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The therapeutic process

A final analysis

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Psychotherapy: What is it?

“verbal interaction between a professional counsellor and one or more persons

suffering from a psychological disorder”

Psychologist vs. therapist vs. psychiatrist

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Differences

• Training• Quality/ Organization/ Ethics• Medication• Legal right to Dx• Training in assessment or therapeutic

orientations• 8 vs 6• Research• Psychological testing

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Who Seeks Treatment with Mental Health Specialists?

• Olfson & Pincus (1994)– Americans made 79.5 Million visits for psychotherapy– More likely to seek and use psychotherapy:

separated or divorced

women

white

ages 35-49 years

more than 15 years of education– Greater likelihood of seeking treatment if in poor general

health and have health-related functional impairments

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Types of Treatment Available

• Psychotherapy Orientations– Psychoanalytic / Psychodynamic / Insight-oriented– Behaviour Therapy– Cognitive / Cognitive Behavioural Therapy– Humanistic Therapy

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Orientations – Psychoanalytic/Psychodynamic

• This is the school of thought that Freud started – recall from personality lecture. Was the first real model of psychotherapy early 1900s

• Analogy – therapist is on an archaeological dig – trying to gently uncover the unconscious material that is buried by repression/defense mechanisms

• Unconscious material is central, work to develop client’s insight into unconscious motives, conflicts; emphasis on early childhood functioning

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Criticisms - Psychoanalytic

• Vague, imprecise and unscientific• Abstract concepts (id, ego, superego) not related to

reality or day-to-day behaviour• Difficult to test / evaluate effectiveness (when do we

know the unconscious has been uncovered?)• More appropriate for high functioning, intelligent

verbal individuals…• More expensive, time consuming than other equally

effective therapies

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Orientations – Behavioural

• Behavioural approach – historically, the school formed as a reaction to psychoanalysis

• Highly structured, focus on here-and-now, behavior (not feelings, insights)

• Advantages: sometimes it’s not necessary to explore childhood conflicts. BT is more appropriate for certain focal, circumscribed problems (fear of heights, social skills training, difficulty public speaking, smoking cessation). Also is much shorter term, less expensive than psychoanalytic. If applied appropriately, BT can be very effective.

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Orientations – Behavioural

• Psychopathology: problem behaviours are learned through operant conditioning (+ and – reinforcemt) and classical conditioning (forming associations)

• Setup: behaviourist is a directive helper / trainer; therapy is structured; discuss behaviour and contingencies; no discussion of thoughts, feelings, unconscious; no attention to relationship with therapist

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Behaviorism

• Intervention: change problem behaviour through learning, reinforcement, modeling

• Goal: unlearn problem behaviours, replace with more adaptive behaviours; learn new positive behaviours

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Behaviour Therapy - Techniques

• Operant Cond. – reinforce desired behaviours– Token Economies (earn stars, points, chips for desirable

behaviour, can exchange for desired object or activity)– Extinction (stop reinforcing undesirable behaviour)

• Classical Cond.- “Counter-conditioning” (re-condition a more desirable response to stimulus) – Systematic desensitization (learn to relax; then describe

anxiety-producing situation; then engage in anxiety producing situation)

• Modeling – teaching by example, role-play

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Criticisms - Behaviour Therapy

• Too simplistic, reductionistic• Doesn’t account for where the symptoms came

from in the first place• If you eliminate the behaviour, the client may still

have an underlying problem that will cause them difficulty in other areas

• Problems are not always with the person’s behaviour sometimes it’s their thinking, feelings, self-esteem…

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Orientations – Humanistic / Person-Centred• Humanistic therapists - believe that

human experience is unique; all humans are born with an innate desire to try to fulfill themselves, reach their full potential; there is no objective right way/wrong way to live; people are viewed as basically good, believe we all naturally move towards developing into our own ideal self.

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Orientations – Humanistic / Person-Centred

• Psychopathology : Not pathology, but disrupted development; problems arise when there is a mismatch between the real self and desired self, or when envt prevents person from reaching potential

• Setup: therapist is nondirective, empathic; engages in an sharing experience with the client as an equal

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Humanistic continued…

• Intervention: focus on what / how things happen for the client (not why); empathic understanding, reflects; unconditional positive regard; client defines own cure

• Goal: promote growth, fulfillment; evaluate self and world from own perspective; focus on present, future

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Criticisms – Humanistic Therapy

• Concepts are hard to define (self-actualization), vague (each person is unique)

• Very nice…but how does the therapy affect lasting change in thinking/behaviour?

• Is it wise to let the client guide therapy and formulate their own treatment goals?– What if they have impaired judgment,

impulse control problems?

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Orientations –Cognitive (& Cognitive Behavioural)

• Psychopathology: problems arise when people have faulty, irrational thought patterns; these result in negative feelings, problems in relationships/behaviour

• Setup: structured; client & therapist are a team; set agenda, work problems together in a systematic way; client does homework & tests out in real life

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Cognitive

• Intervention: focus on here & now; may involve thought records, discussion & teaching of new rational ways of thinking; role-play

• Goal: to change the way clients think about themselves, the world; behaviour change will follow

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Techniques –Cognitive (& Cognitive Behavioural)

• Identifying maladaptive thinking (handout), e.g:– Mind reading, catastrophizing,

overgeneralization, all-or-nothing thinking

• Thought Records (handout)• Cognitive reframing / restructuring• Exploring alternatives• Homework / in-vivo experiments

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And…

• In vivo experiments –new way of thinking, go into world and try it out. Discuss how client feels, acts; reinforces idea that changing thinking can change feelings, behavior. Generalize what they learn in therapy to outside world.

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Criticisms –Cognitive (& Cognitive Behavioural)

• Too much emphasis on cognition; suggests that everything is “mind over matter”; that all problems can be corrected by changing thinking

• Suggests clients are irrational, not logical

• Too structured, simplistic, mechanical• Doesn’t give enough emphasis on where

maladaptive thought patterns came from, where problems originated

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New on the market: The Integrative Approach

• Integrate elements from various approaches– Primarily CBT, but spend more time exploring

where the core beliefs came from, where the problem originated

– Humanistic, but use some CBT techniques to help client achieve goals

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Is Psychotherapy Effective?

Eysenck (1952) sparked a debate– reviewed 24 studies of psychotherapy with emotionally

disturbed people

Therapy: 67% improved

No Therapy: 72% improved

Spontaneous Remission– improvement without psychotherapy; often attributed to

positive life events or passage of time/maturity

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Key Words

• Demand characteristics

• Double-blind technique

• Placebo effect

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Eysenck’s Study: The Fallout

• Several important methodological problems with Eysenck’s study

• Many studies followed; psychotherapy shown to be more effective than no Tx

• Widely accepted that psychotherapy is better than than no treatment

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Evaluating Effectiveness: Psychotherapy Research

• Difficult to define what “effective” means– Freudian: Insight into unconscious processes

– Behaviour: Changes in maladaptive behaviour

– Cognitive: Changes in irrational thinking

– Humanist: Acceptance of one’s self

• Who judges whether change has taken place?– Client, therapist, friends, family, teachers, employers

• There are literally hundreds of types of therapy today…

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Is Psychotherapy Effective?Smith (1980)

• Reviewed 475 studies on effectiveness• Results

– typical client is better off than 80% of those untreated (compared to waiting list)

– little overall difference across various approaches– psychotherapy does work, but no one therapy is better

than the rest

MODEST EXCEPTION: Behaviour Therapy

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Factors PredictingEffective Psychotherapy

• If psychotherapy is effective, and it depends little on the type of therapy used, then what does it depend on? (Luborsky, 1971)

– Therapy characteristics

– Client characteristics

– Therapist characteristics

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Therapy Characteristics: Worst Predictor of

Effectiveness• Overall, therapy characteristics was the worst of

the three sets of predictors

• Exception: Number of Sessions

– more sessions meant more improvement

– Luborsky reviewed 15 studies with more than 2400

clients

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Client Characteristics:Best Predictor of

Effectiveness

Improvement was markedly higher if the client:

– had a higher IQ– had a less severe disorder– was better educated– was in a higher socioeconomic class– was highly motivated to get better

The perfect client…

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Therapist Characteristics:2nd Best Predictor of

Effectiveness• Improvement was markedly higher if the

therapist:– had more experience

– was perceived as empathic

• Paraprofessionals are at least as effective as professionals for specific problems

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The Future of Psychotherapy Research

• Must still study interaction among predictors– Process research is becoming very popular

– Need to evaluate which therapy works for which clients, under what circumstances