to divide. 4.​ Families with adolescents. Often need to argue with parents, show difference, independent. Normal that children become more and more distant from the family- Paul was someone who could not experience his own identity in this period. Could not fight for his independence 5.​ Launching children and moving on in midlife. ​ Emptiness syndrome A lot of anorexias develop between 4 and 5, to prevent separation “triangulation”: when children become emotionally involved in marital problems. Usually alliance of same-sex dyad vs the other​ All of them should take part in the therapy sessions. Everybody should understand the reciprocality. The boy also needs to change. Family dynamics are easy to recognise even in studio. Not accepted for therapist to go live with them​ 6.​ Families in late middle age 7.​ Families nearing the end of life GROUP THERAPY We hear very little of it. However, looking at the “age of loneliness” situation. This is the one we will probably need the most. People are losing social abilities, and belief that relations can make you feel better Usually 7 group members Aim: several clients meet regularly with one or more therapists to resolve problems of (inter)personal nature.​  Based on the notion that: 1.​ learning that others also share their problems leaves people feeling less alone and ashamed; (which is often what prevents us from talking about our problems) 2.​ others may provide useful feedback (if its quality is controlled by the therapist: a contract is established, people are taught how to do feedback Eg “I” communication, FBI, constructive criticism, receiving praise); 3.​ we can model certain behaviors in groups more easily; 4.​ group constitutes a good place for practicing new behaviors and acquiring social skills.  A variant of group therapy is a self-help group.  Self-help groups usually are not led by professional therapists - they are simply groups of people who share a common problem and meet to give and receive support. They are much closer to each other [in Group Therapy strict, participants are actually forbidden to meet outside of therapy (would be much more difficult for therapist to keep track of what happens] Group Therapy: an Interpersonal Emphasis Most forms of group therapy strongly emphasize interpersonal interaction  Take advantage of the fact that the group therapy experience itself is based on interacting with other people  Irvin Yalom is a leader in this interpersonal approach to group therapy -​ Clients’ problems stem from flawed interpersonal relationship skills -​ If they can practice and improve on this with fellow group members, they can generalize lessons learned [overall functioning will improve]. Also, SP research shows that having people around makes our problems less intense. Therapeutic Factors in Group Therapy Instillation of hope as a group therapist, you quickly learn how to paraphrase negative comments into common goals Universality -when we sit alone with our problems we become more and more egocentric -Clients realize that others share the same struggles (i.e., “We’re all in the same boat”)  Especially powerful in homogeneous groups Imparting information Altruism -​ Contrasts the problem of thinking that when we feel bad we need a therapist for ouselves Development of socializing techniques -​ Great benefit of having 2 therapists conducting sessions. When they disagree withoug quarreling that’s a great example for participants Imitative behavior -​ People in the groups start to create their own kind of learning Interpersonal learning The same interpersonal tendencies that contributed to the client’s problems will appear in the group context  Group members form relationships with each other and work to improve them, and those improvements will help with outside relationships eventually 