Systems of Psychotherapy CHP 1 Notes PDF

PAGE 1: Psychotherapy has been fragmented by future shock and staggered by over-choice. Hyperinflation of brand name therapies over the years (500 and growing) Many theories claim success, but which one should be studied? Fragmentation and con...

PAGE 1: Psychotherapy has been fragmented by future shock and staggered by over-choice. Hyperinflation of brand name therapies over the years (500 and growing) Many theories claim success, but which one should be studied? Fragmentation and confusion in psychotherapy may be reduced by a comparative analysis of psychotherapy systems. Comparative analysis requires a firm understanding of each system. Comparative analysis: (steps) 1. Clinical example and developers of systems 2. Trace its theory of personality -> theory of psychopathology -> culminates into therapeutic processes 3. Practicalities of the psychotherapy 4. Summary of controlled research 5. Central criticisms of that psychotherapy from diverse perspectives 6. Analysis of Mrs C. PAGE 2: When comparing systems we will use an integrative model to demonstrate similarities and differences. Integrative model is selected due to rapprochement, which seeks what is useful instead of what is easily criticized. It also represents mainstream contemporary psychology. Integration is the most popular orientation among mental health professionals Integrative endeavors can sometimes lack a comprehensive model for thinking and working. Textbook integrative model assumes a limited number of processes of change. This model assumes that therapy content can be reduced to four different levels of personal functioning Psychotherapy systems are compared on a particular process or combination of processes to produce change. They are also compared on how they conceptualize common problems Textbook limits comparative analysis to 15 major systems of therapy. No system was excluded if at least 1% of American professionals endorsed it. Defining Psychotherapy There is no single definition of psychotherapy. Psychotherapy: psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable. Psychotherapy definition is deemed both broad and neutral in terms of theory and method. PAGE 3: Definition also mentions clinical and interpersonal stances. In some therapy systems the therapy relationship has been regarded as the primary source of change Any psychotherapy activity should be conducted only for the purpose of assisting people The Value of Theory Theory also has many meanings. In psychotherapy, a theory is a consistent perspective on human behavior, psychopathology, and the mechanisms of therapeutic change. These are the necessary but not sufficient features of psychopathology theory. Explanations of personality and human development are frequently included but they are not really supposed to be there. The ideal way to learn about psychotherapy is to see what the best minds have to say and then compare results. PAGE 4:  A psychotherapy theory describes the clinical phenomena, delimits the amount of relevant information, and integrates it all into a coherent body of knowledge that prioritizes our conceptualization and directs our treatment. A psychotherapy system considers what human capacities will be studied, and which will be ignored. It is a common misconception that psychotherapies align themselves with a particular theory and do not wish to change. Good clinicans are flexible, and good theories are widely applicable. Therapeutic Commonalties The core of psychotherapy is composed of nonspecific or common factors shared by all forms of psychotherapy. Mental health professionals have observed that disparate forms of psychotherapy share common elements or core features. Rosenzweig proposes that all forms of psychotherapy have cures to their credit. He proposes for equivalent treatment outcomes, a number of therapeutic common factors, including psychological interpretation, catharisis, and the therapist's personality. PAGE 5: Determined by a study, the most consensual commonalities were clients' positive expectations and a facilitative relationship Positive Expectations Expectation is one of the most widely debated and heavily investigated common variables. Does the patient have faith in the institution itself, the door at the end of the pilgrimage, or the confidence of the therapist and the treatment. Research evidence suggests client expectations contribute to therapy success; however, it is divided on how much. High, positive effectiveness adds to the effectiveness of treatments However, psychotherapy cannot be reduced to expectation effects alone Psychotherapy is more effective than common factors conditions, which in turn were more effective than no treatment at all. The ranking for therapeutic success is psychotherapy, placebo, and control. Psychotherapy is twice as effective as placebo treatments Based on research, we will assume expectation is an active ingredient in all therapy systems. Positive expectation can be a critical precondition for therapy. Therapeutic relationship Psychotherapy is an interpersonal relationship. The single greatest area of convergence among psychotherapists among common factors and treatment recommendations is the development of a strong therapeutic alliance This common factor has contributed to one of the major determinants of psychotherapy success. PAGE 6: The largest variation in therapy outcome is accounted for by preexisting client factors, such as expectations for change and severity of disorder. Therapeutic relationships are the second largest proportion of change with treatment method coming in third. The power of a therapeutic relationship still creates contraversy. Radical behavior therapies view the relationship between client and therapist as exterting little influence. Cognitive therapies view the relationship between client and therapist to be a precondition necessary for therapy to proceed. Rogers person centered therapy considers the relationship as the essential process that produces change. This is the following criteria 1. The therapist must relate in a genuine manner 2. The therapist must relate with unconditional positive regard 3. The therapist must relate with accurate empathy  These three conditions are necessary and sufficient for a positive outcome Psychoanalysis sees the relationship between therapist and patient as a source of content to be examined in therapy The light of these psychotherapies views the relationship between client and therapist as (1) a precondition for change (2) a process of change (3) content to be changed. Hawthorne Effect: Hawthorne effect: psychologists have know for years that many people can improve in such behaviors as work output soley because of having special attention paid to them. Attention is one of the common factors that impact the success of therapy PAGE 7: To conclude that any psychotherapy is more effective than an attention placebo, it is necessary that research includes controls attention effects or simply the passage of time. The most popular design to test for attention is placebo groups. An alternative design is to compare the effectiveness of one treatment with another If both therapies before the same then we cannot conclude that the therapies are anything other than hawthorne effects. Other Commonalities Jerome Frank posited that all psychotherapeutic methods are elaborations and variations of age-old procedures of psychological healing. The features that distinguish one psychotherapy from another receive special emphasis Frank argues that therapeutic change is predominantly a function of common factors: an emotionally charged, confiding relationship, and a therapeutic ritual Specific Factors Common factors theorists also recognize the value of unique or specific factors in disparate psychotherapists As a discipline, psychotherapy will advance by integrating the power of common factors with the pragmatics of specific factors. Which leads into the processes of change PAGE 8: Processes of Change The transtheoretical model (across theories model) reduces the therapeutic morass to a manageable number of change processes. The processes of change represent a middle level of abstraction between global theories (psychoanalysis, cognitive, humanistic) and specific techniques (dream analysis, progressive muscle relaxation) At the intermediate level of analysis, meaningful points of convergence and contention may be found among psychotherapy systems. In addition, it is also at the intermeidate level that expert psychotherapists typically formulate treatment plans Processes of change are covert and overt activities that people use to alter emotions, thoughts, behaviors, etc. Processes are how people change within psychotherapy and between therapy sessions. Consciousness Raising (A PROCESS OF CHANGE!!!) Consciousness raising make the unconscious conscious, all insight psychotherapies begin by raising an individual's level of awareness Insight or awareness therapies work the consciousness When a hand hits us in the back, we process information to make a response. Consciousness raising therapies increase the information available to individuals so they can make the most effective responses to life. The focus on this can be changing the individuals experience or environment  Level: Abstraction Examples High Global Theories Psychodynamic, gestalt, behavioral Medium Change Processes Consciousness raising, counterconditioning Low Clinical Techniques Interpretation, two-chair technique, self-monitoring PAGE 9: Feedback: when the information given a client concerns the individuals own actions and experiences EX: middle aged women does not know how angry she appears to children Education: When the information given a client concerns environmental events EX: Old man concerned that the time it takes him to orgasm increases, he is relieved to find that this is normal for his age. Defenses can ward off threatening information (rose colored classes) How can awareness lead to behavior change? Catharsis (A PROCESS OF CHANGE!!!) Catharsis: release of pent-up feelings Anger, guilt, and anxiety when blocked up beg to be released A patient with blocked emotions is seen as emotionally constipated PAGE 10: By expressing the dark side of themselves client can better accept their emotions as natural phenomena that do not need to controlled as intensely Corrective emotional experiences: cathartic reactions that occur directly within the person Dramatic relief: cathartic reactions can be evoked by observing emotional scenes. For example, watching TV. Choosing (A PROCESS OF CHANGE) The power of choice in producing behavior has been the background of many psychotherapy systems Choosing has lacked respectability in the eyes of scientists Consequently, we will see that many therapy systems implicitly assume that clients will choose to change as a result of psychological treatment From the behavioral perspective, choice is viewed as a function of the number of alternative responses available From the humanistic perspective, the number of choices can increase if we become aware of more choices The easiest choices follow from accurate information that entails an awareness of the consequences of alternative choices. PAGE 11: An example of existential anxiety was seen in a college student who consulted me about the panic attacks she was having about getting an abortion She was worried about having to choose Experiencing the anxiety inherent in being responsible for the choice is a move towards self-liberation When changes in the environment make more alternatives available to individuals, this is a move towards social liberation Social liberation is not widely considered as a change process (other than feminist and multicultural theories) Psychotherapy generally targets change in an individual Conditional Stimuli ( A PROCESS OF CHANGE)  At the opposite extreme from changing through choosing is changing by modifying the conditional stimuli that control our responses Changing our behavior to the stimuli is known as counter conditioning EX: Women modifies her response to her partner when having sex Changing the environment involves stimulus control Structuring the environment to reduce the probability that a particular conditional stimulus will occur PAGE 12: EX: Kid gets anxious when his car starts shaking so he fixes the problem with the car Contingency Control If a response is reinforced, then the probability of the response is increased. Punishment works the opposite way If behavior changes are made by modifying the contingencies in the environment, we call this contingency management Desirable healthy behaviors are followed by reinforcement; in select cases, undesirable, pathological behaviors are followed by punishment EX: a grad student who goes to the bathroom earns two dollars every single time he does this Modifying our internal responses to external consequences without changing those consequences will be called reevaluation Man rethinks the way he is being rejected on dates by saying rejection is a statement about her and not him Change your thinking and change your behavior Initial Integration of Processes of Change The processes of consciousness raising, catharsis, and choosing represent the heart of traditional insight or awareness psychotherapies, including the psychoanalytic, existential, and humanistic traditions These focus mainly on the subjective aspects of an individual, the processes occurring within the human skin. Greater potential for inner directed changes. The processes of conditional stimuli and contingency control represent the core of action therapies, including those in the behavioral, cognitive, and systemic traditions. These psychotherapy systems focus on the external and environmental forces on the individual's potential. PAGE 13: Table 1.3 Change Processes at Experiential and Environmental Levels Awareness or Insight Therapies Action or Behavioral Therapies Consciousness Raising Conditional Stimuli Experimental level: feedback Experiential level: counterconditioning Environmental level: education Environmental level: stimulus control Catharsis Contingency Control Experiential level: corrective emotional experiences Experiential level: reevaluation Environmental level: dramatic relief Environmental level: contingency management Choosing Experiential level: self-liberation Environmental level: social liberation To focus on awareness processes is to act as if inner directedness is the full picture To focus on the action emphasis ignores our potential for inner, subjective, change An integrative model proposes that a synthesis of awareness and action provides more balanced and effective psychotherapy  Integrating the change processes affords a more complete picture of humans by accepting our inner change while recognizing the limits imposed by environments and contigencies Note: consciousness raising, contingency control, etc are not methods suggested by specific theories. They are generic change strategies that cut across many theories Therapeutic Content The processes of change are distinct contributions of a system of psychotherapy. Many books confuse content and process when their distinction is a fundemental difference! Psychotherapy systems without theories of personality are primarily process theories and have a few predetermined concepts Behavioral, integrative, systemic, and solution focused theories attempt to capitalize on the unique aspects of each case Many systems of therapy differ primarily on their content, while agreeing on their change processes PAGE 14: Theories of personality and psychopathology tell us what needs to be changed, theories of process tell us how change occurs Most therapy systems assume a conflict view of personality and psychopathology Intrapersonal Conflicts: conflicts within the individual Interpersonal Conflicts: conflicts between individuals Individuo – social conflicts: conflicts between an individual and society Beyond conflict to attain fulfillment: meaning of life, etc In the integrative model we assume that conflicts occur at different levels of personality functioning At the intrapersonal level, we will examine how each therapy system addresses conflicts over anxiety and defenses, self-esteem, and personal responsibility. At the interpersonal level, we will consider problems with intimacy and sexuality, communication, hostility, and interpersonal control. At the individuo-social level, we will compare perspectives on adjustment versus transcendence and impulse control At the beyond conflict to attain fulfillment level we will examine questions about the meaning of life Any theory of personality can reduce all psychopathology to a single level of functioning Table 1.4 Therapeutic Content at Different Levels of Personality 1. Intrapersonal conflicts a. Anxieties and defenses b. Self-esteem problems c. Personal responsibility 2. Interpersonal Conflicts a. Intimacy and sexuality b. Communication c. Hostility d. Control of others 3. Individuo-social conflicts a. Adjustment versus transcendence b. Impulse control 4. Beyond conflict to fulfillment a. Meaning of life b. The ideal person PAGE 15:  A theory’s level of personality will dictate the number of people in the consulting room and the focus of the therapeutic transcation. EX: interpersonal function leads to couples therapy A individuo-social based therapy will work either for or against a client on the side of mainstream society. For example, a pedophile In comparing psychotherapy systems, we will examine which level of personality functioning is emphasized and whether such an emphasis leads to working primarily with an individual, with two or more people together, or with groups seeking to alter society. The Case of Mrs C Psychotherapy systems are not static combinations of change processes, theoritical contents, and research studies. They are concerned with assisting individuals Mrs C suffers from severe OCD with rituals She showers every part of her body for several hours a day She can only wear underwear once Hoarder Sexual arousal disorder Clincially depressed Obsession with pinworms BIG QUESTION: Was Mrs C symptoms based around OCD or schizophrenia