Treatments Exam 1 Study Guide.pdf

Exam 1 Foundations of Counseling Good Treatment Relies Heavily on Basic Counseling Skills Lambert’s pie DODO BIRD VERDICT? Most treatments effective at least some of the time Differences between therapists >>> differences between therapies Some caveats: ○ Establishing...

Exam 1 Foundations of Counseling Good Treatment Relies Heavily on Basic Counseling Skills Lambert’s pie DODO BIRD VERDICT? Most treatments effective at least some of the time Differences between therapists >>> differences between therapies Some caveats: ○ Establishing “empirical support” is a lengthy process ○ Some treatments clearly better/best for certain conditions (e.g., ERP for OCD, DBT for BPD) ○ Some “treatments” do harm (e.g., conversion therapy, critical incident stress debriefing) ○ Clearly-defined problems easier to treat (e.g., phobia vs. GAD or MDD); less chronic problems easier to treat KEY COMMON FACTORS ○ Strong therapeutic relationship -most important ○ Corrective experiences & new behaviors (modeling, practice) ○ New understanding/perspective ○ Expectation for improvement ○ Confronting/facing the problem (exposure) ○ Establishing mastery & control ○ Attributing success to internal causes ○ “Ritual” of attending therapy NUGGETS OF WISDOM FOR THE BUDDING THERAPIST The client is the expert on their own experience Avoid advice or problem-solving, especially at first Avoid self-disclosure It’s ok to not have the same When in doubt, stop talking & listen Deep listening leads to empath Silence is powerful & therapeutically useful Never work harder than your client The goal of treatment is to leave treatment Demonstrate boundaries & self-care Invite feedback & reflection; it’s ok not to “click” Therapy for yourself is almost never a bad idea INTAKE ASSESSMENT  Goal is to formulate a treatment plan (& often assign a diagnosis) Ask about ○ Demographics ○ Presenting problem(s) ○ Current living situation, employment/educational circumstances ○ Social support & relationships ○ Psychological analysis & assessment (mental status exam, personality, intelligence, GAF, symptoms, etc.) ○ Psychosocial developmental history ○ Health & medical history (including prior psychological treatment) ○ History of high-risk behavior (substance use, eating disorders, self-injury, suicidality or violence) ○ Goals Summary & case formulation ETHICS IN PSYCHOTHERAPY A (DE-IDENTIFIED) ETHICAL DILEMMA WHY DO WE NEED ETHICAL PRINCIPLES IN PSYCHOTHERAPY? Therapeutic relationships are inherently unbalanced ○ Therapist inevitably has more power Therapeutic relationships are complicated (“client/provider”? “doctor/patient”? “teacher/student”?) ○ And clients’ issues are complicated Principles provide guidance & accountability for inevitable complications ○ …But even still, the answers are rarely crystal clear WHAT ARE ETHICAL CODES? Guidelines for what psychologists can & cannot do Developed by each discipline’s organizational body Include principle ethics (obligations) & virtue ethics (aspirations, idealistic) Ambiguous by design First step: Consult SOME KEY ETHICAL ISSUES AFFECTING CLINICAL PRACTICE Competence: Therapists must only provide services for which they are qualified ○ Only provide services for which they are qualified ○ Accurately represent their credentials and qualifications ○ Keep up on current information in the field, especially in specialty areas ○ Seek counseling when they have personal issues ○ Malpractice can occur if therapist fails to provide reasonable care that is generally provided by other professionals & it results in injury to client Termination ○ Must terminate if treatment is no longer effective or no longer needed  ○ Must plan & process ○ Must assess whether client can maintain gains ○ Must discuss follow-up if needed Client welfare: Client needs come before counselor needs; counselor must act in client’s best interest Informed consent: Must tell client re. the nature of counseling & answer questions so decision is informed ○ Cost of treatment ○ Special arrangements (e.g., telehealth? cancellations procedures? after-hours/vacation coverage?) ○ Therapist competencies ○ Nature of treatment ○ Confidentiality & its limits Confidentiality: Cannot share any identifying info with others; necessary for trust & progress ○ 1996: Supreme Court establishes psychotherapist client privilege (Jaffee v. Redmond) ○ Legal protection of the client that prevents therapist from disclosing what was said in session(s) ○ Law specifics vary state to state ○ Exceptions Suicidal (risk assessment required) Hospitalization required Count-ordered evaluations Client sues therapist Client pursuing NGRI or similar legal defense Minor or elder abuse “Duty to warn” someone in danger Dual relationships: Therapist must only serve as therapist; cannot also be friend, student, relative, etc. ○ Guiding questions Is the dual relationship necessary? Is the dual relationship exploitative? Who does the dual relationship benefit? Is there a risk the dual relationship could damage the client or disrupt the therapeutic relationship? ○ DIMENSIONS FOR DECISION-MAKING ABOUT DUAL RELATIONSHIPS Sexual relationships: Strongly prohibited & may be a criminal offense in some states ○ Current clients  Never acceptable Power imbalance means consent is not possible Breaks trust, safety, objectivity 90% are harmed (Pope, 2001) 4% of therapists acknowledge (Giovazolias & Davis, 2001) ○ Former clients Only after 2 years minimum Burden is on you Consider time elapsed, nature of treatment, circumstances of termination, client’s personal history, current mental status, likelihood of adverse impact, any leading suggestions during treatment CURRENT CONTROVERSY: ETHICS IN TELEHEALTH PROS ○ Increased access to care Cost, geography, expertise ○ Enhanced communication ○ Ability to practice skills in real life ○ Convenience ○ Anonymity CONS ○ Privacy, confidentiality, & security ○ Therapist competence & need for special training ○ Communication issues specific to tech ○ Glitches, lost info on non verbals, etc. ○ Research gaps ○ Emergency issues EARLY TREATMENTS PSYCHOANALYTIC & PSYCHODYNAMIC APPROACHES HISTORY & CONTEXT Sigmund Freud, the father of psychoanalysis, offers the first organized way to explain human behavior (1880s – 1930s) ”If Freud’s discovery had to be summed up in a single word, that word would without a doubt have to be __Unconcious ___.” Psychoanalytic = Freud; psychodynamic = broader set of constructs that has analysis as foundation PSYCHODYNAMIC VIEW Client developmental history is critical for full client understanding Most important in developmental history are key people (object relations)  We are unconscious of impact of biology, development, culture in determining behavior We constantly act out developmental history & biological drives in daily lives The task of therapy is to help the client discover the unconscious roots of present behavior FREUD: FEMINIST, LGBTQ+, CLASS-RELATED, & MULTICULTURAL CRITIQUES Many of Freud’s original ideas are now recognized as blatantly sexist &/or heterosexist Traditional Freudian psychoanalysis is often viewed as elitist Personal understanding, insight, self-disclosure & interpersonal openness are not universally viewed as positives CENTRAL CONSTRUCTS OF PSYCHODYNAMIC THEORY The id operates on the pleasure principle, that every unconscious wishful impulse should be satisfied immediately, regardless of the consequences. The ego’s goal is to satisfy the id’s demands in a safe and socially acceptable way. Follows the reality principle as it operates in both the conscious and unconscious mind. Superego is the moral component of the psyche, representing internalized societal values and standards. It contrasts with the id’s desires, guiding behavior towards moral righteousness and inducing guilt when standards aren’t met Denial -“Closing one’s eyes” to the existence of Denial of reality is perhaps the simplest of all a threatening aspect of reality. self-defense mechanisms. It is a way of distorting what the individual thinks, feels, or perceives in a traumatic situation. This mechanism is similar to repression, but it generally operates at preconscious and conscious levels. Displacement-Directing energy toward another Displacement is a way of coping with anxiety object or person when the original object or that involves discharging impulses by shifting person is inaccessible. from a threatening object to a “safer target.” For example, the meek man who feels intimidated by his boss comes home and unloads inappropriate hostility onto his children. Projection-Attributing to others one’s own This is a mechanism of self-deception. Lustful, unacceptable desires and impulses. aggressive, or other impulses are seen as being possessed by “those people out there, but not by me.” Rationalization -Manufacturing “good” reasons Rationalization helps justify specific behaviors, to explain away a bruised ego. and it aids in softening the blow connected with disappointments. When people do not get positions they have applied for in their work, they think of logical reasons they did not succeed, and they sometimes attempt to convince themselves that they really did not want the position anyway. Reaction formation -Actively expressing the By developing conscious attitudes and opposite impulse when confronted with a behaviors that are diametrically opposed to threatening impulse. disturbing desires, people do not have to face the anxiety that would result if they were to recognize these dimensions of themselves. Individuals may conceal hate with a facade of love, be extremely nice when they harbor negative reactions, or mask cruelty with excessive kindness. Regression-Going back to an earlier phase of In the face of severe stress or extreme development when there were fewer demands. challenge, individuals may attempt to cope with their anxiety by clinging to immature and inappropriate behaviors. For example, children who are frightened in school may indulge in infantile behavior such as weeping, excessive dependence, thumb-sucking, hiding, or clinging to the teacher. Repression -Threatening or painful thoughts One of the most important Freudian and feelings are excluded from awareness. processes, it is the basis of many other ego defenses and of neurotic disorders. Freud explained repression as an involuntary removal of something from consciousness. It is assumed that most of the painful events of the first five or six years of life are buried, yet these events do influence later behavior. Sublimation -Diverting sexual or aggressive Energy is usually diverted into socially energy into other channels. acceptable and sometimes even admirable channels. For example, aggressive impulses can be channeled into athletic activities, so that the person finds a way of expressing aggressive feelings and, as an added bonus, is often praised. KEY TECHNIQUES IN PSYCHODYNAMIC THERAPY Free association  ○ The basic technique & strategy of the psychodynamic approach ○ With or without a prompt, client gives voice to all thoughts that enter the mind, without exception Interpretation & analysis ○ Of “Freudian slips” “I have to call my murder later.” ”I’ll pick you up at sex.” “Professor, will this exam be objectionable? ○ Of transference and countertransference Transference: Client unconsciously transfers feelings about someone from the past onto the therapist Positive Negative Sexualized Countertransference: Therapist transfers their own unresolved conflicts or emotions onto the client Can also play out multiple ways Critical to attend to & process in supervision ○ Of dreams Assumption: Unconscious material is processed during sleep & expressed in dreams Disguised fulfillment of a repressed wish Super-ego is weakened during sleep Manifest vs. latent content "manifest content" refers to the literal, remembered details of a dream as it is recalled upon waking, while "latent content" represents the underlying, unconscious meaning or symbolism hidden within those dream elements To understand the significance, the therapist must explore latent content via free association Although some modern therapists focus on manifest content ○ Of resistance “Everything in the words & actions of the client that obstructs his gaining access to his unconscious” These words & actions must be identified & analyzed (perhaps via free association) in order to understand their significance, or rapport & progress are lost Properly managed, can be an opportunity, rather than a problem Interpretation & analysis ○ Sophisticated & complex skill  ○ Intellectual knowledge of psychodynamic theory is integrated with clinical data about the client ○ Renaming of client experience from an alternative frame of reference or worldview ○ Offer interpretation & then check with the client “How do you react to that?” “Does that ring a bell?” “Does that make sense?” “Does that resonate?” THE PSYCHODYNAMIC APPROACH: EMPIRICAL SUPPORT Psychodynamic therapy ○ Comparably effective to other approaches, may excel at long-term follow-up ○ Anorexia nervosa, several personality disorders, depressive disorders, generalized anxiety disorder, panic disorder, social anxiety disorder, somatoform disorders Psychodynamic worldview & constructs ○ Unconscious emotional responses exist ○ We can map defense mechanisms (e.g., suppression) with fMRI ○ Implicit memories, split brain patients, conversion disorder, & more INTERPERSONAL PSYCHOTHERAPY (IPT) HISTORY & CONTEXT Late 1960s: Weissman, Markowitz, & Klerman develop IPT ○ Time-limited (12-16 weeks) treatment for depression ○ Targets the interpersonal context All client problems occur against a social backdrop ○ Social support is protective ○ Mental health problems are often linked to disruptions in social relationships & roles ○ Mental health problems increase during times of interpersonal stress Past social relationships are critical & directly impact current interpersonal context ○ Object relations theory Idea core important people we relate to in a certain way and carry internalized representation of them and impact interpersonal relationships CONTROVERSY PSYCHODYNAMIC INFLUENCES ○ Object relations theory ○ Past relationships are critical ○ Focus on feelings (not thoughts) ○ Shares a lot in common w/ theory  COGNITIVE-BEHAVIORAL INFLUENCES ○ Time-limited ○ Structured interviews ○ Specific assessment tools ○ Shares a lot in common with techniques POTENTIAL INTERPERSONAL PROBLEM AREAS INTERPERSONAL TRIAD SELECTED TECHNIQUES TO HELP INTERPERSONAL UNDERSTANDING Closeness Circle ○ Map to help understand relationships Interpersonal Relationships Worksheet ○ Questions and prompts to explore each relationship Mood Thermometer ○ Score, mood, situation IPT: EMPIRICAL SUPPORT  Major depression, generalized anxiety disorder, eating disorders, social phobia Incorporated into IPSRT for bipolar disorder Teens, adults, elderly, perinatal populations Common group therapy approach ○ Initially validated for use with binge eating disorder ESSENTIAL ELEMENTS OF IPSRT PSYCHOEDUCATION ○ Focus on medication adherence ○ Education about types of BD & meds (side effects, function/duration, common challenges) Monitor meds, hard time taking, numb symptoms SOCIAL RHYTHM THERAPY ○ Link between regular routines & mood ○ Regulate daily routines Do better when you have routine- circadian rhyme, workload, when eating, and how often you engage in social interactions INTERPERSONAL PSYCHOTHERAPY ○ Link between life events & mood ○ Focus on one of the 4 interpersonal problem areas Explicit links INTERPERSONAL PSYCHOTHERAPY ○ Link between life events & mood ○ Focus on one of the 4 interpersonal problem areas GESTALT THERAPY HISTORY & CONTEXT Developed in 1930s in reaction to theoretical “holes” in psychoanalysis Fritz & Laura Perls were trained in psychoanalysis ○ Believed more in freedom & responsibility, immediacy of experience, striving to create meaning in life ○ The first humanistic, client-centered approach? Whole is greater than sum of parts  Failure to integrate parts of personality cause conflict & distress GESTALT THERAPY Resolve conflicts & ambiguities resulting from failure to integrate features of personality ○ Two chair technique Teach people to become aware of significant sensations within themselves & the environment so they can respond fully & reasonably ○ Exaggeration and contrast Focus on here & now ○ But once a client is aware of the present, they can confront past conflicts & “unfinished business” (“incomplete Gestalts”) Empty chair technique Clarify intrapsychic & interpersonal conflicts ○ Act out repressed parts of personality, role play or re-enact a conflict, adopt role of another person, dream work Assumes inclination to health, wholeness, realizing full potential Tell clients to change their language to focus on here & now, increase awareness & responsibility Stay with the feeling EMPIRICAL SUPPORT Equivalent effects to other major treatment modalities Depression, chronic illness, addictions, specific psychological dilemmas Increasing sense of meaning in life is a main mechanism of action CLIENT-CENTERED THERAPY HISTORY & CONTEXT AKA person-centered therapy or Rogerian therapy A humanistic-existential approach Carl Rogers (main work 1930s – 1960s) Initially training to be a minister Began to question religion à spiritualist & agnostic Switched from seminary to MA & PhD in psychology CLIENT-CENTERED VIEW Therapist enters the worldview of the client, facilitates them finding their own new direction & frame of thinking Necessary & sufficient conditions for therapeutic change to occur (Rogers, 1957) ○ Two persons in psychological contact ○ Client is in a state of incongruence ○ Therapist is genuine in the relationship ○ Therapist experiences unconditional positive regard for the client  ○ Therapist experiences empathic understanding of the client & communicates this to them ○ This communication of empathy & unconditional positive regard is at least minimally achieved “Being-in-the-world” ○ We are in the world & acting on it while it simultaneously acts on us ○ Any attempt to separate ourselves from the world causes alienation ○ Racism, sexism, homophobia, etc.--> separation→ alienation→ anxiety & aloneness Failure to make decisions & act in the world-> separation→ alienation→ anxiety & aloneness ○ Clients must assume responsibility for choice & act intentionally in the world CLIENT-CENTERED VIEW MASLOW’S HIERARCHY OF NEEDS CRITIQUES OF THE EXISTENTIAL-HUMANISTIC PERSPECTIVE & THE CLIENT-CENTERED APPROACH TO TREATMENT Intense preoccupation with the individual & free choice Not all groups have the necessary conditions for growth, self-actualization Blind (?) faith that people are positive, forward-moving, basically good, & ultimately self-actualizing Very verbal treatment, no clear endpoint; appeals mostly to middle- & high-SES clients THE CLIENT-CENTERED APPROACH: EMPIRICAL SUPPORT Rogerian techniques essentially form the basis for all therapeutic orientations (Fiedler, 1950a, b, 1951) Therapeutic relationship quality is critical & highly predictive of success, regardless of specific orientation or techniques  Person-centered/experiential therapies yield large pre-post client change, effects are clinically & statistically equal to other therapies, gains are maintained over time Effective for depression, interpersonal difficulties, coping with psychosis, self-damaging behaviors, chronic medical conditions; some support for use with bipolar disorder, generalized anxiety disorder, PTSD