CHAPTER SEVEN CLINICAL INTERVENTIONS – METHODS OF PSYCHOTHERAPY 1. Sigmund Freud is the founder of psychotherapy as we know it today. a) One-on-one treatment involving frank discussion of client’s thoughts and feelings. b) Emphasis on searching for relationships between a person’s developmental history and current problems, conflicts, thoughts and emotions. c) Based on the assumption that mental life is best understood as the interaction among powerful competing forces within the person. i. Both sources of conflicts and the habitual ways of coping with them are largely unconscious and rooted in early experiences. ii. Therapist’s job is to help make the client’s unconscious thoughts conscious. 1 Clients may use a variety of defense mechanisms to prevent this from happening. 2 Sign-oriented interference from therapist d) Key goal is insight – when a client recognizes how the past inappropriately distorts and intrudes on current thoughts and actions. 2. Freud began private practice in Vienna, often seeing patients with neurological symptoms for which no organic cause can be found (conversion hysteria – loss of sight, sensation, etc.) a) Began using hypnosis which produced temporary results. b) Began to combine in with the cathartic method learned from Breuer (Anna O.) i. Talking about hallucinations in a hypnotic state allowed Anna O to enjoy a period of lucidity for a while (talking cure) ii. Treatment of Anna O allowed the conjecture that every symptom she displayed could be traced back to a traumatic or unpleasant memory for which all memory was absent in the waking state (repression) c) Freud found that recalling memories and expressing emotions associated with them is most beneficial when patients remember these experiences after their hypnotic sessions. i. To facilitate conscious recognition of emotional memories, Freud began asking his patients to relax with their eyes closed and report whatever thoughts and feelings that came to mind – free association. 1 Purpose – to allow neurotic patients to recall important, usually unpleasant or traumatic memories and emotions protected by defense mechanisms. ii. Dream analysis – dreams represented the fulfillment of fantasies and wishes, many of which are socially unacceptable. 1 Dreams were the unconscious allowing some form to enter into consciousness and worth study 2 Shifted treatment from recovery of memories to illumination of the unconsciousness. d) When patients understand the real, often unconscious reasons why they act in maladaptive ways and see they are no longer valid, their behavior will change. i. Intellectual recognition - recognition of one’s innermost wishes and conflicts ii. Emotional involvement – discoveries about the self iii. Systematic tracing – how unconscious factors have determined past and present behaviors and present behaviors and affected relations with other people. e) Main goals of psychoanalytic treatment i. Intellectual and emotional insight into the underlying causes of the clients problems ii. Working through or fully exploring the implications of these insights iii. Strengthening the ego’s control over the id and superego f) Involves dissecting and gradually reconstructing a patients personality i. 3-5 session per week for 2 to 15 years, at $100/hour 1 5 sessions a week for 15 years would cost about $400K 3. Treatment techniques a) Free association – say everything that comes to mind without editing or censorship i. Defense mechanisms will come into play b) Dream analysis – unconscious material is closer to the surface in dreams than in waking i. Manifest content – the obvious features of a dream (setting, people, surface description of the dream) ii. Latent content – the unconscious ideas and impulses that appear in the form of a safe compromise between repression and expression 1 Dream work - Transforming latent content into acceptable manifest content iii. Common technique of dream work – free association on the manifest content to get to the latent content c) Analysis of everyday behavior – unconscious wishes, fantasies, and defenses shape all behavior, including apparently meaningless everyday activities. i. Attention is paid to clients’ reports of activities outside of treatment as well as activities that occur within session d) Analysis of resistance – any client behavior that interferes with the analytic process is considered a sign of resistance against achieving insight. i. Missing appointments ii. Failure to pay iii. Lateness iv. Avoidance of certain topics e) Analysis of transference – the client’s feeling toward and the relationship with the therapist are called transference. i. Some of this is influenced by unconscious conflicts ii. Analysts maintain analytic incognito – revealing so little about themselves that the client can be free to project onto them the attributes and motives that are unconsciously associated with other important people in their lives. iii. Transference neurosis – when the patient-therapist relationship creates a miniature of the causes of the client’s behavior. Then becomes the central focus of work 1 Goal is to focus on and work through the meaning of the client’s feelings for the therapist (and getting to the other relationships that are central to the patient’s life) f) Analytic interpretations – analyst guides the process of self-exploration so as not to overwhelm the patient with potentially frightening information. i. Analyst does not interpret everything of unconscious significance as soon as it is detected. 4. Variations a) Adler – individual psychology – deemphasized Freud’s theory of instincts, infantile sexuality and the role of the unconscious i. Believed people’s problems were based largely on the misconceptions they held, his treatment methods focused on exploring and altering the misconceptions. 1 Client sits in a chair level with therapist and transference is viewed not as reflecting unconscious childhood conflicts but the client’s habitual style of dealing with people 2 Interpreted to promote insight into patient’s current lifestyle Emphasized the purpose of the client’s behavior as opposed to the cause 3 Also use modeling, homework, and other techniques b) Franz Alexander – Chicago Psychoanalytic Institute – did not believe psychoanalysis needed to be extensively prolonged. i. Applied principles to nontraditional clients such as the young and severely disturbed. ii. Try to create an empathetic and supportive atmosphere in which the client feels cared for and understood – corrective emotional experiences. 1 Patient begins to reenact conflicts from the past with the therapist 2 Provides a stable context to form plans for progress that can be tested in real life. c) Hartmann, Rapaport, Erikson – Ego Psychology – believed that behaviors is determined to a large extent by the ego, which an function not only to combat the id but also promote learning and creativity. i. Therapists assess and attempt to bolster the client’s ego strengths 1 Reality testing 2 Impulse control 3 Judgment ii. Therapeutic relationship is for supporting and trusting functions in helping the clients explore 1 Therapy is a means of treating disorders by exploring and working through early childhood experiences – can lead to client self actualization BEHAVIORAL AND COGNITIVE BEHAVIORAL THERAPIES 5. Based on the principles of the behavioral approach a) Behavior disorders are seen as developing through learning b) Therapy methods should be guided by results of research on learning c) Therapy should be aimed at modifying overt, maladaptive behaviors as well as the cognitions, physical changes, and emotions that accompany overt behavior d) Treatment should address clients’ current problems by dealing with the contemporary environmental forces, learned habits, and cognitive factors that maintain them. e) There is a commitment to the experimental evaluation of treatment. 6. Behavior therapy (term) – first appeared in 1953 in a paper describing the use of operant conditioning to improve the functioning of chronic schizophrenics. a) Now one of the most popular approaches to treating behavior disorders in adults and children. 7. Ivan Pavlov – classical conditioning 8. Watson & Raynor (1920) a) Albert B and the white furry things – paired the presentation of bunnies with loud sound to condition fears. Fears generalized to all white furry objects, including Santa Claus mask. 9. Mary Cover Jones (1924) – techniques for reducing children’s fears a) Social imitation – helped Peter overcome his fear of rabbits by using three other children to set fearless examples. Eventually, Peter got closer and closer to the caged bunny and his fear was eliminated. 10. In the 50’s and 60’s, behavior therapy began to achieve status as a major treatment approach for many things. 11. Systematic Desensitization – developed by Wolpe. a) If conditioned anxiety could inhibit eating in animals, the principle of reciprocal inhibition must exist – an equal and opposite conditioning possibility. b) Chose three equal and opposite reactions to anxiety to work with humans – he theorized that anxiety could not exist in the presence of: i. Sexual arousal ii. Interpersonal assertion iii. Deep muscle relaxation c) Progressive relaxation training – client is trained to tens and release various groups of muscles and then focusing of the feeling of relaxation that follows. i. Then client constructs a graduated hierarchy of situations in which the client would feel anxiety to be worked through 1 Can be worked through using imagery – imaginal desensitization If client can imagine the scenario for 10 seconds without significant anxiety, move on to the next level of the hierarchy 2 In vivo – clients use relaxation skills in the presence of the therapist and the anxiety causing agent d) Appears effective when clients are exposed slowly and carefully to real (as opposed to imagined) items within their hierarchy e) Virtual reality can be used effectively for heights, situations, etc. 12. Exposure treatments (flooding) – client is asked to be in the same room and/or in contact with the anxiety producing stimulus for a long time – until anxiety disappears. If terminated prematurely, the anxiety is stronger. a) Effective for OCD – response prevention i. Clients are prevented from performing comfort rituals. ii. Can be provided in a group format 13. Social skills training – used in depression, anxiety disorders, antisocial and delinquent behavior, schizophrenia, and social withdrawal. a) Assertiveness training – used especially with adults whose inability to effectively express their needs and wishes leads to resentment, aggression, or depression. i. Teach clients how to express themselves appropriately ii. Eliminate cognitive obstacles to clear self-expression 1 I can’t say no, etc. iii. Often takes place in a group setting including four components 1 Defining assertion and distinguishing it from aggression and submissiveness 2 Discussing client’s rights and rights of others in various social situations 3 Identifying and eliminating cognitive obstacles to assertion 4 Practicing assertive behavior (role play, etc.) 14. Modeling – observational learning – Bandura is the man – usually more efficient than earning through direct reinforcement or punishment. Used for many clinical problems (anxiety, OCD, aggressiveness, etc.) a) Modeling appears to be effective when models i. Are similar to client ii. Have high status iii. Rewarded for their actions 15. Aversion therapy – controversial because of the negative effects on client. a) A set of techniques in which painful or unpleasant stimuli are used to decrease the probability of unwanted behavior i. Pair problem behavior with noxious stimulus 1 May not be durable 2 Does not offer alternative behaviors 3 Therapists may find it aversive to use because it intentionally inflicts discomfort on clients, it may generalize into fear or aggressiveness, and overuse due to quick but nondurable results. 16. Contingency management – any operant technique that modifies behavior by controlling its consequences. a) Shaping – successive approximation i. Behaviors are rewarded in successive levels until the only the complete behavior is rewarded b) Time out i. Removal from place/area/situation in which a functional reward must be and into a place where reward is absent c) Contingency Contracting i. Formal, often written agreement between therapist and client spells out the consequences of certain client behaviors. Five components 1 Responsibilities of each party 2 Rewards for fulfilling the contract 3 System for monitoring compliance with the contract 4 Bonuses for unusual accomplishments 5 Penalties for failure d) Response Cost – punishment contingency that involves the loss of reward or privilege following some undesirable behavior i. Advantages 1 Behaviors decreased through response cost remain suppressed longer than when other types of punishment are employed 2 Response const does not carry as many unwanted side effects as other, more aversive forms of punishment e) Token Economies i. A system for implementing the principles of contingency management to alter a variety of behaviors in some controlled, institutional setting. ii. Four elements 1 Identify target behaviors to be changed 2 A token or medium of exchange is identified as payment for performing target behavior. 3 Back up reinforcers are established – goods or services for which the tokens may be exchanged 4 Rules for exchange Number of token to be earned for each behavior Cost, in tokens, of back up reinforcers f) Biofeedback – behavioral methods used to control heart rate, blood pressure, muscle tension, etc. i. Requires special equipment ii. Reinforcer for improvement is often simply the knowledge of results as measured by the machine. 17. Cognitive Behavioral Therapy – CBT – specifically directed toward changing clients maladaptive cognitions. Cognitive therapists believe that certain cognitions, particularly thoughts about self, are especially important in the development of disorder. a) Aaron Beck & treatment of depression i. Depressive symptoms result from logical errors and distortions that clients make about the events in their lives. 1 Exaggerated importance of trivial events 2 Minimize significance of positive events 3 Draw conclusions about themselves from inadequate or irrelevant information b) Albert Ellis and Rational Emotive Behavior Therapy i. Psychological problems result not from external stress but from the irrational ideas that people hold, which lead them to insist their wishes must be met to be happy. ii. Therapists task is to attack irrational, unrealistic, self-defeating beliefs and to instruct clients in more rational or logical thinking patterns that will not upset them. (They’re already upset enough from the therapy) iii. Therapist is active, challenging, demonstrative, and often abrasive. c) Marsha Linehan and Dialectical Behavior Therapy i. A form of CBT used to help clients who display impulsive behavior, mood swings, fragile self-image, and stormy interpersonal relationships associated with borderline personality disorder 1 Helps clients develop skill at containing erratic behavior 2 Confront traumatic events that might have contributed to disorder (physical or sexual abuse in childhood) – eliminating self blame, reducing PTSD symptoms HUMANISTIC THERAPIES 18. Views humans as creative, growthful beings, who, if all goes well, consciously guide their own behavior toward realization of their fullest potential as unique individuals. a) When behavior disorders arise, they are seen as stemming from disturbances in awareness or restrictions on existence that can be eliminated through various therapeutic experiences. 19. Themes of the humanists a) Assume client’s life can be understood only when viewed from the point of view of the client – the meaning of life is not intrinsic but constructed by the perceiver (Sartre, Kierkegaard) b) View human beings as naturally good people who are able to make choices about their lives and determine their destinies. i. Aim to promote each client’s growth as a unique person – self- actualization c) Therapeutic relationship as the primary vehicle by which therapy achieves its benefits d) Clients are regarded as equals e) Emphasize the importance of experiencing and exploring emotions that are confusing or painful i. Empty chair technique – increase awareness of unresolved conflict by asking client to imagine a significant person sitting in the chair and express true feelings 20. Carl Rogers – Client Centered Therapy a) The client knows what hurts, what directs to go, and what problems are crucial. b) If, then proposition – if the correct circumstances are created by the therapist, then the client will spontaneously improve. c) Unconditional positive regard – accepts the client as they are without judging them i. Therapist cares about the client ii. Accepts the client iii. Trusts the client’s ability to change iv. Manifested by therapist’s willingness to listen d) Empathy – the therapist must try to see the world as the client sees it i. Reflection 1 Communicating the therapists desire for emotional understanding 2 Making clients more aware of their own feelings e) Congruence or genuineness – Therapists’ feelings and actions should be consistent with one another f) Nature of change – as clients experience empathy, unconditional positive regard, and congruence/genuineness, they become more self-aware, self-accepting, more comfortable, less defensive, less rigid in their thinking, more reliant on self- evaluation than evaluation by others, and better able to function in a variety of roles. 21. Perls and Gestalt Therapy – aims at enhancing clients’ awareness in order to free them to grow in their own, consciously guided ways. a) Seeks to reestablish clients’ stalled growth processes by helping them i. Become aware of feelings that they have disowned but which are a genuine part of them ii. Recognize feelings and values that they think are a genuine part of themselves, but which in fact or borrowed from other people. b) Client is encouraged to assimilate the genuine aspects of self that have been rejected and to reject the “phony” features do not belong. c) Focus on the here and now – now=experience=awareness-reality d) Role Playing – used to explore inner conflicts and experiences the symptoms, interpersonal games, and psychological defenses they have developed to keep their genuine selves out of awareness. e) Frustrating the client – hot seat, where all attention was focused on them, and where the symptoms, games, and resistances were pointed out and explored. f) Pay attention to non verbal cues and explore them g) Use of empty chair and unmailed letter technique to express feelings client has suppressed 22. Logotherapy – Victor Frankl – based on existential philosophy and is oriented toward helping clients a) Take responsibility for their feelings and actions b) Find meaning and purpose in life 23. Integration – many therapies overlap in philosophy a) Eclecticism- therapists adopt techniques from several approaches i. Approximately 1/3 of therapists identify themselves as eclectic b) Technical eclecticism – when a clinician selects techniques based on research that show the strongest evidence of helping people with certain characteristics, regardless of which orientation the technique came from c) Combining approaches – specific techniques are paired with specific disorders. d) Theoretical integration – involves blending the various theories and expressing the phenomena described in one theory using the terms of another i. Transference = generalization? e) Advantage of integration or eclecticism – uses empirical data or science to guide treatment, not simply theory.
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