CHAPTER SEVEN

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
                    1 Clients may use a variety of defense mechanisms to prevent this from
                    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,
     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
            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
     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
           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
     e)    Main goals of psychoanalytic treatment
           i.      Intellectual and emotional insight into the underlying causes of the clients
           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
           i.      Defense mechanisms will come into play
     b)    Dream analysis – unconscious material is closer to the surface in dreams than in
           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
           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
                 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
                      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
                      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
              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
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
                       2 Discussing client’s rights and rights of others in various social
                       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
      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
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-
        c)      Therapeutic relationship as the primary vehicle by which therapy achieves its
        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
                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
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
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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