PSY 339 Psychotherapy Introduction PDF

Psychotherapy Introduction 8/27/29 What is Psychotherapy? Bridging the gap between the science and practice of different approaches The connection between patient and therapist, the therapist’s verbal skills, how they explain the therapy is important, and understanding the...

Psychotherapy Introduction 8/27/29 What is Psychotherapy? Bridging the gap between the science and practice of different approaches The connection between patient and therapist, the therapist’s verbal skills, how they explain the therapy is important, and understanding the patient’s characteristics make effective psychotherapy Healing practice based on verbal persuasion and human interaction that occurs in a social context This is a unique relationship in a very specific context There are over one thousand types of psychotherapy. Many of which have not been subjected to scientific scrutiny Transference, countertransference Many individuals with psychological disorders receive questionable or pseudoscientific treatments ○ Leaves patients with a bad feeling about therapy Exploring Different approaches to psychotherapy and the science that supports them (the effectiveness, efficacy, and why) Patient and therapist characteristics that influence the success of treatment Evidence-based treatments for specific presentations of illness What do we do about difficult patients? Ethical and cultural considerations How do we begin treatment? How do you terminate it? Why study it? Effective if done right on ○ Anxiety disorders ○ Depressive disorders ○ Protracted grief ○ Personality disorders Experts Psychiatrists (medications) A broad overview of major orientations/approaches: Psychodynamic: our thoughts, feelings, and behaviors are out of our conscious control. They are in our unconscious mind. ○ Sigmund Freud ○ The therapist helps the patient delve into their unconscious to resolve conflicts Free association, dream interpretation  Humanistic: non-directive and person-centered therapy such as empathy, unconditional positive regard, and being authentic and honest with clients. Includes person-centered, emotion-focused, transpersonal, etc. Cognitive: focuses on emotional responses that occur from our thoughts. Dialectical Behavioral Therapy. Acceptance and Commitment Therapy. ○ Changed cognitions, changed emotions Behavioral: Looks at the power of behavior on our moods and well-being. Based on models of learning ○ Helps with phobias, facing their fears Group Therapy, Family Therapy, Couple Therapy Psychotherapy: Science & Practice 8/29/24 What is psychotherapy? Healing practice based on verbal persuasion and human interaction that occurs in a social context Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles to assist people in modifying their behaviors, cognitions, emotions, and/or personal characteristics in directions that participants deem desirable. Takes place one-on-one with a licensed mental health professional or with other patients in a group setting What do psychotherapists do? Conduct patient assessments to see their level of functional impairment Treat patients with psychotherapeutic approaches that are researched to be effective Monitor patient outcomes throughout the time of treatment ○ Routine outcome monitoring ○ Are they benefiting? Conduct research ○ Not just clinical Issues Within the Field The patients receiving this treatment are forgoing other effective treatments. There are over one thousand types of psychotherapy ○ Some don’t have evidence supporting that they are effective, and they could be dangerous ○ Some psychotherapists “create” their therapy that is not effective ○ Important for therapists to understand the science, what is effective, how to apply it, and who to apply it to Many of which have not been subjected to scientific scrutiny There is no guarantee a patient is receiving tx that is grounded in research and is provided by a skilled therapist  Many individuals with psychological disorders receive questionable or pseudoscientific treatments ○ The patients receiving this treatment are forgoing other effective treatments ○ Theft of services, cost, time, and money ○ Compromises the integrity of the field people less likely to seek treatment Devalues therapy ○ Some people deteriorate during therapy Is psychotherapy effective? Yes! It is demonstrated to be effective in randomized trials Practicing therapists using structure and cogent approaches get outcomes similar to randomized clinical trials for medical interventions Research suggests it’s as effective as medication and it’s longer lasting It’s highly cost-effective and longer lasting. Results persist because you learned something Individuals who receive treatment for a presenting problem do significantly better than those who do not The average for psychotherapy is.6 (meta-analytic research) This is more effective than some evidence-based medical interventions Research suggests therapy can increase the efficacy of a pharmaceutical intervention NNT The number needed to treat (NNT) statistic developed to facilitate the practice of evidence-based medicine (the average number of patients that need to be treated to benefit one person, compared to a control group in a clinical trial) ○ Compare the consequences of doing nothing with the benefits of doing something. ○ Summarizes the potential harm of a treatment ○ Identifies patient populations that are doing well with a treatment ○ Allows comparisons between approaches ○ The reciprocal/inverse of the Absolute Risk Reduction (ARR) The reciprocal/inverse of the absolute risk reduction (ARR) The ARR is calculated by subtracting the post-treatment measurement of disease severity in the treatment group from the measured disease severity in the control group ○ ARR is a way to measure the difference in risk between a group that has received an intervention and a control group that has not  ○ ARR = Disease severity in the control group - disease severity in the treatment group ○ NNT=1/ARR ○ NNT of 3 (For every 3 patients treated, one is effective) Some difficulties with this: ○ Specific categorical outcomes aren’t applicable. Clear categorical outcomes such as response v. non-response don’t exist ○ The definition of response is debated in conditions such as schizophrenia and other major mental illnesses ○ NNT of 3 is good (psychotherapy) Is one treatment approach more effective than another? (Debate) No, if core components are present ○ Dodo bird debate - all psychotherapy has similar effects ○ What matters is you have a relationship with the patient, that causes a change Yes, you must add the active ingredient based on the evidence ○ Need evidence-based treatments, without them, nothing will happen ○ Some interventions work better than the other Combination of both ○ Being able to use the right therapy for their specific problem CARE pathway Caring, attentive, real, empathetic Basic humanistic components How does this help? ○ People are social creatures. Many things put someone at a risk for mortality, but Loneliness, social isolation, and early death are intimately related Those who reported feeling socially isolated had a 32% higher risk of dying early from any cause compared with those who weren’t socially isolated Those who reported loneliness were 14% more likely to die early than those who did not ○ Sharing with a therapist, and connecting with another person is therapeutic within itself, loneliness and isolation (illness) ○ Groups can be helpful for people as long as there is a qualified therapist amongst them, connection with the other person, sharing similar experiences Care pathway facilities: A connection with another person A reduction in loneliness and helps reconcile feelings An enduring relationship → other relationships may not endure certain things/situations ○ The therapist is there every week ○ Without judgement and with empathy Emotional stability  ○ Emotional co-regulation (another human being) ○ Unconsciously ○ The patient’s emotion mirrors that of the psychotherapist You notice the other person is calm, you start to co-regulate, and also calm back down Expectancy Pathway We learn through verbal persuasion from a trusted person (the therapist) ○ The patient trusts the therapist, patient feels that the therapist is confident ○ Persuading them in a way that they feel good about modifying their behavior They trust us and have the expectancy that we are helping them avoid future suffering ○ They expect that the therapist is going to help them and expect to be better after a therapy session They expect to feel better ○ Placebo? Isn’t just thinking or feeling-there are documented physiological opioids, food ○ Not just the belief that they feel better, there are physical signs in the body and brain that make them better Care & Expectancy work together No placebo Cold acupuncturist vs warm acupuncturist ○ Warm acupuncturist had a reduction in IBF symptoms More care, more expectancy (trust you more), better healing Patient characteristics that influence therapy Autonomy motivation Mandated patient ○ Patients who require therapy or jail/not getting your children ○ Not their choice Readiness for change Transtheoretical Model of Stages of Change Pre-contemplation, contemplation, preparation, taking action, maintenance (cycle) ○ Looking at outcomes if they do XYZ (not telling them what to do) ○ Contemplation: why are the patients not ready? ○ Know how to guide them through the stages → preparation Preparation is the market of a healthy therapeutic relationship with the patient ○ Patient takes action ○ Then you maintain this positive change Patient Characteristics that Influence Therapy Attachment style (how they will attach to you) Level of functional impairment Motivation ○ Do they know that they need change, do they want to change, do want to be here Readiness for change ○ Autonomy motivation (v.s. mandated) - the degree to which clients experience participation in therapy as freely chosen ○ Better predictor than therapeutic alliance ○ Therapists who are perceived by the patient as supporting autonomy motivation had patients who were higher in expectancy. Resistance ○ High resistance is better with non-directive therapy. Lack of Commitment Mandated patients are not committed ○ Patients can be fired by therapist Spouse or family member pushed them into Therapy is a contract with the patient, not committed to therapy Cultural factors influence views of psychology and therapy ○ Some cultures do believe in sharing personal stuff with a stranger The patient’s social/family environment affects motivation and healing This is the identity in the family system ○ Don’t want the disruption, if they change I’ll have to change Fear of making problems in the family Family members sabotage - consciously or unconsciously ○ Preventing them from getting therapy because of their fear of the change that the patients will make Four Stages of Competence Focusing on therapeutic strategy, not domain approach Unconscious incompetence ○ The patient presents with an issue. They are incompetent, lacking insight and awareness of causal factors) Conscious Incompetence ○ They gain insight with guidance from the therapist ○ Conscious that there is an issue and how they are going to solve it Conscious Competence ○ The patient is active in making a change Unconscious Competence  ○ It becomes automatic ○ Patient functioning well in life Principles that contribute to change in a therapeutic context Positive expectations - They must believe that change is indeed possible Therapeutic alliance - (part of expectations) helps the patient believe in the treatment. Relationship between the patient and therapist. Agreement on goals, methods Increase insight/awareness into patients' - “attention re-deployers.” How do they contribute to the problem? Creative experience - why? Trust, wanting to show progress. The therapist facilitates this, people will have good experiences and trust more in the process. Ongoing reality testing - processing and understanding increases the new behavior and emotions. Positive reinforcement ○ “You’re doing great” Medical Model Pathway Presenting problem → psychological explanation → Mechanism of change is based on explanation → specific EB treatment → problem resolved Clinical Meaningful Outcomes  Treatment approach + therapist-patient relationship And skills of the therapist Effective therapists Able to form a strong alliance with a range of patients ○ Different demographics Verbally fluent - succinctly and articulately what they explaining Read the affective (emotional/mood) state of the patient ○ Make sure affective state and mood are congruent Modulate their open reactions ○ Want to be able to keep your reactions appropriate for the session ○ Professional, not letting it affect you personally Empathetic Know the literature regarding treatment (tx) approaches, patient characteristics, and presenting problems Unconditional positive regard for the patient ○ Know what group you’re working with ○ Treat them positively because they are there to change Praise the patient when progress is made Are skilled at their treatment approach Understand many areas of psychology ○ Gives patients confidence in you as a therapist ○ Processing potential problems ○ Give information to patients and help them understand potential outcomes Common Therapist Factors that Impede Progress Weak connection Lack of understanding regarding patient abilities Unrealistic expectations Poor skills/knowledge Advice giving Not using evidence-based approaches Psychodynamic Approach 9/2/24 Developing a Treatment plan for psychotherapy Treatment plan: addresses the problems identified in the case conceptualization(a clinical strategy and method for understanding and explaining a client's situation and issues) ○ How the therapist makes sense of the patient’s presenting problems using a theoretical framework  ○ The therapist synthesizes many pieces of information into a well-developed, coherent narrative. ○ This narrative should identify the precipitating cause of the patient’s problems and the internal and external forces that feed them. ○ There are many different approaches to treating patient problems ○ The goal of the therapist is the figure out how this treatment is going to help THIS patient Clinical treatment plan components Establishing a therapeutic relationship ○ The therapy relationship has significant and consistent positive effects related to patient outcomes, independent of the treatment approach. ○ Patient-therapist relationship accounts for clinical gains or lack thereof, more than the treatment approach. ○ Skilled clinicians will adjust the relationship to patient characteristics based on the outcome literature. ○ Cultural competence is very important Identifying goals and creating objectives ○ Academic, relationship, personal development, leisure, marital, etc goals in therapy ○ Improve outcomes in TX studies conducted among adults and depression (if patients identify their goals) ○ Improves patient appliance and participation ○ The patient must agree upon the goals of the treatment They feel good about the goal, which gives them structure and expectations ○ Goals should directly correlate with the problem of the patient ○ Can state goals in the patient’s POV ○ Set up structured goals that patients would strive towards ○ Objectives Focus on what needs to be addressed to meet the goals (social anxiety, isolation, OCD) identify barriers and address them in objectives Understand patient preferences ○ Therapist preferences: the patient’s desires that the psychotherapist will have specific personal characteristics such as gender, ethnicity, religion ○ Treatment preferences: desires for a particular kind of treatment method, such as cognitive-behavioral therapy ○ Activity preferences: the activities that patients hope they and their therapist will engage in throughout psychotherapy Understanding patient expectations and perspectives ○ What do they want to get out of this tx ○ What is your end goal? ○ Before deciding on the intervention ○ Important for patient outcomes  ○ Quick assessment to see what the patient would like in this tx ○ C-NIP, a brief measure of patient preferences, then adapt tx accordingly ○ Patients who receive their preferences, report higher satisfaction and have lower dropout rates** Routine outcome monitoring/measuring ○ The QQ-45.2 measures: ○ symptom distress (anxiety, depression) ○ interpersonal relations (difficulty with marriage, family, friends, colleagues) ○ social roles ○ anything above a 12 is considered a functional problem ○ They are most beneficial in identifying patients who are not making progress or are in jeopardy of leaving treatment. Interventions ○ What interventions are you going to use to achieve these objectives? ○ Hospital psychiatric setting TX plans differ in that they are more medical/symptom-based Psychodynamic Models, Techniques, and Concepts Psychodynamic: an approach that encompasses treatments that operate on a continuum of supportive and interpretive interventions (mind in motion) intrapsychic/unconscious conflicts (particularly ones that involve sexual and aggressive urges in psychoanalysis) (effective for) Ego defences, transference, affect phobia Basic goals of psychodynamic therapy: ○ Understand the elements of the patient’s unconscious that are affecting their conscious thoughts, feelings, and behavior ○ Decide whether uncovering or supporting will help most at the moment ○ Uncover unconscious material or support mental functioning in a way that is going to help the patient best Subtypes: psychoanalysis, ego psychology, object-relations theories, interpersonal analysis, self-psychology, relational and intersubjectivity, brief psychodynamic (meeting once a week) It began with Freudian psychoanalysis and the theory of the unconscious It can be short or long-term Traditional psychoanalysis was long-term and intensive, with multiple weekly sessions. Five unique ways in which psychodynamics seeks to help patients are: Fostering insight into unconscious conflict Increasing the use of adaptive psychological defenses Decreasing rigidity in interpersonal perceptions and behaviors Improving the quality of patient’s mental representations of relationships  ○ Are they viewing current relationships based on past relationships? ○ Insecure attachment to caretakers → Insecure attachment to significant others Increasing their comprehension of their own and other’s mental states Two main dynamic therapy techniques Supportive interventions: ○ Warm and empathic with the patient, stabilization, providing a safe and supportive environment, ego-strengthening interventions, boundary-setting, bolstering adaptive defenses (altruism, self-assertion, sublimation) Expressive (interpretative) interventions: ○ Uncover or “Express” the unconscious conflict behind a patient’s symptoms Exploration of affect and interpersonal themes (free association or selectively focusing the patient’s attention on these themes) ○ Clarification (drawing light on the patient’s attention to the knowledge they already possess but in a new light) ○ Interpretation (i.e making meaningful connections between past and present relationship experiences, especially involving the therapist) Change mechanisms Reflective functioning- the capacity to understand and interpret the thoughts and emotions of oneself and others, utilizing this insight to clarify and influence interpersonal interactions ○ Develops through the empathic mirroring behavior of early caregivers and a lack of disruptive traumatic experiences ○ Therapy can help patients gain if they lack this Individuals with a high degree of RF: ○ Contemplate their own and other’s cognitive and affective states Reflecting on themselves and their thoughts as well as other people ○ Distinguish between the implicit and explicit intentions possible in behavior ○ Understand how relational interactions change and develop over time Psychodynamic Freud’s concept of the psyche Conscious - things we are aware of preconscious - things that we can be aware of if we think of them Unconscious - deep hidden reservoir that holds the true “us” ○ All of our desires and fears Structure of Personality The id consists of sexual and other biological drives that demand immediate gratification. ○ Poor impulse control Ego: rational, decision-making aspect of personality, central executive functioning Superego: contains the memory of rules and prohibitions we learned from parents and others. Unconscious conflicts  ○ If the id produces sexual desires that the superego considers repugnant, the result is guilty feelings. Psychodynamic Model of the Psyche Unconscious conflicts are the core of psychopathology During the intake, the therapist searches for these conflicts and unresolved issues from development During therapy, looking at these aspects of the patient, even if they aren’t aware of them They sometimes are manifested and potentially influenced in the therapy relationship Projective tests Ambiguous stimuli, images, based on patterns and responses The basic assumption of all projective tests: ○ People project their internal dispositions into their responses to an ambiguous stimulus ○ Projective techniques are used mainly intuitively and clinically by more psychodynamically oriented therapists The Rorschach test ○ The person was shown cards depicting inkblots and asked to describe what they looked like The thematic apperception test ○ Pictures of varying degrees of ambiguity about which the person makes up stories Projecting things that are going on in their unconscious onto these ambiguous pictures Draw-a-person (used on kids), better used for screening. Psychodynamic therapy is about Focusing on the patient’s affective state Identifying and patient’s use of ego defenses Identifying patterns in relationships, behaviors, perceptions, and themes that underlie these (explore past) Examining interpersonal relationships Focusing on the way the patient relates to you as a therapist (including transferrence, transferring their feelings and desires onto someone else) Listening to the patient’s dreams and fantasies Providing support, interpretations, and promoting insight Focus: Affective State of the Patient Do they have an affect (emotion) phobia: the idea is that the maladaptive learned emotion can be unlearned through the relationship with the patient Phobic response to emotion causes anxiety, disgust, or discomfort as they pull back and this leads to a defense. ○ They don’t want to get emotional, prepare themselves with a joke (defense mechanism) This develops during childhood. The family system or culture of the patient doesn’t accept this emotional reaction, therefore, the patient learns to bury it.  The learning component is like behavioral models. Support, interpretations, and patient insight The therapist aims to enhance the patient's insight and repetitive conflicts sustaining the patient’s problems and tie them to experiences during the development. Supportive interventions aim to strengthen the patient’s ability to deal with emotions effectively. Focus: Use of ego defenses Understanding that patients are in denial The therapist looks for signs that defenses are being used ○ Missing sessions, changing the subject, arriving late, joking a lot ○ Focusing on aspects of a situation being discussed that aren’t related to emotion or their psychological state  Denial - refusing to accept real events because they are unpleasant Displacement - transferring inappropriate urges or behaviors onto a more acceptable or less threatening target ○ Displacing negative emotionality on something/someone else ○ Displace sexual energy on significant other Projection  ○ Attributing unacceptable desires to others Rationalization ○ Justifying behaviors by substituting acceptable reasons for less-acceptable real reasons Reaction formation ○ Formulating your reaction based on what others think ○ Reducing adopting beliefs contrary to your own beliefs ○ Expressing the opposite of their true feelings Regression ○ Converting back to childhood, to feel like that person ○ Returning to coping strategies for less mature stages of development Repression ○ Suppressing painful memories and thoughts Sublimation ○ Redirecting unacceptable desires through socially acceptable channels Focus: Patterns&Themes Identify and explore recurring themes and patterns in patients’ thought content, feelings, self-concept, relationships, and life experiences. In some cases, a patient may be acutely aware of recurring patterns that are painful or self-defeating but feel unable to escape them. Ex: a patient who has a pattern of relationships with romantic partners who are emotionally unavailable Object-relations Widely used psychodynamic approach ○ Focus: the relationship between self and others ○ The inner mental representations we have of our parents/caregivers ○ Attachment (determines the way we view and relate to other people) Remember: if the attachment process is healthy we internalize the caregiver, and feel okay separating and being autonomous, without an empty feeling Patients with a secure attachment will have healthy relationships It negates a void or feeling of loneliness ○ Patients will test therapists like they test other people in their relationship. Therapists have to be there and not be like the other people in their relationships. ○ How this concept could relate to psychopathology Contact-connection and disruptions - cause trauma in early childhood while the self is still forming → Unstable sense of self and problems in relationships (identity disturbance) Borderline personality disorder: Fear of abandonment A psychoanalytic theory that explores the relationship between people and their internal images of these relationships Change mechanisms The quality of object-relations ○ The capacity to understand and interpret the thoughts and emotions of oneself and others, utilizing this insight to clarify and influence interpersonal interactions ○ Hall hallmarks of good QOR: Long-standing, satisfying interpersonal relationships. The ability to form a strong emotional bond with the therapist. Ability to examine and grow from the strains that emerge in a relationship Relationships are difficult 9/5/24 Goal: Corrective Emotional Experience Experience through which one comes to understand an event or relationship differently or unexpectedly that results in an emotional “coming to terms with it” Patients achieve meaningful and lasting change through new interpersonal affective experiences with the therapist, particularly about situations that clients were unable to master as children. ○ In object relations, you can talk with the patient and they feel secure. Even though they are telling you these things, they feel that the relationship is still intact. ○ Dialectical behavior therapy (DBT) is a type of talk therapy that helps people manage their emotions and cope with difficult situations. How? ○ Through a relationship with the patient ○ Exposing the patient to emotional situations, repairing the traumatic influence of the past, reacting supportively Is it effective? Empirical evidence supports the efficacy of psychodynamic therapy Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as evidence bases Who can benefit from a psychodynamic approach?  Many psychiatric disorders - from milder adjustment disorders to severe personality disorders (like BPD) Patients dx with borderline personality disorder need supportive interventions to develop self-esteem… Example: Psychodynamic Therapy for Depression The psychodynamic view of depression is that it is a sense of loss, guilt over loss, and persistent low self-esteem despite attempts to bolster it (learned helplessness) ○ Empirical evidence supports the efficacy of psychodynamic therapy ○ Effect sizes of psychodynamic therapy are as large as those reported for other therapists that have been promoted as evidence-based It’s as effective as other treatments that are promoted as evidence-based Depression They are as therapeutically effective as alternative treatments, including antidepressants. More effective than no therapy (waitlisted controls) APA Division 12 suggests that they are modestly effective OCD Characterized by distressing, intrusive, obsessive thoughts and or repetitive compulsive physical or mental acts Anxiety, have to engage in a ritual to relieve the anxiety but it comes back. OCD involves persistent, uncontrollable thoughts and irrational beliefs The obsessions are intrusive thoughts that cause compulsive rituals that interfere with daily life ○ Out of control and nothing for us to have anxiety about (when there is a problem) ○ Interfering with functioning ○ Commonly reported obsessions: Contamination, safety, doubting one’s memory or perception, need for order or symmetry, unwanted intrusive sexual/aggressive thoughts, unwanted thoughts that are distressing and obsessive ○ Compulsions/rituals (performed by the person to reduce anxiety): Cleaning/washing, checking (locks, stove, iron, etc), counting, hoarding, confessing/seeking reassurance from others 2.6% of the US population suffers from this disorder A defense mechanism to prevent them from thinking about stressful things, allows them to focus on one thing Nidia’s Case Fear of contamination ○ She feels contaminated after using the bathroom so she has to clean herself from inside and out and wash her hands often. Freud's original recommendation for OCD patients was to expose them to anxiety-provoking situations and to use this to work on the unconscious conflict.  ○ Similar to exposure therapy (CBT/BT) Example: when you have those feelings of contamination, what are you blocking by carrying out your rituals? Can you remember a time in your life when you had similar feelings of disgust? What would it be like if you couldn’t clean yourself after using the bathroom?... Psychodynamic conceptualization Freud (1909) wrote that obsessional neurosis may be created when there is a split between love and hatred from a very early age. His or her sadism can persist and even grow because it remains apart from consciousness and apart from love (which also grows to keep the hatred repressed) Defense mechanism In summary Identifying, regulating, presenting, fostering, gaining ○ Promote inside while being empathic, the patient should gain insight into patterns of behavior Humanistic Approach Humanistic Approach A new view of human beings and approach to psychological therapy Human beings are generally “good” Person-centered approach Maslow and Rogers are two key figures in the development Hierarchy of needs ○ Physiological needs, safety needs, love and belongingness, esteem, self-actualization ○ Fully functional person, get them as close to self-actualization as possible. Maslow’s notion of self-actualization played a significant role in influencing the development of broader concepts within humanistic psychology and subsequently in the field of psychotherapy. ○ Basic physiological needs should be met first (shelter, food, adequate sleep)  ○ Safety needs (Feeling safe and secure in an environment, not hypervigilant to threats) ○ Love and a sense of belongingness ○ Sense of esteem ○ Self-actualization is what we are striving for Self-actualization Profound understanding of oneself, their values, self-acceptance, and purpose Includes qualities such as being one’s authentic self, and having the ability to be free to seek out what creates a sense of fulfillment and well-being This is an ongoing process and maintenance once self-actualized ○ To be our authentic selves, sense of purpose, and well-being. It is an ongoing process ○ Not many people can say they are self-actualized Types of Humanistic Psychotherapy Person/client-centered - Carl Rogers (a type of psychotherapy that helps clients discover their own solutions and understand themselves) Gestalt - Fritz Perls (a type of psychotherapy that focuses on the present moment, personal responsibility, and the relationship between the therapist and client) Transactional analysis - Eric Berne (a communication and psychology theory that helps people understand how they interact with others and improve their communication skill) Person/Client-centered THREE PHILOSOPHICAL BELIEFS Humanism ○ Self-actualization is possible ○ We strive for this Existentialism ○ We have free will → but make choices based on our experiences. Is this contradictory? Phenomenology ○ Our constructed reality may be different than someone else’s who had different experiences. ○ There is no one, single reality but rather reality is constructed through our own individual experience Key theoretical principles The human personality is positive Something is blocking the person from being their authentic self Psychological disorders are from low self-esteem and inability to be one’s authentic self Conditions of worth ○ Conditions of yourself that have to be met to earn that worth in a relationship All can become a fully-functioning person Incongruence - mismatch between who they are and who they would like to be ○ Who they are and who they want to be  Self-actualization/actualizing tendency Congruence Ideal self (who they want to be, the autonomy to become their authentic self), perceived self (what they see in themselves) If they have more overlap, then they are in a better position to self-actualization. ○ Self-actualization is possible Carl Roger’s Six necessary and sufficient conditions for positive change 1. That two persons are in contact 2. The patient is in a state of incongruence, being vulnerable or anxious 3. The therapist is congruent in the relationship (open, genuine, transparent) a. Need to know who you can work with as a therapist, not judgemental, and genuinely want them to do better. Introspection. The more you understand human behavior, you become the person who genuinely accepts the person regardless of what they have done 4. The therapist is experiencing unconditional positive regard toward the patient 5. The therapist is experiencing an empathetic understanding of the patient’s internal frame of reference a. The patient feels that you are genuine 6. The patient perceives condition 4 and 5 Mary Reports experiencing low self-esteem and feelings of inadequacy ○ Anxiety, and depression, which may come from her childhood experiences of never being “good enough” in her parents’ eyes What is something Dr. Hand should address? ○ Asking her why she feels that way ○ What is the situation, what about your parents? ○ Conditions of worth about gaining approval need to make Mary aware that she has worth regardless of what she feels about her conditions of worth.  Dr. Hands makes sure Mary is aware that she is accepted and has worthwhile interacting with her. ○ Question Mary what would make her worthy of love and acceptance in the eyes of her parents ○ Conditions of worth are external standards or expectations that individuals believe they must meet to gain approval, love, or acceptance from others. Holding themselves to standards that usually are unattainable ○ Being mean to yourself, would you say those things to your child? ○ Make sure what you’re doing is congruent with your ideal sense of self, not other people’s conditions. Conditions of Worth Criteria that individuals believe that they must meet to be valued, accepted, or loved by others including the therapist Can hinder personal growth and self-acceptance by denying or distorting their own needs to fit this framework. What are some conditions of worth? ○ Good grades, how much money you make, creating a family, fitting in with everyone (not everyone’s going to like you), physical appearance ○ I will only be loved if I… ○ I am not successful unless… ○ I am not a good person unless… Patient Growth in Humanistic Psychotherapy The therapist must: Experience and communicate unconditional positive regard for the patient There are no conditions of worth ○ They must be nonjudgemental ○ Genuine (congruence) ○ Actively listen ○ Reflect and paraphrase ○ Consistent across sessions ○ Achieve relational depth ○ Be non-directive (need to know for exam!!!) Listening and providing all the ingredients for growth You’re not telling them or directing them what to do This provides an environment for the person to self-actualize and become their true, authentic self Mark Has issues related to anxiety and self-esteem, and arrives visibly distressed, overwhelmed by feelings of failure and uncertainty about his future. Dr. listens with genuine empathy, creating a warm and nonjudgemental atmosphere. Maintains eye contact, and provides consistent and focused attention to his words and emotions. She reflects on  his feelings and experiences, helping him feel truly heard and understood. HELPS ACHIEVE RELATIONAL DEPTH Relational Depth As a deep and meaningful connection between therapist and patient The therapist consistently maintains elevated levels of empathy and acceptance for the patient, fostering, a transparent and open interaction Deep relation between patient and therapist Relational depth could describe a moment or a relationship Mearns and Cooper (2018) suggest that relational depth in therapy can be characterized as a state of profound contact and engagement between therapist and client… the therapist experiences high and consistent levels of both empathy and acceptance towards the client and relates to them in a highly transparent way. Authentic self A person’s true, genuine, and core identity, unburdened by external expectations, conditions of worth, or societal pressures ○ Self-image is congruent with the ideal self ○ Part of the journey to self-actualization ○ An innate drive we all have The fully-functioning person Reached or very close to self-actualization Is open to their experience without defenses Has a self-structure that is congruent with their experience Possess no conditions of worth ○ Unconditional self-regard Meets situations with behavior which is a unique and creative adaptation to the newness of that moment Is free of distortions, and unconscious conflicts Before, therapists were the ones who provided unconditional positive regard, now you do it for yourself. Effective? YES! Active and influential in different therapy models Core conditions used in other approaches and disciplines Is as effective as psychodynamic and CBT in RCTs (relational cultural therapy) Associated with large pre-post-patient change large gains relative to no treatment Recent studies show enough efficacy for mild-moderate depression, anxiety, psychosis, and SUDs- but not yet listed. Ethical Guidelines Treatment Rules of Confidentiality and Agenda Patients can say whatever they want to say and it stays in that room. You want the patient to be their genuine selves in the room, confidentiality is very important. The fundamental ethical and Legal principles in Psychotherapy and mental health treatment Therapists’ obligation to protect the privacy of the patient and keep their personal information and therapeutic interactions confidential They cannot disclose any information shared by the client during therapy sessions without the client’s explicit consent, except in specific situations outlined by law. ○ Consent to share patient information (what you will share and who you’re going to share it with) ○ Let them know right off the bat if you are going to share their information/confidentiality. What should the therapist do? A patient has been expressing intense and persistent thoughts of suicide during therapy sessions. They shared detailed plans to take their own life and have indicated that they have the means to carry out these plans. ○ Important: the safety of the patient ○ Decide what you’re going to do. Most of the time you will have to put them in the hospital to make sure they’re safe. John John reveals he has murdered in the past and indicates remorse and guilt for this action but has not disclosed this information to anyone else. ○ Does the therapist break confidentiality? No, because harm has already been done. He won’t hurt someone else. Don’t call the police unless you believe he is going to harm someone else. ○ Our job is the help the patient get better. It’s not our role in this situation to report them. Don’t want to break confidentiality or they will not come back to therapy. Breaking confidentiality may involve the following steps 1. Assessment of risk 2. Informing the patient 3. Involving appropriate authorities 4. Notifying others (if appropriate) 5. Documenting the situation Duty to Warn Warn somebody that could potentially be in danger He confides in therapy of his intent to kill Tatiana (his ex) Therapist notifies the university police and hospitalizes him with a diagnosis of paranoid schizophrenia  Tatiana was not notified of this threat, nor her parents ○ Later, he carries out his threat and murders Tatiana at her home The court rules that mental health professionals have a “duty to protect” … when they know or reasonably should have known that they have been threatened Credible and imminent threat: The therapist has reasonable grounds to believe that the client presents a credible and imminent threat to harm a specific individual or individuals Warning potential victims: therapists are required to take steps to warn the other person So, when do we break confidentiality? Imminent risk of harm to self: if a patient expresses a clear and immediate intent to harm themselves (e.g. suicidal ideation with a specific plan and means) Imminent risk of harm to others: duty to warn Child or elder abuse: therapists are mandated reporters In response to a court order or subpoena ○ But even then sometimes, therapists have their attorneys, because they believe in confidentiality. Relationships with Patients Mary and John John talks to Mary (his therapist and coworker at the same company) about his work-related stress and his memories of murdering someone. Mary and John have developed a positive therapeutic relationship and John values the support he receives from Mary. Is this ok? ○ Conflict of interest (Mary is also his coworker), work life, and therapy life might be blended. ○ Develop a personal relationship outside of therapy, murky situation Conflict of interest: Mary may find it challenging to separate her professional responsibilities as a therapist from her work-related interactions with John… Confidentiality: privacy may be compromised if coworkers become aware of his therapy sessions or if therapy-related discussions inadvertently arise at work Boundaries: the boundaries between therapist and coworker can become blurred, ​potentially affecting the therapeutic process and John’s comfort in discussing personal issues. What’s the big deal if they are both ok with it? You want just the patient-therapist relationship, not a dual relationship You’re not a friend, you're a therapist Ethical behavior: Dual relationships At the same time in another role in the patient’s life Relationship with someone closely associated with the patient (patient’s sister) Promises the patient to have a relationship with the patient or someone close to the patient once they end treatment Dr. Smith He is a licensed therapist and provided therapy for Sarah for two years, and the therapeutic relationship ended on good terms when Sarah felt she had achieved her therapeutic goals. Several years later, she gets tipsy and reveals she was attracted to him Dr. Smith asks her to go back to his place for a nightcap. They begin seeing each other for “nightcaps” regularly. ○ He can take advantage of certain vulnerabilities ○ It’s NOT good Romantic/Sexual Relationships with Patients Before engaging in a romantic and or sexual relationship with a former patient, therapists must consider the following factors: ○ The amount of time that has passed since counseling services terminated (2-year minimum) ○ The nature, duration, and intensity of counseling ○ The circumstances of termination ○ The patient’s current mental and emotional state ○ This should be avoided unless unusual circumstances (profound love and attraction?) Once a patient, always a patient Transference Psychodynamic concept The therapist can evoke reactions from the patient, that signify a theme in relationship problems, and this can alert the therapist if a type of transference is occurring. ○ Positive, negative, or sexual It occurs through unknowingly transferring feelings from someone from their past onto the therapist. This can help the therapist understand their relational past. Countertransference - therapist transferring feelings onto the patient What characteristics do you look for in a romantic partner? Someone who can listen to you without judgment, respectful, forgiving, caring, adventurous, someone you feel safe with What characteristics do you want in a therapist? The same ^^ Someone can interpret that relationship as something romantic. Transference from other relationships that hadn’t gone the way we want them to. The patient doesn’t know you but they might think that they do because you are “there for them” every session. Confidentiality guidelines are disclosed to the patient at the start of a treatment Lisa&Dominick Dominick was Lisa’s patient for 2 years. They sat at the same table at the festival.  Leave the table and go somewhereo if she isn’t seen by Dominick. If you are somewhere and a patient shows up, excuse yourself. Only say hi if he says hi first. DO NOT: say hi and tell him that she’s proud of him for leaving the house (sharing what she learned from therapy), pretend she doesn’t know him, and stay at the table. Behavior Therapies Behavior Therapies Goal: change maladaptive behavior that is contributing to emotional/psychological distress ○ Cognitions are seen as the consequence of depression and will change with behavioral changes. ○ Based on learning theories - operant and classical conditioning, social learning theory ○ Ex: depression is from a behavior-environment relationship ○ Low positive reinforcement ○ Observed depressed individuals Changing the behavior, they have the opportunity to change their behavior or situation but they don’t, they stay in it (learned helplessness) ○ Toxic relationship used to it, they’ve tried everything but nothing changes, consistently punishing Connected to physical/biological illnesses Key characteristics in behavior therapy Functional analysis- identifies the causes and consequences of behaviors ○ Is the person being regarded for a behavior ○ How is the behavior contributing to psychopathology? Recognizes the importance of the interaction between the person and the environment in facilitating change Plan and goal to change the behavior Goals are specific and measurable: ○ The patient will reach out to one person a week and set up a social activity for the next month Principles of learning overlapped with empirically evaluating intervention effectiveness Behavioral therapies (BT) Contextual techniques based on functional analysis of the patient. Ex: ○ Behavioral activation - a short-term psychotherapy treatment that helps people with mood disorders, like depression and anxiety, by engaging in activities that improve their mood ○ Contingency management - rewards people for positive behavioral changes ○ Systematic desensitization (exposure) [baby Albert] ○ Exposure and response prevention psychoeducation/training to change maladaptive behaviors ○ Social skills training ○ Anger management Patients assume an active role in the therapy  ○ Learn and practice coping skills, and roleplaying behavior ○ Homework assignments are given Systematic desensitization Classical conditioning ○ Fear of clowns: Talking about clowns, looking at pictures of clowns, videos of clowns, holding a clown doll, seeing a clown in person, interacting with a clown (pairing relaxation with the clown) Conditioning themselves and relearning that clowns are not going to hurt them ○ Albert and the white rabbit Behavioral Activation Identify and access sources of positive reinforcement to increase mood and decrease depressive symptoms. Directive therapy, with homework. The goal is to reengage in life through focused activation strategies Patient and therapist explore what activities used to bring them joy A plan is developed with measurable goals ○ Create a schedule with the patient, start with simple goals, and work your way to challenging activities. ○ Patient who has depression: goals to get out of bed, eat breakfast, go out to talk to friends *you can mix different therapies to customize the therapy for specific people* Behavior Activation and Depression Negative cognition ○ Too few rewards for dealing with life’s many problems Withdraws/isolate ○ People isolate and withdraw when stress builds up, causing depression and disrupting basic routines. Depression ○ Withdrawal and isolation increase depression and make problem-solving more difficult. Increased positive emotions ○ Identifying what activities would be most helpful and what small and manageable steps you can take to get started ○ Session time is used to discuss steps to engage in activities to improve mood and address problems. ○ Doing something that they love Symptoms attenuate/Believe ○ Maintain activities ○ Adequate reward from the environment maintain behaviors Is it effective? YES! For depression Increases the reward-seeking and reward response by increasing positive reinforcement →> leads to learning cues that predict possible rewards in the environment. The patient gets the feeling that they’re retaking control of life and in situations that increase dopamine. Increasing activities improve self-concept, depression As effective or more effective than cognitive therapies Focus: prevent avoidance of cues that produce negative affect Exercise prevents relapse, maintenance of the activity that they love reduces depression Exposure and Response Prevention A CBT with a behavioral focus that teaches how to engage with triggering situations and is based on learning theory Use of hierarchy Expose people to the anxiety-provoking situation Good for OCD ○ Expose them to anxiety-provoking situations (touching dirty door knob) –> Anxiety increases → then they want to wash their hands, prevent them from washing their hands for a certain amount of time (and increase it) Anxiety will drop over time ○ Relearning that they can be okay, and don’t need to panic. Marie Scared that weight would make the floor fall into the apartment below Exposure, want the patient to learn that the anxiety will go down She’s trying to increase her anxiety so that the patient learns that they don’t need to compulse and anxiety will go down Exposure and Response Prevention Based on learning theory -habituation A person needs to see that nothing bad happens The ability to see the anxiety is reduced fast ○ Don’t let them be compulsive The ability to see that nothing bad happens can take time to learn It is not the same as systematic desensitization because that uses relaxation training Behavior Therapies Used to treat a wide range of psychological disorders in specific populations Applied in the fields of developmental disabilities, mental illness, special education The focus is on directly observable behavior What are the determinants of behavior  Learning experiences that promote change in target behaviors ○ Using learning theories, positive reinforcement Treatment strategies are tailored to individual patients ○ If the exposure is too much, dial it back ○ They might need medication Rigorous assessments of progress Flooding Throw them in anxiety-inducing situations and leave them there (not used anymore) Cognitive Therapy CBT with Cognitive Focus Starting with cognition: what is the patient’s cognition? Maladaptive cognitive distortions, change their cognition and will lead to changes in behavior. Cognitive Therapy - Aaron Beck 1960’s Cognitive Therapies: Focus is on how our brain relates thoughts, feelings, and behaviors and how this relationship can affect our experiences. Thoughts, behavior, feelings (interact and affect each other) Albert Ellis: Rationale Emotive Behavior Therapy (REBT) Cognitions, emotions, and behaviors interact and have a cause-and-effect relationship We learn irrational beliefs from significant others during childhood and then re-create these irrational behaviors throughout our lifetime The repetition of learned irrational beliefs underlies psychological and behavioral dysfunction “Shoulds”, “musts”, “oughts”, demands, and commands are explored and disputed Confrontational therapists, challenge patients (I should have, nobody loves me) ○ So what if that’s the case ○ Challenged their thinking, is it as bad as what they were thinking? What would happen? ○ Catastrophizing ○ Are their thoughts rational? ○ Is that rational? Basic “musts” “shoulds and ought to’s (Irrational beliefs) These lead to self-defeating behavior and include I must do well and be loved and approved by others Other people must treat me fairly, kindly, and well ○ That’s not going to happen The world and my living conditions must be comfortable, gratifying, and just, providing me with all that I want in life ○ Setting you up for disappointment A-B-C (D-E) Framework Activating Event/ Adversity Belief about A (which leads to C) Emotional Reaction Dispute ○ Disputing the emotions related to it ○ Most people won’t care Effect ○ Your thinking will change Techniques are used and Taught by the Therapist Emotive and dispute irrational beliefs Unconditional acceptance ○ During this, the therapist may interrupt patients and challenge them if they think the belief is irrational such as “I am a failure” or “I am unworthy of love” Rational emotive roleplaying ○ During this, the therapist may interrupt the patient and challenge them if they think the belief is irrational such as “I am a failure” or “I am unworthy of love” Rational emotive imagery ○ Not wanting to wear an outfit or speak in front of a crowd ○ … Behavioral Cognitive Therapy The process of thinking influences emotional difficulties Distress is alleviated by challenging and correcting faulty thinking and perceptions Beck’s Negative Cognitive Triad Regardless of the cause of depression, once depressed, thinking reflects negative views of ○ The self (self-criticism) ○ The world (pessimism): people are generally not kind, they have a hidden agenda, and this is a terrible place to live ○ The future (hopelessness): what’s the point, the more hopeless you feel the more depressed you get Image: self-criticism, pessimism, hopelessness ○ Negative cycles This maintains depression, even if negative thoughts are not the original cause. Cognitive therapy Three important components of cognition ○ Core beliefs  Parents may leave you with feelings of not being good enough (a core belief), which will lead to automatic thoughts about people not being trustworthy. ○ Automatic thoughts I might as well not try to get into a college, I’m not good enough so I shouldn’t get into a relationship, I’m not good enough so I shouldn’t even try applying for the job. ○ Cognitive distortions Personality disorder What we need to focus on is to help the patient gain insight and understand that the thinking is distorted. Core Beliefs (Cognitive Schemas) Foundational, inflexible assumptions that we have about ourselves and the world around us ○ Impact every area of the person’s life ○ How they view themselves ○ What careers do they work toward ○ How they navigate in society (right and wrong) Antisocial beliefs ○ Relationships ○ Sometimes we aren’t aware of them, but our behavior tells the story Beliefs about the self and the world Core beliefs about the self that can be a problem I’m not the type of people fall in love with There’s something weird about my personality My opinions don’t matter to other people I’m too unattractive to find anyone I don’t deserve happiness I’ll never live up to the expectations My needs aren’t important I’m not bright enough to do anything academic Cognitive therapy is very directive, giving homework, and challenging them to change their thoughts. Automatic thoughts Immediate perceptions and interpretations of events ○ I.e. Text messages ○ how they perceive certain things in a distorted way based on their core beliefs and cognitive distortions Shape both our emotions and behavior in response to events If they are dysfunctional, maladaptive, distorted → psychopathology Cognitive distortions  Cognitive distortions are irrational thoughts that shape how you see the world, how you feel, and how you act. It’s normal to have these thoughts occasionally, but they can be harmful when frequent or extreme. ○ Magnification and minimization Catastrophizing ○ Overgeneralization “I am always so awkward” Challenge this thinking: “Think of a time when you aren’t awkward” ○ Magical thinking ○ Personalization “My mom is always upset. She would be fine if I did more to help her” ○ Jumping to conclusions “They don’t like me”, where is the evidence? Mind reading Fortune telling: the expectation that a situation will turn out badly without adequate evidence “I’m going to embarrass myself, I’m going to fail” ○ Emotional reasoning ○ Disqualifying the positive ○ “Should statements” ○ All-or-nothing thinking It is hard to see out of that during an emotionally charged situation Negatively biased errors in thinking have been cited in the research literature to increase vulnerability to depression and anxiety ○ …. Cognitive Reconstructing Identify core beliefs Identify automatic thoughts Identify cognitive distortions Cognitive Model in CBT Situation: social engagement Core beliefs: I’m always awkward ○ Change to I’m OK around people, there are times when I’m not awkward Automatic thoughts: I’ll embarrass myself ○ It’ll be fun Reaction: Retreat and isolation, which leads to anxiety ○ Look forward, go, and enjoy the event General Cognitive-Behavioral Therapy Reframe the situation  … OCD CBT and SSRI combination is the best treatment for patients with OCD CBT is more effective than the others, but “best” combined with SSI Combining SSRIs is helpful what about other psychotherapy approaches with CBT? Unconditional positive regard Empathy Exploring causes and defenses and gaining insight These can be used in combination with CBT if the patient characteristics align accordingly. However, being directive is part of CBT Dialectical Behavior Therapy A comprehensive cognitive-behavioral treatment Developed as a treatment for clients struggling with severe and persistent emotional, behavioral, and thought difficulties, especially those diagnosed with borderline personality Emotionally dysregulated: ○ Highly reactive ○ Hypersensitive → hypervigilant (rejection sensitivity in BPD) Get upset easily, thin skin, very sensitive Perceiving things in a negative way and highly emotional, very distressing ○ Fight or flight ○ Slow return to baseline They stay emotional for longer Self-harming behaviors Suicidal ideation/behavior Biological Predisposition Temperament: an organized style of behavior that appears early in development ○ Shapes an individual’s approach to his or her environment ○ Three primary dimensions Positive affect and approach Fearful or inhibited Negative affect or irritability Linked to a higher risk of psychopathology Style may be related to a specific disorder The condition may develop from the features related to their temperament ○ Stable throughout the lifespan ○ If you have a difficult temperament, more at risk for certain types of psychopathology Linked to a higher risk of psychopathology  Style may be related to a specific disorder The condition may develop from the features related to their temperament Environment: Transactional model of emotion dysregulation development Invalidating developmental environment Some individuals have a sensitive temperament that predisposes them to react with intense emotions or it’s a consequence of something that happened. Caregivers don’t understand or allow these reactions or help with emotion management. Doesn't learn emotional regulation, how to label emotions and talk about them, how to cope with them etc. ○ They get upset about something and see it through a cognitive distortion their response is disproportionate to the situation. ○ Afterwards, they beat themselves up. They can’t regulate their emotions The child becomes further dysregulated; caregivers become more frustrated, and becomes a cycle of dysfunction into adult life ○ Doesn’t advance goals ○ Isn’t typically true ○ Regret later when emotional arousal is attenuated ○ Damage to relationships Stress during development Predictable stress in moderate amounts (fairly predictable and controlled) builds resilience, they are learning. ○ Bringing them to daycare, giving them chores, doctor’s appointments, arguments with siblings, sports;/extracurricular activities Unpredictable stress (chronic, long-term, and intense) → starts to develop vulnerabilities to have emotional problems later in life. ○ Bullying, parents with substance abuse (explosive parents, no dinner) Environment: caregiver interaction Caregiver interaction, architecture of the brain developing early on To develop a healthy brain, if the caregiver is not there for them, there will be problems later in life Environment: shaping the brain Brain systems are shaped by early experiences and developmental history Early adversity contributes to being emotionally reactive to stress and poor emotional regulation Imaging studies of those who experienced childhood maltreatment point to frontolimbic circuits as the compromised region Undermodulated emotion is related to heightened amygdala activation and attenuated prefrontal inhibitory activation ○ BPD patients perceive faces that are more neutral than angry as angry  Overmodulated emotion (e.g. dissociation, flat emotionality is related to extensive prefrontal inhibition of limbic activity) ○ Support for the dissociative subtype of PTSD Emotion Dysregulation Nice balance between excessive leniency and authoritarianism, normalizing pathological behaviors and pathologizing NORMAL behaviors, fostering dependence and demanding autonomy Explaining emotion, assists them in processing their emotions, feeling comfortable with autonomy, and not overly dependent on caregivers. If not done right → identity confusion (patients with a personality disorder) ○ Patient with personality didn’t have a stable identity, and couldn’t ground themselves in their own identity. Ex: Their boyfriend’s interest was their whole identity, changed with different boyfriends Chronic and pervasive emotional dysregulation Emotion dysregulation: exaggerated or misattributed emotions lead to maladaptive behaviors used to try to regulate emotions However, they then cause situations that make the negative emotionality more intense. The negative reactions from others confirm their distorted core beliefs Fear of abandonment ○ Patient’s distorted perception of a situation based on their core beliefs leads to reactions that cause others to feel uncomfortable and then confirm their core beliefs. Personality Disorders Distorted patterns of thought Problematic emotional response Over or under-regulated impulse control Problems in interpersonal relationships These four core features are common to all personality disorders Comorbidity rates are high Must demonstrate significant and enduring difficulties in at least two of those four areas for dx Most people are hospitalized for the symptoms of personality disorder. Borderline Personality Disorder Pathological personality traits in the following domains Emotional liability ○ Anxiousness, separation insecurity (boundary breaching), clinging/codependency (demanding attention), hostility Disinhibition (behavior) ○ Impulsivity, risk-taking, substance abuse, sexual promiscuity  While a person can see it from a perspective of what it is (not all-or-nothing thinking), patients with borderline personality disorder are unable to see the situation for what it is that causes them anxiety. That’s how they perceive it, that’s how they’re feeling (separation anxiety, clinging, and codependency) ○ “See this is how people are” ○ Getting them to see the insight into their behavior is a good way to change it. Biosocial Model of BPS Emotional vulnerability, emotional sensitivity (more easily triggered emotions), … Perception BPD patients scored higher than either healthy controls or patients with anxiety disorders on a questionnaire measuring rejection sensitivity Compared with either group, they reported a greater tendency to both expect and perceive rejection (Even if they were not rejected)... BPD These findings… BPD Cyberball study Patients engage in an online ball-tossing game with partners who they believe to be co-participants In the “inclusion” condition, all players receive the same number of ball roses, whereas in the “Exclusion” condition the co-players stop tossing the ball to the subject, thereby excluding him from the game BPD patients felt more rejected than healthy controls independent of the experimental conditions, i.e. they felt more rejected even when they were being equally included ○ Perceiving being excluded when they were not excluded Social pain-physical pain Brain bases social pain are similar to those of physical pain The anterior cingulate cortex (ACC) was more active during exclusion than during inclusion and correlated positively with self-reported distress Cyberball study findings parallel results from physical pain studies: ○ Reported being not included, painful ○ Social pain is seen in the same areas of physical pain This combination Increases distress in the patient Distorted perceptions + Increased sensitivity + Frontal cortical impairment (Contol/impusivity) → serious distress and dysfunction Treat this with dialectical behavioral therapy 9/24/24 Synthesizes three paradigms:  Dialectics Behaviorism Mindfulness Purpose: Reducing dysfunctional behaviors Increasing skillful behaviors Patients need a validating environment in which they are helped with regulating emotions, interpersonal conflicts, tolerating distress, and finding balance* You need to validate their feelings to help them Dialectical Paradigm Dialectics is the theory that opposites can co-exist Therapist: ○ Acceptance and validation ○ Guiding the patient to modify perceptions and reactions Patient: ○ Two opposing truths can exist simultaneously ○ As the patient changes the environment they live in changes Therapists’ stance in DBT The patient is doing the best they can Validation of the feeling, even if disproportionate or maladaptive Patient cannot “fail” at DBT The patient needs to do better and stay motivated to get better The relationship with the patient is real and a genuine relationship (like humanistic) They accept the patient for who they are and where they are at in the treatment Non-judgemental and validating There is contact between sessions ○ Coaching skill building The therapist MUST have support from other professionals due to the nature of emotional regulation (ER) disorders. Targets for Stabilizaiton Reduce ○ Life-threatening behaviors: suicidal ideation/attempts/superficial attempts/risky behavior Threatening to blame you if they harm themselves, threatening to harm themselves (superficial attempts) ○ Therapy interfering behaviors: missing sessions, not completing homework, behaviors that interfere with the therapist’s motivation to treat the client Missing sessions, not doing homework  ○ Quality of life-interfering behaviors: substance use, eating disordered behaviors, inability to sustain a job, school, etc The patient stops eating and loses a lot of weight to get a message across to therapist, and the therapist needs to notice that DBT: Psychotherapy for People with Personality Disorders Personality Disorders in the DSM-5 There are three clusters of PDs from the DSM-5 ○ Cluster A: odd, eccentric (e.g. paranoid, schizoid, schizotypal) rare ○ Cluster B: dramatic, emotional, erratic (e.g. Borderline, narcissistic, antisocail) ○ Cluster C: anxious, fearful (e.g. avoidant, dependent, obsessive-compulsive) What makes personality disorders challenging to treat? There is not enough research on different types of personality disorders There is a lot of work to be done The patient not motivated to do therapy Ensure that the patient is on board with changing and moving forward, even if they don’t know why they need to change yet. Dialectical behavioral therapy Increasing insight into why he feels the way he feels Emotional regulation strategies Anger issues, aggression Therapy involves finding/revealing things about yourself that you don’t like It will be painful to realize Need to be motivated to change or to accept something they are refusing to accept History and Presenting Evidence Developed by Marsha Linehan after determining that traditional CBT is not effective for BPD, chronic suicidality A third wave of therapy, multimodel intervention incorporating aspects of CBT, Psychodynamic psychotherapy, ACT, Zen Buddhism, Catholicism, and more! The key component - the dialectical balance between acceptance and change Studies show that it’s more effective than CBT and other interventions in treating BPD and suicidal behaviors The Dialectic Acceptance and Change  Acceptance: in DBT, clients begin to learn how to accept who they are and how they feel, think and act Change: in DBT, clients begin to learn new skills and ways of relating with others and themselves Important to consider both sides Components of DBT Treatment Skills Group Individual therapy ○ Serves the function of helping the patient/client apply the skills that they go through in their day-to-day life Phone Coaching ○ Helping the client apply some of the skills to get through the toughest moment in their life ○ If they can’t get through the situation on their own, it’s the role of the phone coach to offer some in-the-moment help (the specific situation right now, directive advice to cope with the situation right now) DBT Consultation Team ○ Think about what we could’ve done differently ○ Team members offer advice to help the therapist navigate different situations DBT's goal isn’t to prevent them from suicide but to help them find a life that is worth living. Priorities to discuss: ○ Suicidal behaviors ○ Therapy preventing behaviors ○ Quality of life behaviors DBT skills 1. Mindfulness (core skill) a. Focusing on the present moment, not letting the mind wander to the past or future, which can interfere with what you’re engaging in right now b. *Awareness that arises through paying attention, on purpose, to the present moment,, non-judgementally c. Emotional mind + reasonable mind = wise mind 2. Emotional regulation: improving the ability to flexibly respond to emotions a. Check the facts: check whether your emotional reactions fit the facts of the situation. Changing your beliefs and assumptions to fit the facts can help you change your emotional reactions to situations b. Opposite Action: when your emotions do not fit the facts, or when acting on your emotions is not effective, acting opposite (all the way) will change your emotional reactions i. Acting the opposite of your urge, acting the opposite of your anger, helps you pull back to the reality of the situation c. Problem solving: when the facts themselves are the problem, solving the problem will reduce the frequency of negative emotions  i. Focusing on solving the problem will distract you from the negative automatic thoughts and reduce negative emotions by solving what you can control 3. Distress tolerance: learn that distressing emotions are tolerable a. Survive crisis situations: without making them worse b. Accept reality: replace suffering and being “Stuck” with ordinary pain and the possibility of moving forward c. Become free: of having to satisfy the demands of your own desires, urges, and intense emotions 4. Interpersonal effectiveness: improve relationships, manage conflict Radical Acceptance Worksheet Incorporates distress tolerance and mindfulness skills If you have trouble accepting the reality to life Distress Tolerance Skills STOP skill Stop: Do not just react. STOP! Freeze! Do not move a muscle! Your emotions may try to make you act wihtout thinking! Stay in control! Take a step back: Take a step back from the situation. Take a break, let go. Take a deep breath. Do not let your feelings make you act impulsively Observe: Notice what is going on inside and outside. What is the situation? What are your thoughts and feelings? Proceed mindfully: Act with awareness, in deciding what to do. Consider tour thoughts and feelings, the situation, and other people’s thoughts and feelings, teh situation and other people’s thoughts and feelings. Think about your goals TIP Tip the temperature (cold/ice bath) Intense exercise Paced Interpersonal Effectiveness DEAR MAN ○ Describe the situation, expres yourself, assert yourself, reinforce, (stay) mindful, appear confident, negotiate GIVE ○ (Be) Gentle, (act) Interested, Validate, (Use an) Easy Manner FAST ○ (Be) Fair, (No) Apologies, Stick to values, (Be) Truthful  Exam Review 1. Which of the following best describes psychotherapy? A. 2. Whcih of thr folowing i something that a psychotherapist would do under their scope of practice? D. 3. Which of the following can conduct psychotherapy? E. a. Psychiatrists and nurse practitioners can prescribe b. Pschologista nd listeneced mental counserlors and clinical social workers cannot prescribe Is psychotherapy effective? YES, NNT for psychotherapy is 3 (good)! Number needed to treat (NNT) = 1/ARR ARR = disease severity in control - disease severity in treatment group Debate: Is it the treatment or is it the relationship? (dodobird debate) It’s both! The therapeutical aliance, therapist is well-oriented in their practice, patient trusts therapist. Using that as foundation, therapist integrates the psychotherapy techniques, CBT, BT, etc. 4. Love and Dr. Springer… A. a. You have to adjust the therapy to the specific patient Case conceptualization helps us decide how we will approach the characteristics with this specific patient. Establish a therapeutic relationship Identifying goals and creating objectives 5. CNIP. C. measures patient preferneces regarding therapy and therapists Psychodynamic: understand the patient’s defenses, make them feel safe, find a way to best help the patient Look for unconscious conflicts in unresolved issues from development or in therapy relationship (transferrence) 6. A. (thematic apperception test, rorshach test) Psychodynamic therapy is about focusing on the aptient’s affective state, identifying and patient’s use of ego defenses, identifying patterns in realtionships, beahviors, perceptions, themes, examining interpersonal relationships Dream analysis Hypnosis Free-association (I say a word and you say the first thing that comes to mind, their immediate response) Patient’s phobic response to the emotion causes anxiety, disgust, or discomfort (affect phobia) Ego defenses (different types need to know) Object relations (Attatchement): coontact connection and disruptions in early childhood leads to unstable self and problems in realtionship (identity disturbance) Quality of Object Relations: the capacity to understand and interpret the thoughts and emotions of oneself and others utilizing this insight to clarify and influence interpsersonal interactions Does the patient have problems in their relationships, not bonding with therapist? Speaks to identity disturbance, borderline personality disorder Goal: Corrective Emotional Experience (coming to terms with it) How? Expose patient to emotional situation → repair the traumatic influence → therapist responds differently than original caregiver and patient gains insight → patient relearns the experience, abandom maladaptive view → psychopathology resolves Case Conceptualization (through the lense of different psychotherapies) Humanistic Appraoches: humans are generally good, striving for self-actualziation Person centered approach (humanism, existentialism, phenomenology) ○ Psychological disorders are form low self esteem and inability to be ones authentic self ○ Conditions of worth ○ Incongruence (ideal self and perceived self) Carl Roger’s Six neceassary and sufficient condiitons for positive change Patient can say whatever they want, thearpist help the patient become more congruent 7. Confidentiality, self harm. C. a. Suicide lethality scale and make sure they’re safe Duty to Warn Behavior Therapy Systematic desensitization (pairing relaxation with phobia) Behavioral Activation (finding fun activities, positive rewards to boost emotion) ○ YES IS EFFECTIVE FOR DEPRESSION. Increases reward seeking and reward response, increases self-confidence 30 mulitple choice, true or false questions Somatic Symptom Disorders Revisedin the DSM 5 - making it easier to differentially diagnose patients…  The emphasis on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion Somatic Symptom Disorder The fear and anxiery is disproportionate to what’s actually going on Emphasizes that Dx is made based on the presence of disrressing symptoms + abnormal thoughts, feelings and behaviors in response to them.. They do have symptoms but their *REACTION/FEAR* is disproportionate to their actual symptoms DSM-5 Diagnostic Criterioa (table) The emotions and psychological response that is preventing them from functioning High levels of anxiety Excessive amount of time focusing on the symptoms ○ Doing research on google, looking up the symptoms Persistent state of being symptomatic (more than 6 months) Excessive thoughts, feelings and behaviors that are disproportionate to their actual symptoms ○ Taking their mind away from things they need to deal with What is illness anxiety? defined by excessive worry about having or developing a serious disease/illness that has not been diagnosed Persistent anxiety, internet searching, misinterpretation of physical symptoms/bodily sensations Preoccupations with bodily functions ○ Interpret normal bodily sensations as something being seriously wrong Death anxiety ○ Anxiety about death Have normal everyday symptoms, or none at all, but they will demand tests from doctors Illness anxiety disorder (the focus is on having the illness even without any actual symptoms) DSM 5: illness anxiety disorder Somatic sumptoims are not present or if present are only mild in intensity People with IAD may be uncomfortable experiencing normal bodily sensations, and they may label the subtle bodily changes as psychological (table) Short Health anxiety Inventory (HAI-18) How much time the patient takes worrying about their health Hypochondria (always worrying abou their health) Risk Factors Having a serious childhood illness  Experiencing a significant health scare Close family member or friend with a serious illness or death Fear and anxiety manifesting as i am going to die, I have an illness Anxiety disorder diagnosis in the past Family history of anxiety disorders Case study (illness anxiety disorder) : patient comes to the doctor saying they have pancreatic cancer, takes tests, nothing is wrong. Patient is always hyperfocused on pancreatic cancer, convinced with no medical diagnosis to confirm that they are ill, so they take a lot of time creating videos and letters for their daughter. stressful. Her marriage has been deterioration for some time Financial issues have left her worried about losing her home She is not interested in her husband romantically Her children are not doing well in adult life Husband has a “Fantasy football” addiciton that drained their bank accoutn without her knowledge What is her diagnosis? How owuld we apply the different psychotherapy approaches? ○ Psychodynamic conceptualizations Unconscious conflicts underlie the disorder Unconscious aggresive feelings manifest as physical complaints Undealt with traumatic or frustration during childhood manifest in adult life as symptoms Angry and disappointed in children Frustrated towards husband, guilty for not loving husband/being proud of husband Suppressing these emotions ^ Defense used to avoid attendance to actual problems that are too difficult to face ○ Psychodynamic Affect phobia - keeping real emotions about real situations at bay People will harm themselves to get attention from doctors and people around them. They will infect wounds, eat things that will cause intestinal issues, something in them needs nurturing (that they didn’t get early on) Explore areas of unconscious trauma Explore areas of anxiety and or underlying conflicts Therapist help with these wounds Does the patient feel trapped Trauma (remembered in the trauma) Feelings of anger/hostility Feelings of being “trapped” in a situation Loss of control? ○ Resolve on a conscious level Object relations: attatment transferred to phsycial symptoms? ○ Be there for the patient and form a theraputic relationship Psychodynamic Negative therapeutic reactions… Just listen to the patient and answer them empathically while exploring the other things in the patient’s life becuase it is the other things that Deeper understanding of the patient that helps them get better Cognitive-behavioral appraoch Core beliefs Remember: congnitive theory of psychopathology, disorders are reso=ult of maladaptive core beliefs about themselves and the world Not concerned about past events or unconscious conflicts Cognitive distortions Application to illness anxiety (slide) Challenging maladaptive patterns of thought ○ Core belief: good health means no physical symptoms or physical symptoms lead to death → is this a cognitive distortion? All or nothning? Catastrophizing? You can be in good health and have symptoms Functional Neurological Disorder (FND) Conversion disorder DSM4 (used to be called that) Features nervous system Neurological symptoms that can’t be explained by neurological disease or other medical conditon ○ However, the symptoms are real and cause significant distress or problems functioning Tells the doctor they can’t feel anything in their hand, but nothing wrong with the nerves A neurological condition caused by changes in how brain networks work, rather than changes in the structure of the brain itself, as seen in many other neurological disorders Common symptons ○ Psychogenic non-epileptic seizures (PNES) ○ Psychogenic dystopia (movement disorder) ○ Sensory disruptions: eharing, seeings, numbness of a limb ○ Paralysis ○ Tremors and ticks Having a neurological disorder due to a psychological problem Physological change after thinking about something (like a midterm or fight) ○ Cascade of physiological effects in our body just from thinking ○ Stress effects the immune system CBT for Psychogenic Dystonia (Psychogenic Movement disorder) -type of FND When there is muscle movements that are ambnormal ○ Nothing going on in their biological health, no physcial problem ○ Needs psychological examination Case study  ○ Body buckle ups ○ They get angry with themselves or frustrated with themselves when they bottle things up. Doesn’t allow herself to get angry. (affect phobia) ○ Doctor used CBT to help the patient 16 weeks post-treatment: symptom free Fucntioning properly Predisposing Factors A history of childhood trauma Comorbid mental health disorders, especially depression or anxiety A recent stressful or traumatic event A recent health condition Cognitive Behavioral Model for the Developnnent of FND (image) traumatic/adverse event →symptoms occur → catastrophizing thoughts → stress-intensified symptom → serious functioning difficulties Cognitive Restructuring – Bottom up to top down Access the thoughts and take control of them Bottom up processing is a primitive automatic implicit and preconsicous information processing system that is activated by the salient features of relevant stimuli or situations ad associated schemas Studies of emotional evalluation using fMRI have associated bottom up processing (implicit and automatic) with the amygdala Top down processing is a slower, deliberate (explicit) Mass Psychogenic Illness A number of cases of FND within a certain area There is increasing recognition this is understudiesd, unerrecognized, under-reported and is cause for significant social and health concerns Two Types Anxiety hyteria ○ Mostly seen in western countires ○ Triggered by intense, acute stress within a close group of people ○ Typically, not always, someone will report an odd odor and coice concern it is a harmful toxin ○ Symptoms are transient, do not pose a health threat → dizziness, headache, passing out and hyperventilating ○ Most recover within 24-48 hours ○ There is an absence of pre-exissting tension within the group of people ○  Motor hysteria ○ Caused by long term anxiety and features motor agitation ○ Sumptoms include twtiching, tremors, unsteady gait, uncontrollable laughing, crying, communication difficultites and being ina trance ○ onset is slow and takes weeks or months to subside…. Mass Psychogenic Illness Someone who has some type of connection In october 2011 several adolescent girls at a high school in the town of Leroy, NY spontaneously developed facial tics, muscle twitching and a garbled speech. By early january 2012, it was revealed they were diagnosed with conversion disorder. Traditionally there is a stressor that provoke a physical reaction in the body. It is unconscious, the stress has to come out of its body in some way shape or form. What elements from DBT could we bring in to the therapy? Mindfulness, stress managements skills Hunanistic (person-centered)? Treating patient with unconditional positive regard, help the patient overcome illness Case Study In denial stressful job Defense mechanism was to continue what you are doing it’ll all pass in time With depression, negative thoughts, everything is seen in a negative light. Not doing job properly, low self esteem low confidence, questioning decisions he was making. Sleep was affected, ruminating in the middle of the night Very anxious, panic attacks when there were other people in the room, wondering if they see that. Struggle with emotions, hoping that things would go away, but they just got worse Met with manager, noticed issues, Deep down he knew it but it took someone to tell him Noticed changed after 2 weeks of taking medication, attributed it to the medication. Enjoying things more, less negative thoughts. Things were starting to improve, took time off work and dealt with them in an appropriate manner. Can notice the trigger signs and what stresses him out a lot quicker and can prevent it. 2) feeling of uncertaintly, feeling unsure of himself for a long time. In secondary school, his best friend moved and he didn’t mized in and retreated himself, was alone and just studied What happened since then: avoid people as much as he can, looking busy, trying to avoid sharing the lift with others. Anxious all the time around people (social anxiety?). Don’t want people critiquing him.  Somehow avoids people, dreading the htought of someone speaking to him and gets all sweaty, has had a panic attack, picked on round do a case press, froze and it was awful, felt sick. Family: anxiety mood problems in mother, mother is like a warrior, “don’t do that you will hurt yourself” dad died when he was 11. Mother was very anxious. Mood: such an effort to get through, doens’t want to quit. For the first case, the therapist could use cognitive behavioral therapy. According to our class CBT slides (lecture 6), CBT focuses on “how our brain relates thoughts, feelings, and behaviors and how this relationship can affect our experiences.” The patient states that he has depression and has strugged with a lot of negative thoughts and low self esteem, and ruminating in the middle of the night and not getting enough sleep. This could suggest that he may have maladaptive cognitive distortions associated with how people view him o