Clinical Psychology Past Paper PDF

**[LESSON 5: ASSESSMENT IN CLINICAL PSYCHOLOGY]** INTELLECTUAL AND NEUROPSYCHOLOGICAL ASSESSMENT - - - INTELLIGENCE TESTING: **Classic Theories of Intelligence** What is intelligence? - Clinical psychologists have never reached a consensus regarding the definition of intelligence....

**[LESSON 5: ASSESSMENT IN CLINICAL PSYCHOLOGY]** INTELLECTUAL AND NEUROPSYCHOLOGICAL ASSESSMENT - - - INTELLIGENCE TESTING: **Classic Theories of Intelligence** What is intelligence? - Clinical psychologists have never reached a consensus regarding the definition of intelligence. - ***Speed of mental processing*, *sensory capacity,* *abstract thinking*, *imagination*, *adaptability*,** capacity to learn through experience, ***memory*, *reasoning*,** and inhibition of instinct, to name a few (as summarized by Sternberg, 2000; Sternberg & Grigorenko, 2008; Wasserman & Tulsky, 2005) **Charles Spearman: Intelligence Is One Thing** - In the early 1900s, **Charles Spearman** proposed a theory: Intelligence is a singular characteristic. - "**g" for general intelligence** and argued that it represented a person's global, overall intellectual ability. - Spearman acknowledged that more **specific abilities ("s")** existed, but he argued that they played a relatively minor role in intelligence. "Singular theory of intelligence" - In the debate about defining intelligence, perhaps no specific issue has received as much attention as the singular versus plural nature of intelligence (Wasserman, 2018). In other words, is intelligence one thing or many things? - His theory was based on research in which he measured many different, specific capabilities of his participants, including academic abilities and sensory-discrimination tasks. The primary finding was a strong correlation between this wide range of abilities, suggesting that a single factor underlies them all. **Louis Thurstone: Intelligence Is Many Things** - Intelligence should not be understood as a single, unified ability but as ***numerous distinct abilities*** that have little relationship to one another. - Thurstone was a pioneer of the statistical procedure called [multiple factor analysis], which enabled him to identify underlying factors in a large data set. - Examinations of various intellectual abilities, he could have found one dominant factor underlying all abilities. Instead, he found several independent factors. These factors were given labels such as ***verbal comprehension, numerical ability, spatial reasoning*, and *memory.*** - Louis Thurstone was among the first and the strongest opponents to Spearman's singular theory of intelligence - Eventually, Spearman and Thurstone each acknowledged the validity of the other's arguments and came to somewhat of a compromise. They settled on a **hierarchical model of intelligence i**n which specific abilities ("s") existed and were important, but they were all at least somewhat related to one another and to a global, overall, general intelligence ("g") (Willis, Dumont, & Kaufman, 2015a). **More Contemporary Theories of Intelligence** **James Cattell proposed two separate intelligences:** 1. **Fluid intelligence---t**he ability to reason when faced with novel problems 2. **Crystallized intelligence---**the body of knowledge one has accumulated as a result of life experiences. - Cattell's theory falls somewhere between Spearman's theory of a singular intelligence and Thurstone's theory of many intelligences. **John Carroll's (2005)** ***[three-stratum theory of intelligence,]*** in which intelligence operates at three levels: a single "g" at the top, eight broad factors immediately beneath "g," and more than 60 highly specific abilities beneath these broad factors. **OTHER INTELLIGENCE TESTS** **Woodcock-Johnson tests** - The **Woodcock-Johnson IV Tests of Early Cognitive and Academic Development** (for children aged 2.5--7) - the **Woodcock-Johnson IV Tests of Cognitive Abilities** (generally for clients aged 5--95), - **Kaufman Assessment Battery for Children-II** (for children aged 3--18) **Wechsler Intelligence Tests (David Wechsler)** - The three Wechsler intelligence tests cover virtually the **[entire life span].** They vary slightly from one another, as necessitated by the demands of measuring intelligence at different ages. - They yield a single **full-scale intelligence score**, four or five index scores, and about a dozen (give or take a few, depending on optional subtests chosen) specific subtest scores. - The full-scale intelligence score reflects a general, global level of intelligence ("g") - the index/factor scores and subtest scores represent increasingly specific areas of ability ("s"). 1. Wechsler Adult Intelligence Scale---Fourth Edition (WAIS-IV) 2. Wechsler Intelligence Scale for Children---Fifth Edition (WISC-V) 3. Wechsler Preschool and Primary Scale of Intelligence---Fourth Edition (WPPSI-IV) - They are administered one-on-one and face-to-face. In other words, the Wechsler tests cannot be administered to a group of examinees at the same time, nor are they entirely pencil-and-paper tests (e.g., multiple choice, true/false, essay) that examinees simply administer to themselves. Administration of the Wechsler intelligence tests is a structured interpersonal interaction requiring extensive training, typically received during graduate programs in clinical psychology (Raiford, Coalson, Saklofske, & Weiss, 2010). - Each subtest is brief (lasting about **2--10 minutes**) and consists of items that **increase in difficulty** as the **subtest progresses**. Most often, the subtests are designed such that examinees continue **until they fail a predetermined number of consecutive items** (or "max out," to state it informally). - Originally, the Wechsler tests were designed with two categories of subtests: **[verbal]** and **[performance]**. - **Verbal Comprehension Index**---a measure of verbal concept formation and verbal reasoning - **Perceptual Reasoning Index**---a measure of fluid reasoning, spatial processing, and visual-motor integration. - **Working Memory Index**---a measure of the capacity to store, transform, andp recall incoming information and data in short-term memory - **Processing Speed Index**---a measure of the ability to process simple or rote information rapidly and accurately - - The **[Wechsler intelligence tests]**---and most other intelligence tests, for that matter---are used for a wide range of ***clinical applications***, including evaluations that focus on issues of ***intellectual disability*** (intellectual developmental disorder), ***developmental delays***, ***giftedness, educational*** and ***vocational planning***, ***school placement*** and qualification, and other targeted assessment questions (Zhu & Weiss, 2005). - The Wechsler intelligence tests were among the first to become available on a **digital platform** as an alternative to the traditional pencil-and-paper format. Known as the **["Q-interactive" system]**, this new method of administering and scoring Wechsler tests allows psychologists to use tablets (e.g., iPads) and promise to reduce both the overall length of the tests and the number of scoring errors that can happen when a person rather than a machine does the computations (S. W. Clark, Gulin, Heller, & Vrana, 2017). **Stanford-Binet Intelligence Scales---Fifth Edition (SB5)** What is the SB-5? An individually administered assessment of intelligence and cognitive abilities. Authored by **Gale H. Roid**; published in **2003**. **Child-friendly materials** (*toys, manipulatives, colorful artwork*). Includes high-end items for gifted and low-end items for very young children and low-functioning older children/adults with MR - Appropriate for examinees ages 2 to 85+ - Untimed, but usually takes 45 to 75 minutes (full scale) - Full Scale IQ, Abbreviated Battery IQ, Nonverbal IQ scale and Verbal IQ scale Typical Uses: - Clinical and neuropsychological assessment - Research on abilities - Early childhood assessment and psychoeducation evaluations for special education placements - For career assessment (school-work transition) - Employee selection & classification - Forensic context - Diagnosis of conditions (MR, LD, developmental cognitive delay, placement for intellectually-gifted) **Additional Tests of Intelligence: Addressing Cultural Fairness** - 1. The UNIT-2 consists of six subtests organized into a two-tiered model of intelligence. The two tiers are identified as Memory and Reasoning. The three subtests contributing to the **[memory tier]** are - - - The three subtests contributing to the [reasoning tier] are - - - **Culture Fair Intelligence Test (**Raymond B. Cattell**)** **[Test description]** - - - - - It is a **nonverbal test** / a **paper and pencil test** - It requires examiners to be able to perceive relationships in **shapes and figures** - **[Scales of CFIT]** **Scale 1 is designed for children ages 4-8 years old** - it may also be used for older, mentally handicapped individuals - It utilizes eight subtests - It is administered individually - It requires the examiner to understand and respond to verbal instructions **Scale 2 and 3 are administered in group** - - Classification - Matrices - Topology **Scoring** - When hand-scoring the tests, two general observations are to be done: - Check first the patterned responses that would indicate an invalid protocol - Check that inappropriate multiple responses have not been made - **Two types of scoring keys are available, depending upon whether:** - separate answer sheets were used, or - answers were marked directly in the test booklets **NEUROPSYCHOLOGICAL TESTING** - **Neuropsychological testing** represents a specialized area of assessment within clinical psychology. - The intent of Neuropsychological tests is to **[measure cognitive functioning] or [impairment]** of the **[brain]** and its **[specific components] or [structures].** - Neuropsychological tests can indicate [**how the brain is actually functioning**.] Such tests are especially useful for targeted [assessment of problem]s that might result from a *head injury, prolonged alcohol* or *drug use*, or a *degenerative brain illness* - They can also be used to make a [prognosis] for [improvement,] plan rehabilitation, determine eligibility for accommodations at school or work, and establish a baseline of neuropsychological abilities to be used as a comparison at a later time (Dawson & Jacquin, 2015). - Some **Neuropsychological testing** procedures are **lengthy, comprehensive batteries** that include a broad array of subtests. - Other **Neuropsychological tests** are much **briefer** and are typically used as **[screens for neuropsychological impairment]** rather than as full-fledged neuropsychological assessment tools. - Over time, the field has evolved from a **["fixed-battery phase]**" in which psychologists typically use the same **[standard set of tests]** for most clients to a more **["flexible-battery phase"]** in which psychologists create a more customized battery by picking and choosing tests after considering the specific referral questions and areas of concern (Hale, Wilcox, & Reddy, 2016). - Typically practiced by clinical psychologists whose training includes extra training in neuropsychology during graduate school courses, the predoctoral internship, and the postdoctoral internship (Hill & Westervelt, 2015; - **Medical procedures such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomogra- phy (PET) scans** - Can be administered to police & military personnels - Prognosis -- future **Full Neuropsychological Batteries** **[Halstead-Reitan Neuropsychological Battery (HRB) ]** - Battery of [eight standardized] neuropsychological tests. - Age: clients of age [15 years and older] (alternate versions are available for younger clients). - Administered only as a [whole battery]; its components are not to be administered separately. - Its primary purpose is to [identify people with brain damage] and, to the [extent possible], [provide detailed information] or hypotheses about [any brain damage identified], including specific [cognitive impairments] or [physiological regions] of the brain that may be deficient. - findings of the HRB can help in diagnosis and treatment of problems related to brain malfunction (Broshek & Barth, 2000). - Eight tests in the HRB involve sight, whereas others involve ***hearing, touch, motor skills,*** and **[pencil-and-paper tasks. ]** - **Example: Trail Making Test,** which resembles the familiar "dot-to-dot" puzzles that children complete, but this **[test is timed]**, contains both numbers and letters, and produces a rather haphazard line instead of an identifiable figure or shape. - **Pros**: its tests have been established as ***reliable and valid***; its ***comprehensiveness*** and ***clinical usefulness*** - **Cons**: its **[length]** (and corresponding expense), **[inflexibility]** (as a fixed battery), and a **[limited overlap with real-life, day-to-day tasks]** (Broshek & Barth, 2000; Hebben & Milberg, 2009). **Luria-Nebraska Neuropsychological Battery (LNNB).** - It is a wide-ranging test of neuropsychological functioning. - It consists of 12 scales - It emphasis on qualitative data in addition to quantitative data (the LNNB relies on qualitative written comments from the examiner about the testing process) - These comments describe what the examiner observed about the client, such as problems comprehending the test (e.g., confusion, poor attention), how or why the client is missing items (e.g., slow movement, sight or hearing problems, speech flaws), or unusual behaviors (e.g., inappropriate emotional reactions, hyperactivity, dis- traction). - A strong body of psychometric data supports the LNNB's reliability and validity (Golden, 2004). **Brief Neuropsychological Measures** **Rey- Osterrieth Complex Figure Test** - A brief pencil-and-paper drawing task, but it involves only a single, more complex figure. - Features the use of pencils of different colors at various points in the test. - The examiner can trace the client's sequential approach to this complex copying task. - Clients are asked 3 to 60 minutes after copying the form to reproduce it again from memory (Helmes, 2000; Lacks, 2000). **Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998).** - The RBANS tests not only visuomotor abilities but also **verbal skills, attention, and visual memory.** - It takes **20 to 30 minutes** to complete and includes 12 subtests in 5 categories: ***immediate* and *delayed memory*, *visuospatial/constructional*, *language, attention*, and *delayed memory.*** - The subtests involve such tasks as learning a list of 10 words presented orally, naming pictures of various objects, recalling an orally presented list of numbers, recalling a story told 20 minutes earlier, and (like the Bender-Gestalt and Rey-Osterrieth) copying of visual figures **Bender Visual-Motor Gestalt Test---Second Edition (Bender-Gestalt-II)** - Lauretta Bender produced a groundbreaking monograph of "Visual Motor Gestalt Test and Its Clinical Use" - "All Integrative processes within the nervous system occur in constellations or patterns, or gestalten, the whole setting of the stimulus and the whole integrative state of the organism determine the pattern of the response" (Bender,1938, pp. 3-4) - Its results cannot specify locations of brain damage, but poor performance on the Bender-Gestalt can suggest brain damage in a diffuse way. - it can alert the clinical psychologist to the general presence of neuropsychological problems, and more thorough testing can subsequently be conducted. **Bender Visual-Motor Gestalt Test---Second Edition (Bender-Gestalt-II)** - The **KOPPITZ-2 i**s a highly reliable, valid measure of visual-motor integration skills that applies the developmental approach to scoring model. - Provides separate scoring systems for young children (ages 5-7 years) as well as older children and adults (ages 8-85 years and older). - Includes: 25 Examiner Record Forms Ages 5-7, 25 Examiner Record Forms Ages 8-85+, 25 Emotional Indicator Record Forms, and a Scoring Template **HIGHLIGHTS OF THE BENDER GESTALT II** - - - - - - - **MATERIALS:**  **[Lesson 6: PERSONALITY ASSESSMENT AND BEHAVIORAL ASSESSMENT]**\ **MULTIMETHOD ASSESSMENT** - No measure of personality or behavior is [perfect]. Some have excellent reliability, validity, and clinical utility, but even these have their limitations. - Personality is best assessed by using multiple methods, including tests of different types, interview data, observations, or other sources. - Multiple tests rather than only one, the clinical psychologist can assert them with confidence. The advantages of multimethod assessment hold true even in less formal and professional settings. For that reason, it is import- ant for clinical psychologists not to rely exclusively on any single assessment method. **Example:** Your initial "assessment" of your part- ner's personality may take place on the first date---at a restau- rant and a movie, perhaps. As the relationship continues, you'll have a chance to "assess" your partner's personality using other "methods"---you'll see his or her personality and behavior with family, with friends, at parties, at home, at work, at school, and so on. You may get a strong first impression on the first date, but you probably won't feel that you genuinely know and under- stand your partner's personality until you've "assessed" him or her in a variety of contexts, because each situation will reveal a different aspect of personality. **EVIDENCE-BASED ASSESSMENT** The movement toward **evidence-based assessment**, resting on the same principle of "what works" empirically, isn't far behind. Who practice evidence-based assessment select only those ***methods that have strong psychometrics***, including ***reliability, validity***, and ***clinical utility*** (each defined in Chapter 8; Therrien & Hunsley, 2015). They select tests that have ***sufficient normative data*** and ***are sensitive to issues of diversity*** such as age, gender, race, and ethnicity. They typically target their assessment strategies toward a particular ***diagnosis or problem***, such that **"what works**" for assessing attention-deficit/ hyperactivity disorder (ADHD) might be a different set of assessment tools than "what works" for assessing panic disorder, schizophrenia, bulimia, PTSD, or any other clinical issue (Glynn & Mueser, 2018). How do researchers determine "what works" when assessing particular clinical problems? In other words, what criteria should distinguish evidence-based assessment methods from those lacking evidence? "**adequate"** **[test-retest reliability]** this way:\ "Preponderance of evidence indicates test-retest\ correlations of **[at least.70]** over a **period of several\ days to several weeks**" (Hunsley & Mash, 2008a,\ p. 8). They go on to define "good" test-retest reliability as the same.70 level "over a period of several months" and "excellent" test-retest reliability as the same.70 level "over a period of a year or longer" OBJECTIVE PERSONALITY TESTS Objective personality tests-include unambiguous test items, offer clients a limited range of responses, and are objectively scored. The objective personality tests that clinical psychologists use are questionnaires that clients complete with pencil and paper (or in some cases, on a computer). They typically involve a series of direct, brief statements or questions and either true/false or multiple-choice response options in which clients indicate the extent to which the statement or question applies to them (Morey & Hopwood, 2008). 1\. **Minnesota Multiphasic Personality Inventory-2** **[Purpose]** - Clinical practice of psychiatry as a self-reported personality scale - Research work - Other medical disciplines and research on human behavior - Judicial trials, criminal investigations, education, and career choices. - Widely used in psychological consultation centers, psychosomatic medicine clinics, psychiatric hospitals, talent markets, employment agencies, colleges and schools, etc., - Evaluation of talents\' psychological quality, personal mental health level, and degree of psychological disorder. **Administration procedures** ***Test Range*** - Clinical and non-clinical population - Reading ability: at least elementary-level - Separate forms for adolescents and adults - Recommended IQ of 80 or higher(?) **Test Site** - Quiet room - Good lighting - Comfortable chair and table - Paper, pencil, and relevant forms **Factors Influencing Performance** - Test conditions - Instruction - Age, Gender, Race, and Sociocultural Background - Faking - Social Desirability - Item Omission - Problems of Interpretation - Self Deception - Lack of Insight **Completion Time** - 567 true/false items - 90 to 120 minutes **(L) Lie Scale** - Hathaway and McKinley developed - To assess that the test taker approached the instrument with a defensive mind set. - **TRIN scale** be examined for possible acquiescent or non acquiescent response styles of prior to interpreting scores on lie scale **The scoring of the MMPI-2 is a completely mechanical process** of counting the items endorsed for each scale and converting the raw scores thus derived to T-scores. - hand-scoring the MMPI-2 is not only more cumbersome and time consuming than computer scoring, but it is also subject to errors of counting, transcription, correction, plotting, and profiling. **Steps for Scoring MMPI-2** 1. Select profile forms appropriate to the patient\'s gender. 2. Place the identifying information on the profile form in the spaces provided. 3. Identify the number of item omissions (unmarked and double-marked items) to derive the Cannot Say (?) score. 4. Derive raw scores for each of the MMPI-2 scales. 5. Prepare a list of Critical Items.\* 6. Transcribe raw scores, including the (?) score, to the appropriate spaces on the profile forms. 7. Transcribe fractions of K from the "Fractions of K" table on the clinical scale profile form onto the spaces provided below the raw scale scores for those scales receiving this correction. 8. Add these corrections to the raw scores of these scales. 9. Convert all raw scores to **T-scores.** 10. Plot profiles of T-scores for the scales. 11. Print the MMPI-2 profile code. **II. NEO Personality Inventory-3** - (NEO-PI-3), Paul Costa and Robert McCrae, - A personality measure that assesses ["normal"] personality characteristics. - the NEO-PI-3 (who also put forth the corresponding five-factor model of personality or "Big Five") argue that the many words our language offers for describing *personality traits* ["cluster"] into five fundamental traits of personality that characterize everyone in varying degrees. - It is a 240-item, pencil-and-paper, self-report questionnaire. The items are short statements with multiple-choice responses ranging from "strongly agree" to "strongly disagree." - the NEO-PI-3 lacks any substantive measurement of the test taker's approach to the test, leaving it rather vulnerable to "faking" or inattention by clients. **III. Beck Depression Inventory-II** - These tests are typically briefer and focus exclusively on one characteristic, such as depression, anxiety, or eating disorders. - The BDI-II is a self-report, pencil-and-paper test that assesses depressive symptoms in adults and adolescents. The original BDI was created by [Aaron Beck], a leader in cognitive therapy for depression and other disorders, in the 1960s (Rosner, 2015a) - The BDI-II is brief---only 21 items, usually requiring a total of 5 to 10 minutes to complete - best describes their personal experience during the previous 2 weeks (a time period chosen to match *DSM* criteria) PROJECTIVE PERSONALITY TESTS - Projective personality tests are based on a fundamentally different assumption: People will "project" their personalities if presented with *unstructured, ambiguous stimuli* and an *unrestricted opportunity to respond* (Tuber & Meehan, 2015). - Projective personality tests are similar to a series of "clouds" that psychologists display to clients. - Critics of projective tests stress that they are *far too inferential to be empirically sound*; that is, they rely too heavily on a *psychologist's unique* way of scoring and interpreting a client's responses (Hunsley, Lee, & Wood, 2003). - The standing of projective tests has undoubtedly declined in popularity in recent decades, to the satisfaction of critics who claim that their reliability and validity are insufficient to justify psychologists - (The term *performance-based test* is sometimes used synony- mously with *projective test* \[Krishnamurthy & Meyer, 2016\].) - Clients are given freedom to make sense of these stimuli in any way they choose---they are not restricted to multiple-choice or true/false options. - Clients' responses may be compared with those of others in a normative group, and psychologists will ultimately form hypotheses about the clients' personalities based on their responses. I**. Rorschach Inkblot Method** - Hermann Rorschach (1921) - 10 inkblots, 5 with only black ink and the other 5 with multiple colors. - Administration occurs in [two phases]. In the ["response"] or "free association" phase, the psychologist presents one inkblot card at a time, asks, "What might this be?" and writes down the client's responses verbatim. - the ["inquiry"] phase begins, in which the psychologist reads the client's responses aloud and asks the client to describe exactly where in the inkblot each response was located and what features of the inkblot caused the client to offer that response. - John Exner combined aspects of many scoring systems to create the Comprehensive System, which has become the most common method of scoring the Rorschach (Exner, 1986) **Comprehensive System includes the following:** *[Location].* Does the response involve the whole inkblot, a large portion of it, or a small detail? *[Determinants.]* What aspect of the inkblot---its form, color, shading, and so on--- caused the client to make a particular response? *[Form Quality.]* Is the response easily identifiable and conventional? Or is it unique or distorted? *[Popularity.]* Each card has a response or two that occurs relatively frequently. How often does the client offer these popular responses? *[Content.]* What kinds of objects appear with unusual frequency in the client's responses? People, animals, food, clothing, explosions, body parts, nature, or other categories of items? **II. Thematic Apperception Test** - Henry Murray and Christiana Morgan - it involves presenting the client with a series of cards, each featuring an ambiguous stimulus - the TAT cards feature interpersonal scenes rather than inkblots. - They are asked to consider not only what is happening in the scene at the [moment] but also what happened [before] and what may [happen after the scene]. - TAT responses would emphasize recurring themes across multiple stories rather than an interpretation based on a single story. - The TAT includes a total of 31 cards, but psychologists typically select their own subset of cards---often about 10 or so---to administer to a particular client. \\ - - Currently, the TAT is often analyzed without formal scoring at all: "Most clinicians today seem to rely on their own impressionistic inferences," resulting in "idiosyncratic and inconsistent" use of the TAT (Moretti & Rossini, 2004, p. 357). **Sentence Completion Tests** They are the beginnings of sentences. The assumption is that clients' personalities are [revealed] by the [endings they] add and the sentences they create. **III. Rotter Incomplete Sentences Blank (RISB)** -.The original RISB was published in 1950, with the most recent revised edition (including *high school, college, and adult versions*) appearing in 1992. - The RISB tests include 40 written sentence ["stems"] referring to various aspects of the client's life. Each stem is followed by a blank space in which the client completes the sentence. - The RISB includes a formal scoring system, but clinical psychologists may not use it regularly, and when they do, scoring is [highly dependent on the clinical judgment] of the psychologist. **IV. Draw A Person Test (DAPT)** - Draw a Person test is a human figure drawing tests which is meant to be administered to children, and adolescents, however at some point, it is administered to adults. - The aim of the test is to assess how the child perceives the people around them including the family and other psychological activities on interpersonal and cognitive setting. - The subject is asked to draw a picture of a man, a woman, and themselves. No further instructions are given and the pictures are analyzed on a number of dimensions. **TEST APPLICATION** - It is being used in all settings. - It may be used to culturally disadvantaged, educationally deprived, mentally retarded and aged individuals. - It is usually presented to children, adolescents and adults **ADMINISTRATION OF THE TEST** - Clients should be seated in a comfortable position, with a sufficient room to freely move their arms while drawing - a single sheet of paper measures 8 1/2 x 11-inch - \#2 pencil with an eraser (If chromatic drawing is desired give the client a crayons, colored pencils, or different colored felt-tip pens) - Subjects are given another 8 1/2 x 11- inch (draw a person of the opposite sex) - TIME: No time limit. **BEHAVIORAL ASSESSMENT** - Behavioral assessment challenges all these assumptions and offers a fundamentally different approach to assessment - According to behavioral assessment, client [behaviors] are not signs of underlying issues or problems; [instead,] those [behaviors *are* the problems]. Another way to state this is that [the behavior a client demonstrates is a sample of the problem itself,] not a sign of some deeper, underlying problem. - So to assess the problem, assessment techniques should involve as little inference as possible. Rather than inkblots or questionnaires that may get at the problem indirectly, behavioral assessors would choose the most direct way to measure problem behavior. - The most essential technique in behavioral assessment is **behavioral observation** or the direct, systematic observation of a client's behavior in the natural environment - Behavioral observation also typically includes keeping a record of the events that occur immediately before and after the target behavior - Documenting these events allows for clinical psychologists to understand the function- ality of a particular behavior or how the behavior relates to the environment and con- tingencies that surround it **Methods of Behavioral Assessment** 1\. Naturalistic Observation (*behavioral observation* ) - This practice involves taking a direct sample of the problem at the site where it occurs (*home, work, school, public places, etc*.). - The first step in [behavioral observation] involves identifying and operationally defining the problem behavior. This takes place *via interviews*, *behavioral checklists*, *consultation with those who have observed the client* (family members, coworkers, teachers, etc.), or self-monitoring by the client. - Once the target behavior is identified and defined, systematic observation takes place. This process usually involves tallying the frequency, duration, or intensity of the target behavior across specified time periods---first as a baseline, and then at regular intervals to measure improvement as compared with that baseline. **[Lesson 7: PSYCHODYNAMIC PSYCHOTHERAPY]** - For much of the first half of the **1900s,** the **psychodynamic approach** was so **dominant** that it was practically synonymous with psychotherapy itself. - Many of the **pioneers** of **nonpsychodynamic therapies** were initially **trained in psychodynamic programs** but later abandoned that approach to create something different. - Freud had many intellectual descendants, including some who were his contemporaries (such as Carl Jung, Alfred Adler, and Erik Erikson) and others whose ideas arrived in subsequent generations (such as his daughter Anna Freud, Harry Stack Sullivan, Frieda Fromm-Reichmann, Melanie Klein, Karen Horney, D. W. Winnicott, and Heinz Kohut). **PSYCHODYNAMIC PSYCHOTHERAPY** - refers broadly to the pioneering work of Sigmund Freud and all subsequent efforts to revise and expand on it. - Freud's original approach to therapy, which in its classic form is known as psychoanalysis. - At various points in the evolution of his theory by others, Freud's original term *[psychoanalysis]* was replaced by terms such as *[psychoanalytic psychotherapy], [neo-Freudian therapy]*, and *[psychodynamic psychotherapy]*, each of which has generated even more specific terms for its offshoots. **Goal of Psychodynamic Psychotherapy** - The primary goal of psychodynamic psychotherapy is [to make the unconscious conscious] (Cabaniss, Cherry, Douglas, & Schwartz, 2011; Karon & Widener, 1995). - Psychodynamic psychotherapists help their clients become aware of thoughts, feelings, and other mental activities of which the clients are unaware at the start of therapy. - **INSIGHT**, used often by psychodynamic therapists and clients alike, captures this phenomenon---[looking inside oneself] and [noticing something that had previously gone unseen ] - The process of making the unconscious conscious presumes that an [unconscious part of our mind exists in the first place]. - "mental processes that are outside the awareness of the individual and that have important, powerful influences on conscious experiences" (Karon & Widener, 1995, p. 26; see also Mendelsohn, 2015). - Freud changed the way we think about ourselves by proposing "mental processes that are outside the awareness of the individual and that have important, powerful influences on conscious experiences" (Karon & Widener, 1995, p. 26; see also Mendelsohn, 2015). **Accessing the Unconscious** - Psychodynamic psychotherapists gain an appreciation of their clients' unconscious process in a variety of ways. Of course, these methods are quite inferential. - In more casual language, psychodynamic psychotherapists try to "read" their clients and hypothesize about their unconscious activity using the following processes. **1.Free Association** - psychotherapists simply ask *clients to say whatever comes to mind* without censoring themselves at all. - The client's task is *to verbalize any thought that occurs*, no matter how nonsensical, inappropriate, illogical, or unimportant it may seem (Kernberg, 2004; Skelton, 2006). - *Note:* It is important to distinguish [free association] from word association, a technique associated with Carl Jung. In word association, the therapist presents the client with a list of words. After hearing each word, the client is to respond with the first word that comes to mind. - Consider how rare it is for any of us to speak with complete spontaneity, **without editing** ourselves in one way or another. - Speech in daily life are when we listen to **very young children** or **very intoxicated adults**. Nonetheless, the words of people in such states of mind can be revealing about their innermost thoughts and feelings, according to the psychodynamic approach 2\. **Freudian "Slips"** - all our behavior is determined; ***there is no such thing as a random mistake***, ***accident***, or ***slip***. - Psychodynamic psychotherapists who witness a client's slips of the tongue during a session or who hear clients' stories of such events ***may be able to glimpse the clients' underlying intentions.*** 3\. **Dreams** - Although some emphasize **dreams** more than others, psychodynamic psychotherapists generally believe that our dreams communicate unconscious material (Cabaniss et al., 2011). - **latent content** (the raw thoughts and feelings of the unconscious) - **manifest content** (the actual plot of the dream as we remember it). - Freud theorized that when we sleep, our minds convert latent content (the raw thoughts and feelings of the unconscious) to manifest content (the actual plot of the dream as we remember it). **Resistance** - When certain issues come up during the course of therapy, clients make it clear that they *["don't want to go there."]* - Psychodynamic psychotherapists have a name for this client behavior: resistance. - Psychodynamic psychotherapists could be frustrated by clients' resistance, but more often they are intrigued by it and use it to guide future efforts. - The resistance itself may be an important factor in the client's daily life and could become a productive topic of conversation later in therapy. **Defense Mechanisms** Freud's structural model of the mind includes three forces: The id, the superego, and the ego 1. **Id *(Pleasure)*** = the part of the mind that generates all the pleasure-seeking, selfish, indulgent, animalistic impulses. It seeks immediate satisfaction of its wishes, most of which are biological in nature, and is oblivious to any consequences. 2. **Superego *(Morality)*** = the part of the mind that establishes rules, restrictions, and prohibitions...should" do; an internalization of the **rules and morals** taught to each of us, and it stands in direct opposition to the id (Kernberg, 2004; B. E. Moore & Fine, 1990; Skelton, 2006). So, according to Freud, our unconscious mental processes involve a constant battle between an id demanding instant gratification and a superego demanding constant restraint. 3. **Ego *(Reality)*** = is a mediator, a compromise maker between the id and the superego, can be quite creative in the ways it handles id/superego conflict. The ego can be quite creative in the ways it handles id/superego conflict. Over time, it develops a collection of techniques on which it can rely. It is this set of techniques that Freud and his followers call defense mechanisms. **Defense mechanisms:** In psychodynamic psychotherapy, techniques used by the *ego* to [manage] conflict between the *id* and *superego;* Defense mechanisms are psychological strategies used by individuals to cope with reality and maintain self-image*.* 1\. **[Repression]**. When the id has an impulse and the superego rejects it, the ego can *repress* conscious awareness of the impulse and id/superego conflict around it. [Unconsciously blocking out painful or unwanted thoughts and memories]. (Ex: *A victim of a traumatic event has no recollection of the incident*) Note: (Repression) Denial is a similar defense mechanism, but it usually refers to events that happen to us rather than impulses that come from within us. 2\. [**Projection**.] When the id has an impulse and the superego rejects it, the ego can *project* the id *impulse onto other people around us*. [Attributing one's own unacceptable feelings or thoughts to someone else]. (Ex: *A person who is angry at their boss feels that their boss is actually the one who is angry at them*) **3. [Reaction formation].** When the id has an impulse and the superego rejects it, the ego can ***form a reaction against* the id impulse---essentially, *do the exact opposite*.** [Acting in a manner opposite to one's true feelings]. (Ex: *A person who feels insecure about their appearance might overly praise others' looks* ) **4. [Displacement]. W**hen the id has an impulse and the superego rejects it, the ego can ***displace*** the id impulse toward a safer target. [Redirecting emotions from a threatening target to a safer one]. (Ex: *After a stressful day at work, a person comes home and yells at their family instead of addressing the stressor directly)* - **Regression**: Reverting to behaviors typical of an earlier stage of development (Ex: *An overwhelmed adult starts to throw temper tantrums similar to a child*) - **Identification**: Adopting the characteristics of someone else to cope with feelings of inadequacy (*A child who feels powerless starts to imitate a superhero*) - **Intellectualization**: Using logic and reason to avoid dealing with emotional stress (*A person who has been diagnosed with a terminal illness focuses on learning about the disease instead of processing their emotions*) - **Compensation**: Overachieving in one area to compensate for failures in another (*A person who feels inferior academically might excel in sports to boost their self-esteem*) **5. [Sublimation].** When the id has an impulse and the superego rejects it, the ego can *sublimate* it---essentially, redirect it in such a way that the resulting behavior actually benefits others. [Channeling unacceptable impulses into socially acceptable activities]. (Ex: *A person with aggressive tendencies becomes a professional boxer*) "imagine how the ego might manage the internal conflict caused when the superego rejects it" Psychodynamic psychotherapists believe that some of these defense mechanisms are more mature or healthy than others **Examples** 1. Denial and Repression are considered rather immature, largely because they don't effectively satisfy the id, so similar id demands resurface later. 2. Sublimation is viewed as [uniquely mature] because it satisfies the individual's id impulses and a societal need simultaneously. ***The goal of psychodynamic psychotherapy is to help clients become aware of their unconscious processes, including their defense mechanisms. As clients become enlightened about defense mechanisms they use, they can exert some control over them and, in the process, move toward more [mature ways of managing their internal conflicts. ]*** **Transference** - It refers to clients' tendency to form relationships with therapists in which they unconsciously and unrealistically expect the therapist to behave like important people from the clients' pasts. - In other words, without realizing it, a client "transfers" the feelings, expectations, and assumptions from early relationships usually parental relationships onto the relationship with the therapist. - According to psychodynamic theory, in a much broader sense. *We all experience powerful early relationships in our formative years*---especially with parents---and those relationships shape our expectations for future relationships. ***Goal: The role of the psychodynamic psychotherapist is to help clients become aware of their own transference tendencies and the ways these unrealistic perceptions of others affect their relationships and their lives.*** - After the therapist identifies these transference tendencies in the client--therapist relationship, the therapist can call the client's attention to them---in other words, offer interpretation of the transference (crucial elements of this kind of therapy) - With any interpretation, it may take clients a long time to fully understand it, accept it, and see its impact on their day-to-day lives. After all, an interpretation can represent a drastically different explanation than the client had ever considered for his or her own behavior. - These comments by the therapist to the client---observations, essentially, of the unconscious tendencies the client shows when he or she forms relationships---are crucial elements of this kind of therapy - For this reason, psychodynamic therapy often involves a lengthy **working through process,** in which ***interpretations are reconsidered* and *reevaluated again and again*.** Frequently, it takes *many sessions* for an important interpretation to "sink in" fully and take effect on the client's psychological functioning (Gabbard, 2009c; Wolitzky, 2016). - The **"blank screen" role** of the psychodynamic psychotherapist is essential to the transference process. Psychodynamic psychotherapists ***typically reveal very little about themselves to their clients through either [verbal] or [nonverbal communication]*.** *(In fact, this was a primary reason why Freud had clients lie on a couch while he sat behind them in a chair, out of their line of sight.*) - Note:*in the Internet age, it is increasingly difficult, and perhaps impossible, for therapists to maintain it. Research shows that many clients google their therapists, either before or after therapy has begun (Eichenberg & Sawyer, 2016). And when they do, they can find all kinds of information, both professional and personal.* Psychodynamic psychotherapists call this transference by therapists toward clients **countertransference**, and, generally, they strive to minimize it because ***it involves a reaction to the client that is unconsciously distorted by the [therapist's own personal experiences ]*** One reason that many psychodynamic training programs **require *trainees to be clients in psychodynamic psychotherapy*** themselves is to become aware of their own unconscious issues so they won't arise as countertransference toward their own clients (Erwin, 2002) **PSYCHOSEXUAL STAGES: CLINICAL IMPLICATIONS** ***Freud's psychosexual stages of development*** - the implications most relevant to clinical psychologists and to the psychodynamic psychotherapy approach in particular. - Of the five stages, the first three have generally received the most attention from psychodynamic psychotherapists, especially regarding **fixation** (Karon & Widener, 1995). - **Fixation** refers to the idea that as children move through the developmental stages, they may become emotionally "stuck" at any one of them to some extent and may continue to struggle with issues related to that stage for many years, often well into adulthood. 1\. **Oral Stage** - the child experiences all ***pleasurable sensations*** through the mouth, and feeding (breast or bottle) is the focal issue. - kids whose ***parents mismanage this stage*** may display blatantly ***"oral" behaviors*** later in life: smoking, overeating, drinking, nail biting, and so on. - If ***parents overindulge children*** in the oral stage, children may learn that ***[depending on others]*** always works out wonderfully. - if ***parents are not responsive enough*** to children during the oral stage, children may learn that ***depending on others never works out*** - These **oral issues** (extreme form)-root of clients' individual and **[interpersonal problems ]** - According to *psychodynamic theory*, a primary issue at this stage is *[dependency. (]*They cannot feed, clothe, bathe, protect, or otherwise take care of themselves, so they must depend on the adults in their lives). 2\. **Anal Stage** - occurring when the child is about **1.5 to 3 years old** - **Toilet training** is a primary task of this stage - At this age, adults (especially parents) begin to place demands on children **regarding their speech and behavior.** - **[If parents are too demanding]** of children at this stage, children can become ***overly concerned about getting everything just right*** (having everything in exactly the right place at the right time). - They ***meticulously organize their desk***s, they program their ***daily schedules from start to finish*** - **[if parents are too lenient]** toward children at this stage, children can become **lax about organization**...Their desks are covered in ***messy piles***, their schedules are ***sloppy and haphazard*** - **Clinical Implications**, including ***anxiety disorders*** such as ***[obsessive-compulsive disorder]*** and ***[relationship problems]*** stemming from incompatible living styles. - control is the central issue of this stage. - These children often grow to become adults who think obsessively and behave compulsively in order to stay in control: 3\. **Phallic Stage** - About age **3 to about age 6** - Freud's most **controversial.** - Closely tied to **[gender-specific biology]**, have fallen out of favor and are widely disputed by contemporary psychodynamic psychotherapists (Erwin, 2002; - the fundamental idea implied by the **Oedipus** and **Electra complexes.** - Children at this age wish to have a special, **close relationship with parents.** The parents' response to the child's wish is the **crucial issue**. - For parents to **[respond positively to kids' overtures]**. But when **[parents respond too positively]**, when they reciprocate the child's wishes too strongly, ***they overinflate the child's sense of self.*** - **[Parents who reject their child's wishes]** for a special, close relationship ***can wound a child's sense of self-worth***. - The parents' response to the child's wish is the crucial issue for clinical psychologists, because this ***parental response powerfully shapes the children's view of themselves.*** This view of the self---essentially, **[self-worth]** But when parents respond **too positively**, when they reciprocate the ***child's wishes too strongly, they overinflate the child's sense of self.*** Such children may grow into adults whose opinions of themselves are so unrealistically high that they strike others as **arrogant or egotistical.** **MORE CONTEMPORARY FORMS OF PSYCHODYNAMIC PSYCHOTHERAPY** **Ego psychology** - most of these revisions have deemphasized the biological and sexual elements of the theory (Erik Erikson and Freud). To highlight *social relationships* and emphasized the *adaptive tendencies* of the ego over the pleasure-based drive of the id; as exemplified by ***Erik Erikson*** and his eight-stage theory of development, revised Freud's psychosexual stages. **Object relations** - deemphasized *internal conflict* (id vs. superego) and instead emphasized relationships between internalized "objects" (essentially, important people from the client's life; school, led by ***Melanie Klein, Otto Kernberg, Ronald Fairbairn,*** **Self-psychology** - emphasizes *parental roles* in the child's development of self, with special attention paid to the meaning of *narcissism* at various points, including in therapy (Wolitzky, 2016); school of ***Hans Kohut*** **Brief psychodynamic psychotherapy** have become far more common in recent years than the classic, *orthodox version of Freudian psychoanalysis* from which they derived (H. Levenson, 2010). It often refers to therapy lasting ***fewer than 24 sessions*,** which amounts to about ***6 months of once-a-week sessions**.* With such a small window of time (by psychoanalytic standards), the therapist and client must quickly form an alliance, develop insights that facilitate new ways of understanding, and translate these insights into real-world changes. **Interpersonal Therapy(IPT)** - The interpersonal school of psychodynamic thought of which **[Harry Stack Sullivan.]** - It is designed to last about ***14 to 20 sessions***, and, as such, its goals are more ***focused and limited*** than ***structural change of the entire personality***. - The ***fundamental assumption*** of IPT is that **[depression]** happens in the context of ***interpersonal relationships***, so improving the client's relationships with others will facilitate improvement in the client's depressive symptoms (Lipsitz & Markowitz, 2013). A **[few specific interpersonal problem]** areas tend to contribute to clients' problems 1. ***Role transitions** (* becoming a parent or graduating from college). 2. ***Role disputes** (*entering a marriage) 3. ***Interpersonal deficits** (*lack of social support ) 4. ***Grief (***the reaction to loss of a loved one) - which Harry Stack Sullivan was a leader, was developed in the 1980s by Gerald Klerman, Myrna Weissman, and colleagues. - It was originally created to treat depression, but it has since been used to treat numerous other disorders. - It focuses on [current interpersonal relationships] and [role expectations] and tends to deemphasize some of the aspects of more traditional psychodynamic psychotherapy related to [intrapsychic structure and childhood fixations ] **IPT proceeds in three stages** 1. The **first stage** **(about 2 sessions in most cases)** involves [categorizing the client's problems] into one of the four categories listed above (*role transitions, role disputes, interpersonal deficits, and grief*). 2. The **intermediate sessions (10--12 sessions)** emphasize [improving the client's problems] as identified in the first stage. Common psychodynamic methods are used, including a *focus on current emotions, explorations of transference*, and *resistance*. Also, the intermediate stage often includes an *educational component* in which the therapist teaches the client about depression and its symptoms. 3. The **final stage (2--4 sessions)** involves a review of the client's accomplishments, recognition of the client's capacity to succeed over depression without the therapist's continued help, and efforts to prevent relapse. More recently, a variation of IPT... ***Interpersonal and Social Rhythm Therapy* (IPSRT)** - it is specifically designed for clients with ***bipolar disorder.*** - It efforts to **control** and **stabilize daily rhythms**, sleep/wake cycles, and social interactions (Weinstock, 2015). Irregularities in these kinds of daily activities and interpersonal relationships can be especially disruptive to ***people prone to extreme variations in mood***. - Clients in IPSRT are encouraged to ***make and follow detailed daily schedules*** and ***to track their behavior and mood in detail***. **Time-Limited Dynamic Psychotherapy** - TLDP is experiential in nature; the here-and-now relationship between therapist and client is the main tool for therapeutic change. - Time-limited dynamic psychotherapy (TLDP) is a modern application of the classic and often-referenced concept of the *["corrective emotional experience"]* (F. Alexander & French, 1946): - Clients will bring to therapy the same *[transference issues]* that they bring to many of their other relationships, and the *therapist's task* is to make sure that this time, the interaction will end differently. - If the client's relationship with the therapist follows the same unconscious *["script"]* as the client's other relationships, it may end badly, but *if the therapist can make the client more aware of this script* and *offer a chance to enact a healthier*, more realistic one, the *["emotional experience"]* will be *["corrective" or therapeutic]* (Betan & Binder, 2017) - The **[therapist's primary task]** is to identify the **"script"** that the client appears to be unknowingly following. This **script** is the by-product of ***previous relationships*** (often with parents), in which the ***client learned what to expect from others***. - The TLDP therapist assumes that the ***client's problems are at least partially due to an application of this script*** to inappropriate relationships or situations. - In this way, they do not perpetuate the outdated script, and the ***client is forced to develop a new***, more ***realistic way of relating to others*** that is not bound by the assumptions of the script that he or she had been unconsciously following (Binder et al., 1995; Steenbarger, 2008). When therapists conduct TLDP, they often use a visual diagram called the **[cyclical maladaptive pattern]** (H. Levenson, 1995). the client's primary issues organized into four categories: 1. **Acts of Self** (how a person actually behaves in public; e.g., how a client interacts in a job interview). 2. **Expectations about others' reactions** ("I'm sure the interviewer didn't like me") 3. **Acts of Others toward the self** (the interviewer says, "Your application looks great. We'll call you in the next 2 weeks," and the client interprets this as rejection) 4. **Acts of the Self toward the Self** (the client tells self, "You are such a failure," and spends next day alone and miserable). By identifying these four components of the cycle, TLDP therapists can help clients become more aware of specific thoughts and behaviors that contribute to the faulty script that they may enact, as well as healthier alternatives to these thoughts and behaviors. *Can we measure the extent to which the unconscious has been made conscious?\ Can we calculate the amount of insight a client has achieved or the extent to which his or her relationships have improved?* - These questions haunt psychodynamic psychotherapy and elicit criticism from those who prefer therapies of other kinds. **[Lesson 8: HUMANISTIC PSYCHOTHERAPY]** - **Abraham Maslow** - **Carl Rogers** pioneered the humanistic movement in psychology and its clinical application, **humanistic therapy**. - **Carl Rogers** was trained psychodynamically. But he didn't stay psychodynamic for long. - The humanistic approach to understanding people stood in opposition to the bio- logically based, id-dominated, cynical Freudian view that prevailed at the time. - Carl Rogers was the single most prominent figure in terms of influence on the way they practiced psychotherapy (Cook, Biyanova, & Coyne, 2009). - Maslow (1968) summarized its theoretical foundation: - *Inner nature \[of people\] seems not to be intrinsically or primarily or necessarily evil\....Human nature is not nearly as bad as it has been thought to be\....Since this inner nature is good or neutral rather than bad, it is best to bring it out and encourage it rather than to suppress it. If it is permitted to guide our life, we grow healthy, fruitful, and happy. If this essential core of the person is denied or suppressed, \[the person\] gets sick sometimes in obvious ways, sometimes in subtle ways, sometimes immediately, sometimes later. (pp. 3--4)* - *humanistic* to cover the family of therapies created by Rogers and his followers. At various times, the terms *nondirective, client- centered*, and *person-centered* have been used by Rogers and others to describe these approache **Humanistic Concepts: Clinical Implications** - There are compelling parallels between this **[plant]** and **[human beings]**, according to the humanistic approach. - Humanists assume that people, **like plants**, arrive with an inborn tendency to grow. Humanists call this tendency **[self-actualization]** and presume that ***if the person's environment fosters it***, ***self- actualization proceeds without interference*** (Cain, 2002, 2010). - Humanists also recognize that ***people need certain things to live***, and ***just as plants need sunlight***, ***people need positive regard***. - **[Positive regard]**, from the humanistic point of view, is essentially the ***warmth***, ***love***, and ***acceptance of those around us***. (Carl Rogers's frequently used term **[prizing]** may best capture this experience of receiving positive regard from others; e.g., C. R. Rogers, 1959.) - **As children**, we bask in the **glow of positive** regard from our parents; like plants with sunlight, we need it to grow - If we discover that **our parents provide positive regard** only when we behave in certain ways, we will emphasize certain aspects ("branches") of ourselves and suppress others in order to attain it. **\ GOAL OF HUMANISTIC PSYCHOTHERAPY** - The primary goal of humanistic psychotherapy is to **foster self-actualization**. - Humanists believe that psychological problems---***depression, anxiety, personality disorders, eating disorders***, and most other forms of **psychopathology---**are the by-products of a **stifled growth process**. - The task of the humanistic therapist is, through the therapeutic relationship, to create a **[climate in which clients can resume their natural growth]** toward psychological wellness (Erekson & Lambert, 2015). - The fact that the need for positive regard can, at times, ***override the natural tendency to self-actualize***. - Problems arise when this **positive regard** is ***conditional rather than unconditional***. Conditional positive regard communicates that we are prized **["only if"]** we meet certain conditions. **Family** **Example:** - **Conditions of worth** that parents place on their children. - We'll love you **only if you** get good grades, dress how we like, adopt our values, excel in sports, don't gain weight, stay out of trouble, and so on. - ***because they need their parents' acceptance, they do their best to meet these conditions.*** - When they compare the selves they actually are---the **real self**---with the selves they could be if they fulfilled their own potential---the **ideal self**---they perceive a discrepancy. - Humanists use the term **incongruence** to describe this discrepancy, and they view it as the root of psychopathology (J. C. Watson & Bohart, 2015). - In contrast, **congruence**---a match between the real self and the ideal self---is achieved when self-actualization is allowed ***to guide a person's life without interference by any conditions of worth***, and, as a result, mental health is optimized. - If you consider your own family or those of your best childhood friends, you can probably identify some of the **conditions of worth** that parents place on their children. - It is important to note that although conditions of worth originally come from others, they can eventually become incorporated into our own views of ourselves. That is, conditional positive regard from others brings forth conditional positive ***self*-regard**, whereas unconditional positive regard from others brings forth unconditional positive ***self*-regard**. **\ ELEMENTS OF HUMANISTIC PSYCHOTHERAPY** - The therapist does not directly heal the client, per se; instead, the therapist fosters the client's self-healing tendencies toward growth. Therapist--client relationship characterized by **three essential therapeutic conditions** 1. **Empathy** - A therapist experiences **empathy** for a client when the therapist is ***able to sense the client's emotions***, just as the client would, to ***perceive*** and ***understand*** the events of his or her life in a compassionate way. - the term ***[client-centered therapy]***, often used synonymously with humanistic therapy, reflects this emphasis on empathic understanding (Bozarth, 1997). - **Empathy** involves a deep, nonjudgmental understanding of the client's experiences in which the therapist's own values and point of view are temporarily suspended. 2\. **Unconditional Positive Regard** - **Unconditional positive regard (UPR)** is, essentially, ***full acceptance of another person*** "*no matter what*." Carl Rogers (1959) stated that the therapist proving UPR to a client - It means making ***no judgments***. It involves as much feeling of acceptance for the client's expression of painful, hostile, defensive, or abnormal feelings as for \[the client's\] expression of good, positive, mature feelings. - UPR allows clients to grow in a ***purely self-directed way***, with ***no need for concern about losing the respect*** or acceptance of the other person in the relationship. - which clients realize they are ***free to be wholly true to themselves,*** without modifying, amending, or retooling themselves to meet the standards of another person - It facilitates higher levels of **[congruence]** and **[self-actualization. ]** - According to humanists, such relationships impede growth and eventually cause us to drift away from our true selves. Therefore, as therapists, humanistic therapists make it a top priority to accept clients entirely and unconditionally. This provides an opportunity for clients to grow naturally into their own potential rather than being pressured by others to grow in various directions (Cain, 2010; Tudor & Worrall, 2006). 3\. **Genuineness** - Humanistic therapists must, therefore, be ***genuine in their relationships with clients***. - When we sense others (friends, family, or therapists) doing that, we tend not to reveal much of ourselves. On the other hand, when we sense that others ***authentically care about us and accept us***, we tend to ***open up*** and ***engage*** more fully in the relationship (Gillon, 2007). - ***Being genuine*** with clients helps humanistic therapists establish therapeutic relationships that feel **"real."** - the ***[therapist's personality plays]*** a more prominent role. As might be expected, Carl Rogers and other humanists encourage a relatively ***high degree of transparency by the therapist***. - Empathy and UPR are worthless if they aren't honest. - Unlike the "**blank screen"** psychodynamic therapist, humanists tend to be more forthcoming and candid about their own thoughts and feelings during sessions. - These **three conditions**---***empathy, UPR, and genuineness***---are the essential elements of the relationship between humanistic therapists and their clients, which, in turn, is the ***cornerstone of the humanistic approach to psychotherapy*** **\ Necessary and Sufficient?** - When Rogers described ***empathy, UPR***, and ***genuineness*** as the three core conditions for successful psychotherapy, ***[he wasn't merely suggesting that they might be effective for some clients]***. His claim was much bolder: - Those three conditions were both necessary and sufficient for psychotherapy to be successful with any client (C. R. Rogers, 1957). In other words, Rogers argued that to facilitate growth and self-actualization in clients with any kinds of problems, ***the therapist must provide only empathy, UPR***, and ***genuineness***. **[No additional techniques]** or **[procedures are necessary. ]** - **Therapist Attitudes, Not Behaviors** - Humanists balk at formulaic, mechanical approaches to ther- apy, and, as such, they tend not to offer many specific suggestions about *what* therapists should *do* with clients. Rather, they emphasize *how* therapists should *be* with clients: **\ REFLECTION:\ AN IMPORTANT THERAPIST RESPONSE** - **Reflection** takes place when a ***therapist responds to a client by rephrasing*** or ***restating the client's statements*** in a way that highlights the client's feelings or emotions (R. J. Campbell, 2004). - Reflection is ***not a mere parroting*** of the client's words to show that they have been heard **[but]** a ***comment by the therapist that shows the therapist's appreciation of the client's emotional experience*** - Rogers believed, **[reflection]** should be ***an attitude rather than a technical skill***. And this attitude should include some humility, which can be lost when therapists reflect mechanically. When they reflect, therapists should not be telling clients how they feel but, instead, should be asking clients if their understanding of the clients' feelings is correct. - **Humanists** generally agree that one ***therapist behavior---reflection***---can contribute significantly to the success of psychotherapy. It serves as a mechanism by which empathy, UPR, and genuineness can be communicated and as an expression of the attitudes that humanists emphasize. - In other words, therapists should ***not become overconfident in their ability to read clients' emotions*** and should ***always defer to the clients' expertise on their own feelings.*** Rogers went so far as to "suggest that these therapist responses be labeled not '**Reflections of Feeling**,' but 'Testing Understandings,' or 'Checking Perceptions.' Such terms would, I believe, be more accurate \[in communicating\] a questioning desire rather than an intent to 'reflect'" (p. 375). **\ ALTERNATIVES TO HUMANISM** - **Historical Alternatives** 1\. **Existential psychotherapy** is an approach to therapy originally developed by ***Rollo May, Victor Frankl***, and ***Irvin Yalom*** - It centers on the premise that each ***person is essentially alone in the world*** and that realization of this fact can ***overwhelm us with [anxiety]***. This anxiety may take a number of forms and is the ***root of all psychopathology***. - Existential therapists place ***great emphasis on clients' abilities to overcome [meaninglessness]*** by creating their own meaning through the decisions they make. They especially encourage clients **[to make choices]** that are **true to themselves in the [present]** and **[future]**, rather than choices that are determined by **restrictive relationships they have had in the [past]**. 2\. **Gestalt therapy** was founded by Fritz Perls, and it emphasizes a **[holistic approach]** to enhancing the client's experience. - This experience includes both **mental** and **physical perceptions**, and Gestalt therapists attend to both these aspects of client communication - In practice, Gestalt therapists **encourage clients to reach their [full potential]**, often through the use of **[role-play techniques]**. They ***deemphasize clients' past experiences*** and instead focus almost exclusively on the present moment (labeled as "the now"). - Two of the most notable of these historical approaches---existential therapy and Gestalt therapy. - They aid clients in assuming control and assigning significance to their lives **Motivational Interviewing** - **Motivational interviewing (MI)**, developed by **William Miller**. Miller describes his MI approach to therapy as a ***revised application*** of basic humanistic principles (Hettema, Steele, & Miller, 2005). - MI was originally developed to ***[treat addictive behaviors]*** such as ***substance abuse***, but it has been used with a wide range of client problems. - MI centers on addressing clients' ambivalence or uncertainty about making ***major changes to their way of life.*** - MI therapists acknowledge that it is a ***normal challenge for anyone facing the [difficult decision ]***of ***[continuing]*** with an unhealthy familiar lifestyle or committing to live in a more healthy but unfamiliar way. - A key to the MI approach is that its practitioners ***don't pressure clients to change***, because such tactics may backfire, resulting in clients arguing against their own improvement. - they ***elicit*** motivation from within the clients, rather than ***imposing*** it from without. This enables the clients to activate their own intrinsic values as inspiration to change their behaviors. - If the therapist utilizes some MI principles at the outset to successfully elicit the client's own motivation, the cognitive or behavior therapy may progress more smoothly. - In fact, one empirical study found that clients who got a single session of MI before starting cognitive-behavioral therapy for an anxiety disorder showed greater engagement than comparable clients who underwent the same cognitive-behavioral therapy without the single session of MI. **The central principles of MI reveal its humanistic roots** 1. ***Expressing empathy***. Taking the clients' points of view and ***honoring their feelings*** about their experiences are vital to MI. 2. ***Developing the discrepancy**.* MI therapists highlight how a ***client's behavior is inconsistent*** with his or her goals or values. This ***enhances*** the ***client's self- motivation to change*** and puts him or her (rather than the therapist) in the position to argue for a new way of living. 3. ***Avoiding argumentation**.* MI therapists ***do not directly confront clients***, even if clients are engaging in self-destructive behaviors. They ***recognize that clients must choose to change*** rather than being strong-armed by a therapist. 4\. ***Rolling with resistance**.* MI therapists ***accept*** and ***reflect*** it rather than ***battle against it***. They ***[respect that clients have mixed feelings]*** about changing. 5\. ***Identifying "sustain talk" and "change talk."*** ***[Sustain talk]*** takes the form of client statements in ***favor of continuing the problem behavior***. ***[Change talk,]*** on the other hand, is the statements clients make ***in favor of changing the problem behavior***. - MI therapists acknowledge that both these voices are within the client. 6\. ***Supporting self-efficacy**.* MI therapists make efforts to communicate to clients that ***they have the power to improve themselves***. Resistance to change is often communicated by clients as ***sustain talk**.* - MI therapists acknowledge that both these voices are within the client. They compassionately understand the internal dispute and allow clients to work out a resolution for themselves. **Positive Interventions and Strength-Based Counseling** - **Positive psychology. [Martin Seligman ]**is a broad-based approach that ***emphasizes human strengths*** rather than pathology, and ***cultivation of happiness*** in addition to reduction of symptoms in psychotherapy (A. L. Duckworth, Steen, & Seligman, 2005; Seligman, 2011). - It suggests that ***bolstering these strengths*** is an often-overlooked way of ***preventing psychological problems*** such as ***depression*** and ***anxiety or improving the lives*** of those who already experience them (Seligman, 2003; Seligman & Peterson, 2003). - A corresponding commitment to clinical work designed to enhance those strengths and capabilities. - Therapists influenced by positive psychology assume a therapeutic role that ***"embraces both healing what is weak and nurturing what is strong"*** (Seligman & Peterson, 2003 - The latter emphasis---nurturing what is strong in clients - The most often labeled ***positive interventions*** or ***strength-based counseling.*** - These therapies look past mere diagnosis-based symptom reduction to the ***enhancement of a client's overall well-being***, particularly such aspects as the client's positive emotion, engagement with life, relationships, meaning, and achievement. - The latter emphasis---nurturing what is strong in clients---is a contemporary echo of Rogers's original theories. In particular, it captures the essence of healthy growth inherent in the self-actualization tendency, a core of the humanistic approach (Joseph & Patterson, 2008). **Parks and Layous** (2016) describe **[seven (7)]** **[basic categories of positive psychology techniques]**, each of which could take on a variety of forms: *1. **Savoring***, in which clients intentionally focus on and extend, ***without distraction***, ***moments of joy and happiness***. *2. **Gratitude***, in which clients purposefully ***focus on reasons to be thankful*** by writing letters, journaling, visiting important people in their lives. 3\. ***Kindness***, in which clients deliberately ***do nice things for others***, including the donation of money or time for charity, volunteering, tutoring, or similar activities 4\. ***Empathy***, in which clients intentionally build a ***sense of understanding***, forgiveness, and perspective-taking with others in their lives 5\. ***Optimism***, in which clients purposefully cultivate ***positive expectations about the future*** and anticipate good things that may happen in their lives 6\. ***Strength-based activities**,* in which clients deliberately use (or write about) their ***personal strengths in meaningful*** or novel ways 7\. ***Meaning***, in which clients intentionally ***remind themselves of their own values*** and set goals to live a life that falls in line with them **Emotionally Focused Therapy** - **Emotionally focused therapy (EFT)** is a ***short-term humanistic therapy*** that has garnered significant empirical evidence. - It emphasizes the ***expression, acknowledgment***, and ***healing power of emotions*** in the present moment, as well as emotions that may have been **["bottled up"]** for a long time. - Therapists encourage clients to ***experience their feelings wholly*** and ***completely***, and show them unconditional acceptance when they do so. - They encourage clients to share their feelings toward others, sometimes using an **["empty chair"]** technique in which clients speak directly to an imaginary person such as a family member or partner toward whom they have typically withheld their feelings - EFT with **[couples]** involves each person experiencing his or her own feelings more authentically and accepting the authentic feelings of the partner more fully, which **[enhances closeness]** and the likelihood of sharing feelings in the future. - The goal is to ***replace patterns of blaming*** and ***withdrawing with patterns of empathy*** and ***self-disclosure***