PSY_339_Midterm_Reveiw.pdf

Review MIDTER M I Which of the following best describes psychotherapy? a. Informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions...

Review MIDTER M I Which of the following best describes psychotherapy? a. Informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable. b. Two people connecting on a deep level through dialogue about life's truths and meaningful events. c. A healing practice based on mutual trust and human interaction that occurs in an unstructured, safe, environment.  “Healing practice based on verbal persuasion and human interaction that occurs in a social context”. (Wampold, 2014) What is “Psychotherapy is the informed and intentional Psychotherapy? application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable" (Norcross, 1990, p. 218- 220 ); Takes place one-on-one with a licensed mental health professional or with other patients in a group setting. Which of the following is something that a psychotherapist would do under their scope of practice? a. Conduct patient assessments b. Treat patients with psychotherapeutic approaches c. Monitor patient outcomes d. All the above  a. Psychiatrists b. Psychologists Which of the c. Licensed Mental Health following can Counselors conduct d. Licensed Clinical Social psychotherapy? Workers e. All the above  Is Psychotherapy effective? YES! It’s demonstrated effective in randomized trials. Practicing therapists using structured and cogent approaches get outcomes similar to randomized clinical trials for medical interventions. Research suggests it’s as effective as medication-and it’s longer lasting. It’s highly cost-effective, longer lasting. Results persist because you learned something. Individuals who receive treatment for a presenting problem do significantly better than those who do not. The APA considers psychotherapy “an established evidence- based practice”. Is Psychotherapy Effective? The findings of individual studies have been quantified in meta-analytic research using effect size as the metric. (The difference between the mean of the tx and control groups) Different meta-analyses report different effect sizes Average for psychotherapy is.6 This is more effective than some evidenced- based medical interventions. Research suggests therapy can increase the efficacy of a pharmaceutical intervention. NNT The reciprocal/inverse of the Absolute Risk Reduction (ARR). The ARR is calculated by subtracting a post-treatment measurement of disease severity in the treatment group from measured disease severity in the comparison group. ARR = disease severity in the control group – disease severity in the treatment group NNT= 1/ARR Example: In a pharmaceutical clinical trial with a response rate in the treatment group of 50%, and the response rate in the placebo group of 35% NNT= 1/(0.5-0.35)=6.67 or 7 The NNT for psychotherapy is 3, which is considered good! 1/.15 For every 3 patients seen in psychotherapy, 1 has a better outcome than if they didn’t come to therapy.  Is One Treatment Approach More Effective Than Another? It is important to understand that debates still exist in the field. No, if core components are present. Yes, you must add the active ingredient based in Dodo Bird Debate- Most major schools of evidence. psychotherapy have similar effects if core ❖ You can have these core components, but also components of the therapeutic alliance are must include what has been shown effective present. depending upon what the patient is presenting Beutler says the Dodo bird is extinct- because of with. other factors must be taken into consideration, principles that govern the interaction, not ❖ You cannot treat Bipolar disorder and PTSD with because different approaches are more effective. the same therapy. The core components can be Common factors in treatment and principles of there, however, adding EBT is imperative for change. results. Same technique is applied differently between therapists. Psychotherapy is more than just the ❖ There are some interventions that work better intervention. than others. Studies are all based on ROC’’s. Love is in treatment with Dr. Springer for relationship difficulties with her husband Joe. Love has personality Dr. Springer characteristics of someone with narcissistic personality better watch disorder; however, doesn’t meet the DSM 5 tr criteria. Dr. his step. Springer is becoming frustrated with Love because she isn’t doing her homework and appears disinterested in his suggestions during sessions. What is most likely the problem in this scenario? a. Dr. Springer is being directive with a patient that has personality characteristics that don’t align well with this type of approach. b. Dr. Springer is not using reflective listening with Love, leading her to lose interest in the sessions. c. Dr. Springer isn’t challenging Love enough, which isn’t stimulating to someone with NPD characteristics. Hence, she is losing interest. Developing a Treatment Plan for Psychotherapy TX Plan : Addresses the problems identified in the case conceptualization: How the therapist makes sense of the patient’s presenting problems using a theoretical framework. There are many different approaches to treating patient problems. The therapist synthesizes many pieces of information into a well‐developed, coherent narrative. This narrative should identify the precipitating cause of the The goal of the therapist is how they are patient’s problems and the internal and external forces that going to help THIS patient. feed it.  Clinical Treatment Plan Components (Based on the case conceptualization/formulation for presenting problems) Establishing a Therapeutic Relationship Identifying Goals & Creating Objectives Understanding Patient Expectations and Perspectives Interventions *Hospital psychiatric setting TX plans differ in that they are more medical/symptom- based. Theory and comprehensive conceptualization is typically not done. Some therapists give the Would you patient the C-NIP, this: answer these What the heck is a C- NIP? questions on the C-NIP? a. Measures progress in treatment. b. Measures time spent on therapeutic applications outside of the session. c. Measures patient preferences regarding therapy and therapist characteristics.  Clinical Treatment Plan Components Understanding Patient Expectations and Perspectives Before deciding on the intervention. This has been shown to be important for patient outcomes. Some therapists give the patient the C-NIP, a brief measure of patient preferences, and then adapt TX accordingly. Therapist Directiveness Versus Client Directiveness, Emotional Intensity Versus Emotional Reserve Past Orientation Versus Present Orientation Warm Support Versus Focused Challenge. Patients who receive their preferences, report higher satisfaction and have lower dropout rates.  There are different subtypes of psychodynamic psychotherapy. Psychoanalysis Ego psychology Object-relations theories Interpersonal analysis Self-psychology Relational and intersubjectivity Psychodynamic Brief psychodynamic approach that encompasses treatments that operate on a It began with Freudian psychoanalysis and the theory of the unconscious. continuum of supportive and It can be short or long term. interpretive interventions. Traditional psychoanalysis was long-term and intensive, with multiple weekly sessions.  Psychodynamic- mind in motion. Concepts: Intrapsychic/Unconscious conflicts (particularly ones that involve sexual and aggressive urges in psychoanalysis) Ego Defenses Transference Affect Phobia Psychodynamic Basic goals : 1. Understand elements of the patient’s unconscious that are affecting their conscious thoughts, feelings, and behavior 2. Decide whether uncovering or supporting will help most at that moment 3. Uncover unconscious material or support mental functioning in the way that will best help the patient  Unconscious conflicts are the core of psychopathology. During the intake the therapist searches for these conflicts and unresolved issues from development. Psychodynamic During therapy, looking at these aspects of the patient, even Model of the if they aren’t aware of them. Psyche They sometimes are manifested and potentially influenced in the therapy relationship. Projective tests, used in psychodynamic therapy, primarily involve presenting patients with ambiguous stimuli and asking for responses, to uncover unconscious thoughts and feelings. a. TRUE b. FALSE  Projective Tests Basic assumption of all projective tests: People project their own internal dispositions into their responses to ambiguous stimulus. Projective techniques are used mainly in an intuitive and clinical fashion by more psychodynamically-oriented therapists. The Rorschach Test (1911) Person is shown cards depicting inkblots and asked to describe what they look like. The Thematic Apperception Test (1935). Pictures of varying degrees of ambiguity about which the person is asked to make up stories.  Psychodynamic therapy is about… Focusing on patient’s affective state. Identifying and patient’s use of ego defenses. Identifying patterns in relationships, behaviors, perceptions and themes that underlie these. (explore past) Examining interpersonal relationships. Focusing on the way the patient relates to you as a therapist. (Including transference). Listening to the patients’ dreams and fantasies. Providing support, interpretations and promoting insight.  Focus: Affective State of the Patient Do they have an Affect Phobia- the idea is that the maladaptive learned emotion that can be unlearned through the relationship with the therapist. The patient is said to have a phobic response to the emotion, it causes anxiety, disgust or discomfort so they pull back and this leads to a defense. This develops during childhood. The family system or culture of the patient doesn’t accept this emotional reaction; therefore, the patient learns to bury it. The learning component is like Behavioral Models that we will cover in the course.  Focus: Use of Ego Defenses The therapist looks for signs that defenses are being used. Missing sessions, changing the subject, arriving late, joking a lot. Focusing on aspects of a situation being discussed that aren’t related to emotion or their psychological state. Object-Relations Widely used psychodynamic approach. Focus: relationship between self and others. The mental representations we have of our parents/caregivers.. Attachment (determines the way we view and relate to other people). Remember: If the attachment process is healthy, we internalize the caregiver, and feel okay separating and being autonomous, without an empty feeling. It negates a void or feeling of loneliness. Think about this concept and how it could relate to psychopathology? Contact-connection and disruptions- Unstable sense of self, and problems in cause trauma in early childhood while the relationships. self is still forming. Identity Disturbance. Change Mechanisms. The Quality Of Object-relations: The capacity to understand and interpret the thoughts and emotions of oneself and others, utilizing this insight to clarify and influence interpersonal interactions Hallmarks of Good QOR: Long-standing, satisfying interpersonal relationships. The ability to form a strong emotional bond with the therapist Ability to examine and grow from the strains that emerge in a relationship.  Experience through which one comes to understand an Goal: event or relationship in a different or unexpected way that results in an emotional “coming to terms with it”. Corrective Emotional Patients achieve meaningful and lasting change through new interpersonal affective experiences with the therapist, Experience particularly with regard to situations that clients were unable to master as children APA.org  Corrective Emotional Experience: How? Within the relationship, the therapist must respond differently Re-expose the to the patient than Dissipation of Repair the traumatic Then they abandon patient to emotional the original caregiver pathology (anxiety, influence of previous their maladaptive situations buried did, and the patient depression, experiences. view under defenses. gains insight by substance abuse etc.) recognizing that all relationships don’t have to negative emotionality.  Case Conceptualization: Psychodynamic Freud's original recommendation for OCD patients was to expose them to the anxiety provoking situation and to use this to work on the unconscious conflict. Similar to exposure therapy. (CBT/BT) Example: “When you have these feelings of contamination, what are you blocking by carrying out your rituals?” “Can you remember a time in your life where you had similar feelings of disgust?” “What would it be like if you couldn’t clean yourself after going to the bathroom?” What else would a psychodynamic therapist work on with this patient?  Freud (1909) wrote that obsessional neurosis may be created when there is a split between love and hatred from a very early age in a person's erotic life His or her sadism “is able to persist, and even grow” because it Psychodynamic remains apart from consciousness and apart from love (which also Conceptualization grows to keep the hatred repressed). Is this a deployed maladaptive defense mechanism? Humanistic Approaches  Humanistic Approach ‘Human nature is not nearly as bad as it has been thought to be … It is as if Freud supplied us with the sick half of psychology and we must now fill it out with the healthy half.’ Maslow (1968, p. 10) Humanistic Approach A new view of human beings and approach to psychological therapy. Human beings are generallyy “good”. Maslow and Rogers two key figures in the development. Types of Humanistic Psychotherapy Person-centered - Carl Rogers Gestalt -Fritz Perls Transactional analysis -Eric Berne Humanistic Approach Maslow's notion of self-actualization played a significant role in influencing the development of broader concepts within humanistic psychology and subsequently in the field of psychotherapy. Hierarchy of Needs What is this?  Self-Actualization Deep understanding of one's values, self-acceptance, and a sense of purpose and meaning in life. Characterized by qualities such as authenticity, autonomy, creativity, and a strong sense of personal fulfillment and well-being. A continuous journey, and individuals may progress toward it throughout their lives. Person/Client-Centered Three philosophical beliefs: Humanism Self actualization is possible. We strive for this. Existentialism We have free will and make choices based on our experiences. Phenomenology There is no one, single reality but rather reality is constructed through our own individual experience.  Key Theoretical Principles The human personality is positive Psychological disorders are from low self esteem and inability to be one's authentic self. Conditions of Worth We all have unique experiences and perceptions All can become a fully-functioning person Incongruence-Mismatch between who they are and who they would like to be. Self Actualization/Actualizing Tendency Carl Rogers’ Six Necessary And Sufficient Conditions For Positive Change 3. The therapist 2. The patient is in a state 1. That two persons are is congruent in the of incongruence, in contact. relationship.(Open, genuine, being vulnerable or anxious. transparent) 5. The therapist is 4. The therapist is experiencing an empathic experiencing unconditional 6. The patient perceives understanding of the positive regard towards the conditions 4 and 5. patient’s internal frame of patient reference.  Congruence Incongruent Congruent Self-Actualization is possible. Ideal Self Perceived Self Ideal Self Perceived Self Jane Jane, a 32-year-old woman, seeks therapy with Dr. Adams, a clinical psychologist, because she is struggling with low self-esteem and a pervasive feeling of inadequacy. She often experiences anxiety and depression, which she believes stem from her childhood experiences of never feeling "good enough" in her parents' eyes. Jane In therapy, Dr. Adams notices that Jane exhibits signs of "conditions of worth," a concept from humanistic psychology. Conditions of worth are external standards or expectations that individuals believe they must meet to gain approval, love, or acceptance from others. Jane feels she can only earn her parents' love and approval by achieving high academic and career success, which has led to chronic stress and dissatisfaction.  Conditions of Worth Criteria that individuals believe they must meet in order to be valued, accepted, or loved by others, including the therapist. Can hinder personal growth and self- acceptance by denying or distorting their own needs to fit this framework. What are some conditions of worth? I will only be loved if I…. I am not successful unless… I am not a good person unless….  Patient Growth in Humanistic Psychotherapy The therapist must: Experience and communicate unconditional positive regard for the patient. There are no conditions of worth. They must be non-judgmental. Genuine (congruence). Actively listen. Reflect and Paraphrase Consistent across sessions. Achieve relational depth. Be non-directive. This provides an environment for the person to self- actualize and become their true, authentic self. Relational Depth As a deep and meaningful connection between therapist and patient. The therapist consistently maintains elevated levels of empathy and acceptance for the patient, fostering a transparent and open interaction. This could describe a moment or relationship. The Fully-Functioning Person: Reached or very close to Self- Actualization Is open to their experience without defenses. Has a self-structure that is congruent with their experience. Possesses no “conditions of worth”. unconditional self-regard. Meets situations with behavior which is a unique and creative adaption to the newness of that moment. Is free of distortions, and unconscious conflicts. Confidentiality and Agenda  Talena, a therapist, is counseling Jessie, who has been struggling with severe depression and recently expressed thoughts of self-harm. Jessie has a history of suicide attempts and believes his current thoughts are genuine and he may act on them. How should Talena proceed? a. Talena must respect patient confidentiality and not intervene unless Jessie explicitly asks for help. b. Talena should recommend self-help books to Jessie and encourage him to manage his thoughts of hurting himself. c. Talena should assess the severity of the threat and, if necessary, warn appropriate individuals to ensure Jessie’s safety.  Confidentiality Fundamental ethical and legal principle in psychotherapy and mental health treatment. Therapist's obligation to protect the privacy of the patient and keep their personal information and therapeutic interactions confidential. They cannot disclose any information shared by the client during therapy sessions without the client's explicit consent, except in specific situations outlined by law.  John John, has been attending therapy sessions with a psychologist for several months to address issues related to anger management and past traumas. During a particularly intense session, John reveals that he committed a murder in the past, providing detailed information about the victim and the circumstances surrounding the crime. John indicates remorse and guilt for this action but has not disclosed this information to anyone else. Does the therapist break confidentiality?  1.Assessment of Risk Breaking Confidentiality May Involve The Following 2.Informing the Patient Steps: 3.Involving Appropriate Authorities 4.Notifying Others (If appropriate) 5.Documenting the Situation  Duty to Warn August 1969- Prosenjit Poddar, a student at UC Berkeley met Tatiana Tarasoff at a dance and was infatuated with her. They dated for a few weeks, and she broke it off. October 1969: Prosenjit begins therapy sessions with psychologist Dr. Lawrence Moore at the university's student health service. May 1970 Poddar confides in Dr. Moore about his intent to kill Tatiana. He notifies university police and hospitalizes Poddar with a Dx of paranoid schizophrenia. Tatiana was not notified of this threat, nor were her parents. June 4, 1970: Tragically, Poddar carries out his threat and murders Tatiana Tarasoff at her home. The Tarasoff family sues the Regents of the University of California, alleging that Dr. Moore and the university failed to warn Tatiana of the danger she faced. The court ruled the doctor didn’t have to disclose this; his duty was to his patient. Appealed and reaches the California Supreme Court. The court rules that mental health professionals have a "duty to protect" potential victims when they know or reasonably should have known that their client poses a serious risk of harm. Duty to Warn 1.Credible and Imminent Threat: Therapist has reasonable grounds to believe that the client presents a credible and imminent threat to harm a specific individual or individuals. 2.Warning Potential Victims: Therapists are required to take steps to warn the potential victims or authorities. 3.Originates from a legal case in the United States known as Tarasoff v. Regents of the University of California (1976).  So, when do we break confidentiality? Imminent Risk of Harm to Self: If a patient expresses a clear and immediate intent to harm themselves (e.g., suicidal ideation with a specific plan and means). Imminent Risk of Harm to Others: Duty to Warn Child or Elder Abuse: Therapists are mandated reporters. In response to a court order or subpoena.  At the same time in another role in the patient’s life. Ethical Behavior: Relationship with someone closely associated with the patient. Dual Relationships Promises the patient to have a relationship with the patient or a person close to the patient once they end treatment. I hope Sarah can meet me again tonight- the doctor is IN! Dr. Smith Dr. Smith, a licensed therapist, provided therapy to Sarah for approximately two years. During that time, Dr. Smith helped Sarah address her depression and anxiety, and their therapeutic relationship ended on good terms when Sarah felt she had achieved her therapeutic goals. Several years later, Sarah and Dr. Smith reconnect by chance at a community event. Sarah was a little tipsy and reveals she was attracted to Dr. Smith during her time in treatment. Dr. Smith asks her to go back to his place for a nightcap. They begin seeing each other for ‘nightcaps’ regularly. Is this, ok for Dr. Smith to do as her former therapist?  Romantic/Sexual Relationships with Patients Prior to engaging in a romantic and/or sexual relationship with a former patient, therapists must consider the following factors: The amount of time that has passed since counseling services terminated; (two year minimum) The nature, duration, and intensity of the counseling The circumstances of termination The patient’s current mental and emotional status This should be avoided unless unusual circumstance (profound love and attraction?)  Wait until everyone Lisa sees my pumpkin. Lisa is a psychotherapist in a Anytown USA. Every year there is a Fall Festival with games, a feast, and a pumpkin carving contest. It really brings the town folk together.  Dominick was a patient of Lisa’s for Dominick approximately two years. His I’m going to presenting problem was panic the Fall disorder with agoraphobia. When he Festival… first visited Lisa’s office, he needed Xanax to leave the house to get there. He hadn’t been out in months prior to the appointment. Lisa used behavioral therapy with Dominick, and he was able to slowly venture out into the community again. Guess where he is going this weekend? Dilemma When Lisa gets to the Fall festival, she sits down to eat, and to her surprise, Dominick is sitting at the same picknick table with friends from the community. What should she do?  She did NOT just tell everyone I had agoraphobia He literally couldn’t go ANYWHERE! A. Say hello to him as if she knows him and praise him for still being able to go outside.  She better leave this table. B. Excuse herself and move to a different table where she cannot be seen by him or leave the festival. C. Stay at the table and act as if she doesn’t know him. 61 What should Lisa do? Definitely not A or C Possibly B- Leave the table and go somewhere she isn’t seen by Dominick or leave the festival. OR- say hello and then excuse herself to a table where she cannot be seen or leave. →ONLY -If this was agreed upon while they were in treatment. Behavior Therapies  Behavior Therapies Goal: Change maladaptive behavior that is contributing to emotional/psychological distress. Cognitions are seen as the consequence of depression and will change with behavioral changes. Based on learning theories –operant & classical conditioning, social learning theory. Ex: Depression is from a behavior-environment relationship problem. Low positive reinforcement. Observed depressed individuals.  Key Characteristics in Behavior Therapy Functional Analysis- Identifies the causes and consequences of behaviors. Is the person being rewarded for a behavior? How is the behavior contributing to psychopathology? Recognizes the importance of the interaction between the person and the environment in facilitating change. Empirically Principles Evaluate Goals are specific and measurable: of Learning Intervention Patient will reach out to one person a week and Effectiveness set up a social activity for the next month. Target Date: xx/xx/xxxx  Behavioral Therapies (BT) 1. Contextual techniques based on a functional analysis of the patient. Ex: 1. Behavioral Activation Patients assume an active role in the 2. Contingency Management therapy. 3. Systematic Desensitization (Exposure) Ex: 4. Exposure and Response Prevention Learn and practice coping skills, and role- play new behavior. Homework assignments are given. 2. Psychoeducation/training to change maladaptive behaviors. Ex: 1. Social Skills Training 2. Anger Management Systematic Desensitization Seeing a clown in Holding a person. clown Video of doll. clowns. Looking at pictures Talking of clowns. about clowns. Behavioral Activation Identify and access sources of positive reinforcement to increase mood and decrease depressive symptoms. Goal is to reengage in life through focused activation strategies. Patient and therapist explore what activities used to bring them joy. Plan is developed with measurable goals. Behavioral Activation  Behavior Activation and Depression Negative Too few rewards amongst dealing with life’s many problems. Cognition People isolate and withdraw when stress builds up, causing depression and disrupting basic routines. Withdrawa l Isolation Withdrawal and isolation increase depression and make it make problem solving more difficult. Depression Identifying what activities would be most helpful and what small and manageable steps you can take to get started. Increased Positive Session time is used to discuss steps to engage in activities that improve mood and address problems Emotions Maintain activities. Symptoms Attenuate / Adequate reward from the environment maintained. Relieve  This is Is it effective? GREAT! Yes! For depression. Increases the reward seeking and reward response by increasing positive reinforcement -----> leads to learning cues that predict possible rewards in environments. Increasing activities improve self-concept, depression As effective, or more effective, than cognitive therapies Focus: prevent avoidance of cues that produce negative affect One study: aerobic exercise = Zoloft = exercise + Zoloft Exercise better at preventing relapse Exercise = increased neurogenesis in hippocampus associated with resilience to depression.