Students Clinical Psychology 2 Lectures PDF

Lecture 1 The Art of Counseling Clinical Psychology 2: Counselling and Psychotherapy Counseling as psychological guidance and help - North-American understanding: counseling = therapy - EU understanding: counselling as different forms of psychological help, incl. thera...

Lecture 1 The Art of Counseling Clinical Psychology 2: Counselling and Psychotherapy Counseling as psychological guidance and help - North-American understanding: counseling = therapy - EU understanding: counselling as different forms of psychological help, incl. therapy as one of them. Challenges — Responding to culture and population changes — Less and less of face-to-face relationships, while counseling and helping relationship is based on them. — Can it be replaced with apps or AI? Counsellor = the helper Assists to understand and deal with problems Professional vs non-professional helpers Psychologists as helpers providing counselling Using theory to understand,; Using learned skills to assess difficulties; Offering evidence-based strategies/techniques to deal with them.  ART Represents individual characteristics of the counselor (e.g. sensitivity to non- verbal communication), skills, learned knowledge etc. SCIENCE Counselling as art and science — evidence based strategies; (Okun & Kantrowitz, 2014) — ethical obligation to assess effectiveness of the counselling process delivered, etc. Counseling as a process Change doesn’t happen in one step. Some stages of the counseling like the assessment and treatment may overlap In some approaches it is expected that the assessment is an ongoing process (psychodynamic counseling). Ongoing verbal and non-verbal exchange with their dynamics. 2 basic stages of counselling process Building therapeutic alliance to disclose, uncover & explore thoughts and feelings; to define helping goals; Based on techniques like: active listening, attending, perceiving and responding (compare chapter 5 from Okun & Kantrowitz). Active use of strategies planning and using strategies to introduce change; further evaluation of outcomes. — According to research quality of the helping relationship is more important than techniques but it creates a context for using them. — In Gestalt it’s well illustrated as the phase of “groundwork” (foundation for the change) and “evolutionary molding” (changing). ALLIANCE BUILDING STRATEGIES USE Initiation Mutual goals acceptance identification of the problem Planning strategies agreement on Use of strategies structure/contract Evaluation of their use problem exploration Termination definition of possible goals Follow-up Mutual relations between building alliance and using strategies Second stage pretty much relies on the created earlier alliance and trust. Without well established alliance every true interpretation, brilliant technique or sophisticated solution is pointless. FORMS & GOALS OF COUNSELLING LECTURE 2 Clinical Psychology 2: Counselling & Psychotherapy Counseling diversity Forms: prevention, rehabilitation, crisis and psychotherapy. Settings: individual, group, family, couple Approaches: theoretical models and evidence based interventions. Tenets of all counselling forms, settings and approaches (Okun A warm empathic relationship is the single & Kantrowitz, 2014) most important factor of counseling effectiveness! Communication skills of the helper are essential. Goals include increase of self-esteem, self- acceptance and gaining control and responsibility for client’s own decisions and behaviors. More than one strategy/technique can be used with any client (matching the strategy for the client not the other way). Continuous analysis/evaluation of the helping relationship. Helper must be aware of own feelings, values and thoughts. Ethically helper must be sensitive to gender, culture and other biases. Human Relations Counselling Model change can be an outcome of Client’s exploration and understanding of own thoughts, feelings and actions. Client’s understanding and decisions to modify external environmental factors. Change through 1. Changing the environment 2. Changing the attitude the one takes toward the environment. Aim of counselling To enhance adaptation Aimed at different goals Services provided in different settings – individual, couple, family & group Different depth and focus - different forms of counseling prevention crisis intervention rehabilitation psychotherapy Prevention To avoid the difficulty or its Counselling consequences in the future Prevention counseling Aims on 3 levels Example Primary: to prevent problem from Tobacco smoking prevention occurring. before people smoke 1st cigarette. Secondary: preventing from Cutting number of smoked getting worse. cigarettes to prevent CVD development. Tertiary: preventing the problem from making worse other Changing cigarettes for NRT to problems caused by it (harm avoid further progression of CVD reduction). induced by smoking. Another example - violence Primary: to prevent from happening (PREP). Secondary: to stop violence (prevention of possible death). Tertiary: to help victims cope (Schwartz & Waldo, 2003). Examples of violence prevention Communication skill training For both perpetrators and victims of battering (Pence & Paymer, 1993; Schwartz & Waldo, 2003). At all 3 levels. Anger management trainings. Specific counselling prevention programs PREP – pre-marital counseling program. Health promotion programs e.g. “Eat fruits & veggies at least 5 times a day”. Addictions preventive workshops for minors at schools. Psycho-education meetings for mental disorders patients teaching relapses early detection and prevention. AA groups. Crisis intervention Short and specific counseling for a counselling specific situation Crisis Psychological reaction to unstable and uncontrolled situation. Potentially health or life-threatening. Interruption of everyday life. Need of resources mobilization. Facing helplessness. Finding new ways of coping. Maybe bring a life revaluation. Counseling in crisis when client experiences both: a crisis and difficulties in adaptation (signs of anxiety, depression). Short-term. Aim: to activate inner and external client’s resources to get back to psychological balance. Counseling in crisis Changing the guilt into responsibility or getting rid of it completely (depends on the case). Based on identification of resources (including family, community, social services use). Creating new resources if needed (e.g. getting in touch with social worker, considering applying for a loan, reaching to extended family). Connecting current situation with past experiences (e.g. similar difficulties, something that the person already survived). Developing new meanings and adaptive responses useful in the future beyond the current crisis (empowerment). Rehabilitation Support of personal growth and counselling potential development. Specific goals of rehabilitation counselling Supporting people with disabilities Supporting in development of personal career, independent living, achieving educational progress. Fulfilling own potential. Integrates psychology, social service, community networking and patient advocacy. Rehabilitation counselling All kinds of disabilities: physical, mental, developmental, cognitive and emotional e.g. congenital disorders leading to diability Neuropsychological deficits due to disease or trauma. Their families. Clients may include also criminals, people with difficulties in job placement, child rearing etc. (disability on social functioning level). Joint goal: to achieve as integrated and independent decent living as possible. Examples of rehabilitation counselling skills and techniques Goal setting Skill training (communication, assertiveness, time management etc.) Self-living skill training (e.g. cooking classes, doing groceries, getting dressed) Vocational counseling (e.g. writing a CV) Behavioral interventions (e.g. smoking cessation) Psycho-education on family planning, life care planning etc. Rehabilitation counseling (CRCC, 2014) Use many different models and techniques Start from assessment, diagnosis and treatment planning Are based on counseling Case-tailored management Include advocacy to challenge environmental barriers Uses placement-related services Rehabilitation technology (software apps etc.). Psychotherapy “the talking cure” As a form of counseling Psychotherapy Psychotherapy often used interchangeably with counseling (Corey, 2005). Different from other forms of psychological guidance à aimed at healing. A series of meetings – based on a process. Considers overall patterns, chronic issues and recurrent feelings. Requires an openness to exploring the past and its impact on the present. Resolves the underlying issues which contribute to ongoing difficulties. Therapeutic relationship works as major healing factor. It’s the deepest level of psychological guidance. Psychotherapy Aim examples: to decrease anxiety, depression, social pain, emotional distress; to reinforce insight, emotional expression; to learn new adaptive behaviors; to find hope, sources of social support; to deal with death issues. Techniques: depend on the approach. Foundational Skills for creating a therapeutic relationship Lecture 3 Clinical psychology 2: Counselling & Psychotherapy Therapeutic factors “The actual mechanisms of effecting change in the patient” (Yalom, 1995, p.11) making the process cost-effective (in terms of money and efforts) J Effective counsellors create a therapeutic climate thanks to 3 factors (Rogers, 1980) 1. Genuineness/realness/congruence 2. Unconditional positive regard/acceptance/caring 3. Empathic understanding These conditions create environment for self- actualization. They are expected from therapist during client- centered session. Genuineness Realness, congruence Congruence between feeling, awareness and communicating. Genuine/congruent therapist Openly communicates feelings, thoughts, reactions, and attitudes that are present in the relationship with the client. including anger, frustration, liking, attraction, concern, boredom, annoyance, and a range of other feelings in the relationship. Serves as a model of a human being struggling toward greater realness. Genuine/congruent therapist A trap of being too genuine: when sharing and self- disclosure does not consider a time and aim of sharing. When counselor behaves incongruently, the therapy should be stopped or supervised. Unconditional positive regard All positive regard that is received without specific conditions. All conditions of positive regard may become conditions of positive self-regard as well. Those conditions lead to disturbances in the self structure --> neurosis (incongruence of the self - true vs false), even psychosis (shattered self). Counselor providing unconditional positive regard Caring that is non-possessive and not contaminated by evaluation or judgment: especially in terms of therapist values and expectations; considers both prizing and criticizing; judging as “good” or “bad”. Counsellor providing unconditional positive regard Accepting the clients, as they are and accepting their decisions. Clients have right to have their own beliefs and feelings. Evidence for therapy effectiveness (Rogers, 1977). Empathy „The state of empathy, or being empathic, is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever loosing the „as if” condition. [...] If this „as if” quality is lost, then state is one of identification.” (Rogers, 1957)  Empathic understanding The cornerstone of the person- Grasping the client’s private Empathy helps clients to: centered approach (Bohart & world as the client sees and (1) pay attention and value their experiencing; Greenberg, 1997). feels it, without loosing own (2) see earlier experiences in new ways; separateness. (3) modify their perceptions of themselves, others, and the world; (4) increase their confidence in making choices and in pursuing a course of action.  caring attitude towards oneself Non-judgmental empathic climate accurately based self-concept more congruent genuine self Being listened by someone who understands listening more accurately to oneself The role of empathy – research findings The better integrated the therapist is, the higher his/her degree of empathy is (Bergin & Jasper, 1969). Experienced therapists offer a higher degree of empathy to their clients (Fiedler, 1949; Mullen & Abeles, 1972). But even experienced therapists often over estimate their empathy level (Raskin, 1974): correlation between therapists’ judges on own empathy and independent judges’ is r=-.66! The role of empathy – research findings Clients are better judges of the degree of received empathy (Rogers, Gendlin, Kiesler & Truax, 1967). Therapist’s intellectual competence and academic degree is not related to their empathy level (Bergin & Jasper, 1969). Learning empathy from: Parents Supervisors Teachers Own therapists Close persons Lecture 4 Psychotherapy: relation to other forms of counselling Clinical Psychology 2: Counselling and Psychotherapy Psychotherapy as counseling Can be time or problem limited. Delivered in many different approaches. Examples of counseling techniques used in psychotherapy Clarification Confrontation Interpretation Identifying irrational beliefs Working with phantasies and dreams Free associations Genograms Analysis of resistance Analysis of transference Psychotherapy clients/patients experience Mental disorders Inner and existential conflicts Symptoms of anxiety and depression Repeated patterns Behavioral – e.g. addictions Relational – e.g. dual relationships Cognitive – e.g. OCD Personality disorders Adaptation difficulties Lowered self-esteem … and more.... Practicing counselling as psychotherapy Based on one approach or integrative If integrative still needs specific postgraduate training in those models that counselor integrates Different settings – individual, couple, family or group. Psychotherapy: clinical definition Psychological influence on people well-being characterized by specific means that are used. It’s not about the outcomes! (otherwise other things would be called psychotherapy)... Crucial is mutual relationship between therapist and patient Whatever happens in the relationship is considered as a healing factor (in most of the approaches). Usually applied to treating people with emotional and adaptation difficulties that are psychologically based. E.g. emotional outbursts due to childhood trauma vs emotional outbursts due to Alzheimer’s.  Who is allowed to treat patients with psychotherapy? DIFFERENT REGULATIONS IN POLISH CASE – CURRENTLY THE PSYCHOLOGIST OR MEDICAL EVEN FREUD WROTE THAT DIFFERENT COUNTRIES. LEGISLATION IS BEING DOCTOR (SPEC. IN MEDICAL SCHOOL IS NOT PROCESSED. PSYCHIATRY) WITH ENOUGH IN TERMS OF POSTGRADUATE TRAINING IN PROFESSIONAL COMPETENCIES PSYCHOTHERAPY AND BUILDING IN INTERNSHIPS. PSYCHOTHERAPY/PSYCHOANA LYSIS. Practicing psychotherapy Short- or long-term basis Delivered by trained and qualified psychotherapist Certificates given upon country, state or region regulations (e.g. EU – EAP European Certificate of Psychotherapy). Some countries require Ph.D. degree. Definition by Norcross (2014, p.3) “Psychotherapy is the 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” Informed and intentional Self-awareness of what the therapist is doing All actions should be intentional and informed Applying clinical methods and interpersonal stances Clinical methods, evidence-based, theory driven etc. RWE (real world evidence) – obtained outside from clinical trials. Importance of the relationship. From established psychological principles You cannot come up with an idea of original therapy, it has to be based on theory and research. There might be lots of approaches but they must be all evidence- based. Assisting people Very broad meaning. Many different goals/levels of assistance Some of them could be better attended with use of some approaches more than others. E.g. disturbing thoughts with OCD and relatedness patterns with psychoanalysis. It’s tailored up to patient’s needs. …to modify behaviors, cognitions, emotions and/or personal characteristics... Variety of addressed goals. Crucial is the assessment of specific patient’s expectations and needs Expectations usually don’t represent patient’s needs… …in directions that the participants deem desirable. Again: patient’s unique needs and expectations are in the center. But… What about if patient wishes to feel better about oneself and to be convninced of own omnipotence? Do we play along with patient’s narcissistic side in therapy? The patient must agree on the aim of therapy though therapist’s role is to make any expectation relaistic and healing in its nature. In the session example What was the patient’s issue? What were her needs or expectations from treatment? What is the issue she’s struggling with (initial diagnosis). What would be a next step to take in the assessment or treatment? Psychotherapy during the intake session, contracting and alliance building, using advanced therapeutic skills Lecture 5 Clinical Psychology 2: Counselling & psychotherapy Psychotherapy Intake session The interview/the intake interview. To get to know expectations, the issue, “the problem”. Ends with recognition what type of counselling would the best approach. May be spread over 1-3 consultations. Both the client and the therapist need to agree to work together. The intake session Consider using intake forms – more time effective but worse for alliance building… Discuss with the client: Goal of counselling What sort of counselling the client needs? Crisis intervention, rehabilitation, prevention or psychotherapy? Therapy goal-oriented or time-oriented Long-term or short-term (less than 12M) Setting the time and place The same day, place, even chair that is taken… Therapeutic Contract discussed or written and signed What we are going to do? How often? For how long? What are the payment and cancellation arrangements? Holidays arrangements What rules are applied in here (ethics incl. confidentiality, informed consent etc..) Contact between sessions Cases of bringing family members to sessions Keep the guidelines of the approach you practice (narrative audience vs psychodynamic acting out) Case of non-voluntary counselling clients First meeting and ongoing assessment Be genuine, empathic, non-judgemental Pay attention to both verbal and non- verbal messages Use attending, minimal verbal responses, paraphrasing, open questions If necessary (but carefully) use clarifications Interpretations (even the best ones) can wait J Therapeutic alliance Built from the first meeting 3 Rogerian factors Basis for cooperation Trust Sympathy Informed consent – basic for building the alliance (Corey, 2008) Client knows what to expect from counseling. Client consciously agrees to collaborate. The therapist is not expected to Solve patients’ problems. Reassure patients in whatever they do or think. Make patients feel better. The question sometimes is whether the treatment process should be pleasant or effective. Some amount of conflict/doubt/crisis is necessary for the change… Empirically proven characteristics of effective helpers Self awareness Developed continuously. We work with our “selves” (Yalom, 2002). Crucial for empathy. Crucial for analysis of therapeutic relationship phenomena E.g. in transference recognition and analysis. Empirically proven characteristics of effective helpers Gender and cultural awareness Especially when working with minorities. Thinking about possible biases. Sensitive and empathic towards clients coming from different backgrounds. Respectful of client’s culture (Okun & Kantrowitz, 2015) E.g. respectful working with patient’s concern of establishing good marriage in a culture that recognizes arranged marriages only. Empirically proven characteristics of effective helpers Honesty Basis for trust. In some approaches even persona. values transparency is required (e.g. humanistic models). Fairness and neutrality. Curiosity about the person instead of judgment (Selvinin Palazzolli, Boscolo, Cecchin & Prata, 1978). Empirically proven characteristics of effective helpers Knowledge Theories Strategies Importance of cultural differences Importance of developmental changes Wise use Matching a method for the patient Choosing evidence based treatments Empirically proven characteristics of effective helpers Congruence (Rogers, 1980) Ethical Integrity Working for the client’s welfare. Taking responsibility for long-term processes. Planning terminations wisely (especially in insurance based settings). Basic rules (confidentiality & non-dual relationships). Ability to communicate Set communication skills that include verbal and non-verbal communication. What is not useful Best– knowing – stance Superiority Interrupting Blaming Mocking Violation of ethics … Advanced communication skills (Okun & Kantrowitz, 2015) Perceiving nonverbal messages. Hearing verbal messages. Differentiation between verbal cognitive and verbal affective messages. Communication strategies that are useful in alliance building. Non-verbal Communication More than 2/3 of all messages is nonverbal Empirically more reliable than verbal messages! Some of them are culture specific Goal: to uncover feelings (affective message) form: Body posture Eyes Tone of voice Body movement Skin Facial expression etc. Verbal communication Hearing what was said Context sensitivity Understanding cognitive and affective content VERBAL COGNITIVE vs AFFECTIVE MESSAGES  Client talking about things, objects, people, various topics, behaviors rather than feeling them. Usually every session has a theme. Example in the session summary: “I think today you brought the topic of difficulties while depending on other people. When you started from being angry with me that our session starts at the Verbal cognitive same time, not earlier, that you have to messages wait. And now you described similar experience with your wife, refusing to have children because you are afraid you will need to resign from your own dreams and simply follow others wishes. These stories have in common one thing, you would avoid dependency if possible.” Verbal cognitive messages Part of the story that is cut off from emotions. If we focus on this level we may not capture the core of the problem. The problem of “head-driven therapies” Insight without emotional reaction. Client thinking too much. Client cut off from feelings. Verbal affective messages Affects communicated verbally and non-verbally Anger, sadness, fear, happiness… Often called as being irritated, pissed, annoyed... We carefully investigate client’s language. More difficult to communicate and perceive than cognitive verbal messages Clarification of feelings Identification of feelings Shows our respect for client’s emotions Validates client’s way of experiencing  Useful communication skills for building therapeutic alliance VERBAL NON-VERBAL Responsive listening (active Mirroring (non-verbal listening) communication skills) Reflecting client’s feelings (using Using verbal reinforces (minimal empathy) reactions) Paraphrases (reflecting on what Warm tone of voice (genuine we have just heard; example of concern) an additive/facilitative response) And more… Using understandable language Using questions Silence in counselling Common fear of beginners - being inadequate Uncommon for daily situations Can be used in therapeutic way! Gives room for client’s thoughts What seems uncomfortable for you could be a time that client needs to think Gives room for client’s phantasies - so many different reactions reveal richness of patients’ inner worlds! “When you’re not saying anything I think that maybe I’m boring you” “When you don’t reply I think that you have judged me already” “Thank you for not saying anything, people are usually trying to convince me to do otherwise and you’re the only one who is actually listening” How to work with silence Don’t focus on you r tension, focus on the patient But don’t stare at him/her! Embrace the silence Think what client might be experiencing at the moment How to break the silence What are you feeling right now? I see you are thinking about something, what is that? Carefully with silence During intake sessions With clients who present lower level of functioning (e.g. psychotic patients) With clients with a history of bad reactions towards silence E.g. borderline patient reacting with depersonalization in the past Check client’s reaction With difficult clients introduce silence later once the alliance is built Lecture 6 Research on psychotherapy and its effectiveness (EBM) Clinical psychology 2: Counselling and Psychotherapy Psychotherapy Does it work? How does it work? as an effective How do we measure it? treatment What is a sign that doesn’t work? method Evaluating the Effectiveness of Counselling The research shows strong evidence for the overall effectiveness of therapy (Duncan et al., 2004). The average treated client is better off than 80% of untreated comparison control subjects (Lambert and Barley, 2002). Various treatment approaches achieve roughly equivalent results (Duncan et al., 2004). The similarities rather than the differences among models account for the effectiveness of psychotherapy (Corey, 2008). Evaluating the Effectiveness of Counselling Hubble, Duncan, and Miller (1999) assembled various researchers to review 40 years of investigation and found that the following four factors account for change in therapy: Client factors: 40% Alliance factors (the therapeutic relationship): 30% Expectancy factors (hope and allegiance): 15% Theoretical models and techniques: 15% IT WORKS THANKS TO BRAIN-MIND CONNECTION Links between neuroscience and psychotherapy Is it possible to observe changes in neuro-functioning (neuro- transmitters levels, neurons regeneration, specific brain structures size changes) with the use of psychotherapy? Used to be a controversial idea First meeting with therapist works like a placebo effect (evidence for increase of dopamine levels in Parkinson’s patients, effect size similar to use of dopamine increasing pharmacology!) We can induce psychologically outcomes on somatic/biological level!  Mind Brain How did the neuroscience confirm psychotherapy healing mechanisms? Neuroscience research (Roffman & Gerber, 2008) - some examples Identification of a limbic system as responsible for affect development and processing (Ochsner, 1994). Dissociation of brain regions involved in processing information about self vs others; external vs internal states (behaviors vs emotions) - support for psychodynamic claim of inner representations and their associations. Mirror neurons - support for psychodynamic phenomenon of primary identification. Psychotherapy can induce changes in neurons functioning - Kandel’s evidence Along with environment adaptation process, we observe changes in genes expression which results in changes in neurotransmission; e.g. in victims of severe long-term abuse disorders in short-term memory; smaller hippocampus; Kandel et al. (2000): long-term severe stress results in prolonged glucocorticoids released which destroy hippocampus cells and disturb connections between them.  Summary: how psychotherapy affects the biology of the brain CBT for OCD – evidence for changes in brain metabolism of glucose in areas similar to observed in pharmacotherapy. Cognitive therapy affects thyroid hormones levels in depressed patients. In depressed patients psychotherapy increases blood flow in the limbic system. Patients with disturbed EEG results or having increased cortisol levels benefit less from psychotherapy (Rakowska, 2006). Psychodynamic therapy is followed by changes in brain functioning, similar to those we observe in pharmacotherapy (Brody et al., 2001).  Changes in brain functioning after psychodynamic therapy and pharmacotherapy Fig.1. Decreases in prefrontal activity seen after psychodynamic therapy (in: Brody et al., 2001). Individual differences in SSRI’s metabolism result in different psychotherapy results (Brody et al., 2001).  Research models in studies on psychotherapy effectiveness Naturalistic (no manipulation by Analog the observer) (non-naturalistic) Naturalistic-experimental Experimental and model Case Study Naturalistic-correlational laboratory model (with control groups but (well controlled and still treatment is delivered planned) in natural environment)  Why it’s so difficult to measure therapy efficacy? Healing takes places within and thanks to therapeutic relationship Every couple of therapist and patient is different (created by different people) Comparisons of effects between therapeutic couples is not possible Possible is analysis of shared characteristics of the relationship. History of psychotherapy studies Eysenck (1952): 1/3 – spontaneous remission Current meta-analyses proofed possible outcomes as: Remission due treatment: approx. 60-80%% Spontaneous remission: approx. 18-60% No change: approx. 20% Deterioration: approx. 2-36% History of psychotherapy studies Eysenck (1952): 1/3 – spontaneous remission Current meta-analyses proofed possible outcomes as: Remission: approx. 60-80%% Spontaneous remission: approx. 18-60% No change: approx. 20% Deterioration: approx. 2-36%  Effectiveness of psychotherapy Effect sizes from meta-analyses based on Cochrane Library data for psychodynamic therapy:.97 at the end of treatment 1.51 9 months after (Abbass, Hancock, et al., 2006). Further increase of effect sizes 1, 3 and 5 years post-treatment (de Maat, de Jonghe, et al, 2009). Just to compare: fluoxetine effect size (approved by FDA drug) is.26!  Deterioration 1. Increase of symptoms or development of new symptoms. Statistically is observed in 10% of patients. Therapy process may increase temporarily symptoms (role of the crisis in therapy) – patients need to get worse to get better The percentage of deterioration without therapy is even higher. 2. Deterioration expressed as lowered motivation and energy to use own resources. 3. Deterioration as unhealthy dependency on the therapist and therapy addiction – therapies for life- are they still therapeutic? 4. Deterioration when therapy is not possible to be effective if patients presents unrealistic expectations, disappointments with therapist and therapy. Generalization of negative outcome of one treatment (with one therapist) to all kinds of therapy. Deterioration studies Therapist characteristics Patients’ characteristics Therapeutic group characteristics Deterioration studies Therapist characteristics Unconscious motives guiding therapist work Using patients to satisfy own needs Dual business or emotional relationship with a client Therapist authoritarian, inpatient, insisting that patients express quickly emotions and change their attitudes on therapist request Aversive stimulation – the most harmful style of delivering therapy; full of therapist aggression, provocative behavior encouraging patient’s aggression, group confrontations; physical or psychological. Patients’ characteristics Therapeutic group characteristics Deterioration studies Therapist characteristics Patients’ characteristics Low levels of personality organization (BPD, psychotic) Severe symptoms at the beginning of treatment Negative self-image and lowered self-esteem High expectations Patients using avoidance as a defense strategy Low Ego-strength Low anxiety tolerance Low motivation In groups: Patients not engaged in the group process Patients expressing low interpersonal skills Therapeutic group characteristics Deterioration studies Therapist characteristics Patients characteristics Therapeutic group characteristics Confrontation just for rivalry Forcing to express anger Rejection by the group or the group leader (à scapegoating) Too much feedback from the group to comprehend Group norms forcing unwanted patterns of behaviors (e.g. this is therapeutic group you need to confess like we all did!) Group deterioration Generally groups are safer in this sense than individual setting. Group controls therapist’s behavior Less possible is therapeutic relationship abuse. But if that happens, outcomes are even more destructive than individually. Is there any relationship between therapy approach and deterioration? No evidence indicating one approach to be definitely more effective than others. Different means lead to similar effects. Even frequency of therapy meetings is not influencing deterioration risk. There is never a 100% guarantee of success Deterioration is a risk of every psychotherapy engagement. Interaction of therapist-patient characteristics. What can protect from deterioration? Initial efforts in alliance building. Informing and preparing patient for therapy process e.g. explanation about possibility of temporarily increase of symptoms and resistance. Positively correlates with therapy effectiveness. Drop out is not deterioration! Broad meaning: quitting before reaching therapy goals (Beck & Jones, 1973). Late drop out: after engagement and development of working alliance, e.g. after 5 or more sessions (Davis & Dhillon, 1989). Early drop out: before developing alliance and engagement. E.g. after 1-5 sessions (criteria may vary). According to ambulatory data after 1-2 consultations 37-43% of patients drop out (Rakowska, 2006) In long-term Border-Line PD group 60% drops out within 1st year of treatment. In children and adolescents therapy, approx. 69% attends at least 5 sessions (difficult group to engage). Highest drop out at the beginning of treatment – according to meta-analyses (over 125 studies): almost ½ of patients drop out too soon to get any results (before 8th session).  Low social and economic status Drop out risk (up to 6 sessions). factors Low education. (Grzesiuk , 2004) Addictions. Conclusions Enhance the common factors across all theories that account for successful outcomes. Focus on the client’s perspective and theory of change as a guide to selecting techniques and integrating various therapy models. Obtain systematic client feedback regarding the client’s experience of the process and outcome of therapy.