14- Psychotherapy Flashcards
Theoretical Orientations & Evidence Based Tx
Psychotherapy: A process in which a professionally-trained therapist => Systematically uses techniques derived from psychological principles, To help relieve another person’s psychological distress/Or promote growth
Major schools of thought include:
- Psychodynamic
- CBT
- Humanistic/existential
- Integrative/eclectic
*“Psychotherapist” title
Evidence-Based Treatment
- Efficacy: evidence of tx effects when delivered in context of controlled study => Internal validity
- Typically established through Randomized
- Controlled Trials (RCTs) => ex in drug trials: Assign to active drug vs. placebo
Some Issues with RCTs for Psychotherapy
- What control group? => Compare to another active therapy (ex: tx as usual)?, Wait-list control
- Unlike a pill, diff therapists may give different “doses”
- Patients are usually relatively uncomplicated case (ex: single dx)
- Highly controlled, manualized tx
- Unknown mechanisms of action
- Effectiveness: evidence of treatment effects in “real world” context => External validity
Empirically Supported Therapies => Gold standard for intervention
Evidence-based practice: The integration of the best available research and clinical expertise within the context of patient characteristics, culture, values, and treatment preferences
=> APA and CPA require training programs to train in evidence-based practices
Historical Context: Prior to the 1960s, there was little research on whether or not psychotherapy worked
=> Hans Eysenck (1952): published article arguing that rates of improvement among people receiving therapy were the same as those untreated (Sparked lots of controversy and led to tons of research)
- Now, meta-analyses of hundreds of studies suggest that psychotherapy is indeed effective
3 Waves of CBT
- First wave: Classic beh therapies => Classical and operant conditioning; systematic desensitization *Focus is on beh, not thoughts
- Second wave: Incorporation of cognitions => Rise of cognitive-behavioral therapy (CBT)
- Third wave: New ideas and approaches => Acceptance and Commitment Therapy (ACT) * Dialectical Behavior Therapy (DBT)
Exposure Therapies (3)
Beh => Exposure (+ anxiety) – Avoidance (neg reinf) – Panic – Habituation
Outcome of repeated exposure => mastery of anxiety
1- In Vivo Exposure
- Systematic desensitization through exposure to feared situations or locations in order to produce extinction of the fear response *Imaginal exposure can be used
2- Interoceptive Exposure
- When the feared stimulus is not external, but rather INTERNAL (ex: panic/anxiety dx) with systematic exposure to feared bodily sx
3- Exposure and Response Prevention (ERP)
For OCD
- Focus is on exposure to feared stimuli without engaging in safety beh aka compulsions
*Can also be applied to safety beh in other dx ex: social anxiety
CBT
Cog Triangle: Thoughts, Feelings, Beh => Cog Distortions ex: mental filter, catastrophising
Cognitive Restructuring
- Collaborative approach => Socratic questioning
- Challenge and restructure dysfunctional cognitions ex: Are there aspects of the situation I am not seeing? What evidence do I have to disconfirm this belief?
- Identify underlying schemas (80:20)
- Hypothesis testing in the world (beh experiments)
*Thought record
Evidence for CBT?
- Overall demonstrated effectiveness for many psychological dx
Some specific features useful for specific types of dx:
- Depression to behavioral activation
- Anxiety dx to exposure (Panic: interoceptive exposure/OCD: ERP)
ACT (Acceptance and Commitment Therapy)
Traditional CBT focuses on disputing thoughts
General goals of ACT:
- Foster acceptance of unwanted thoughts and feelings
- Discourage experiential avoidance aka “an unwillingness to experience negatively evaluated feelings, physical sensations, and thoughts”
- Stimulate action that improves the circumstances of living
Evidence for ACT?
- Meta-analyses have demonstrated efficacy
Broad range of transdiagnostic intervention targets:
- Anxiety
- Depression
- Substance use
- Eating dx
- Stress
- Chronic pain
Critical outcome measures: Symptom-based & Functional outcomes (e.g., quality of life)
Dialectical Beh Therapy
Originally developed for suicidal beh and BPD
- Targets core problem of emotion regulation with comprehensive tx structure:
- Individual therapy, group therapy, skills
training, phone coaching - Peer supervision
Core tx strategies:
- Behavioral change strategies (change)
- Validation strategies (acceptance)
- Dialectical strategies
Evidence for DBT? At first, demonstrated efficacy for treatment of:
- BPD
- Self-harm
- Suicidal behavior
And now wide range of problems
- PTSD
- SUD
- ED
- Anxiety
- Depression
DBT Core Treatment Strategies
Behavioral strategies
- Change-orientation
- In order to feel different, you need to do different ex: Behavioral chain analysis (ex: ex with another girl and then self harms) => Problem beh, prompting event, vulnerability factors
Validation strategies
- Acceptance oriented
- Empathy and communicating that client’s perspective is valid in some way
Dialectical strategies => balancing of seemingly opposite, contradictory truths at the same time
- Accept the client as they are AND encourage change => You have a right to feel AND it’s not working for you, It’s not your fault AND it’s your responsibility to change
- Suicidality: Simultaneously wanting to live and thinking of death
DBT Skills:
- Mindfulness
- Interpersonal effectiveness
- Distress tolerance
- Emotion regulation
Dodo Bird Verdict Study
Meta-analyses of 295 studies comparing efficacy of psychotherapies => Test whether all therapies are relatively equally efficacious
- Null hypothesis: If Dodo bird verdict is true,
effect sizes will be roughly equivalent - Alternative hypothesis: If Dodo bird verdict is false, effect sizes will be different
Results: effect sizes very similar, null hypothesis was not rejected
- Supports the idea that different psychotherapies are equally efficacious => Argue that psychotherapies work through “common factors” rather than specific factors
Common “Common Factors” (5)
- Client characteristics
- Therapist qualities
- Relationship elements
- Tx structure
- Change processes
*SEE PPX!!!!!!
Caveats to Common Factors
- A therapy cannot ONLY include common factors => Specific factors are likely the medium through
which common factors operate - And, simply because two therapies are equally effective in general does not mean every person will respond equally => Ind diff between clients may predict the type of therapy to which each client would best respond
The Contextual Model
Pathway 1: The real relationship
- Genuine, authentic, human connection
- Allows client to feel accepted, cared for, valued
Pathway 2: Expectations
- Hopeful for change
- Provision of adaptive understanding
- Believe that explanation and treatment will help
Pathway 3: Specific factors
- Well-specified therapeutic goals
- Elicits healthy actions
Therapeutic Alliance/Rupture-Repair Hypothesis
How to define? Distinguished from an everyday relationship
Collaborative relationship between therapist and client with an agreement on tasks and goals of therapy
=> Meta-analysis showed moderate but reliable relationship between alliance and psychotherapy outcome *Not moderated by tx type (ex: CBT, IPT, psychodynamic)
Alliance Rupture => Tension or breakdown in the collaborative relationship between patient and therapist
Rupture represents a deterioration in alliance due to strain on bond, lack of collaboration on tasks, or disagreement on goals *Can vary in intensity, duration, and frequency
Two main types:
- Withdrawal
- Confrontation
=> Therapist then engages in strategies to repair
Alliance Rupture-Repair Hypothesis
Meta-analyses show that presence of ruptures and repairs is positively correlated with tx outcomes => But failures to resolve ruptures is predictive of poor outcomes (ex: dropout)
=> Repairing an Alliance Rupture:
- Be attuned to markers of rupture
- Acknowledge the rupture directly, openly,
and nondefensively - Change tasks or goals of therapy
- Validate negative emotions
- Do not blame patient
- Link ruptures to interpersonal patterns in patient’s life
- Develop ability to tolerate own defensive reactions
How to Develop Psychopharmaco Tx
- Define the problem
- Identify pathophysiological processes that lead to this problem
- Identify a (chemical) agent that will alter this process
=> BUT
- Poorly-defined constructs
- Poorly-identified boundaries between constructs
- Poor understanding of the pathophysiology of psychological dx
Serendipity
- MAOIs for depression originally studied for tx of tuberculosis
- Tricyclics for depression were being studied as a tx for schizophrenia
- Lithium was first used because scientists believed mania and depression stemmed from an excess of uric acid—lithium was thought to counteract the effects
- Benzodiazepines were initially developed to boost effect of penicillin
Classification => Drugs can be classified in many different ways
- Classification system used in psychiatry (and in your textbook) most often based on their application in tx of different types of dx
- Antipsychotic
- Antidepressant
- Anxiolytic
- Mood-altering
- Psychostimulant
Anxiolytics
Used to alleviate sx of anxiety and muscle tension => Do NOT provide a cure
- Effective while taking medz, typically not associated with sustained improvements
- Often can impede progress in therapy
- Widely used and prescribed, many also highly habit-forming (become addicted quite easily)
Barbiturates => Early class of anxiolytic drugs (Powerful sedatives that act primarily on GABA)
- Highly addictive
- Widely used as a recreational drug (Valley of the Dolls)
- Larger doses required to achieve same effect (tolerance)
- Large doses highly toxic => Due to dangers, now rarely prescribed
Benzodiazepines => Also GABAergic
- Less toxic than barbiturates
- Low doses: soothes anxiety
- High doses: sedative effects
- VERY calming in the short-term
- Highly habit forming *Should not be taken for long periods
- Withdrawal sx challenging
- Relapse rates very high
- Dangerous to mix with alcohol
Antidepressants
Have been available for > 50 years => Imipramine introduced in 1950s & 1987: introduction of Prozac (since then, 14 additional antidepressants introduced)
- No substantial evidence that these medications are more effective than imipramine
- All currently available antidepressants either alter function of serotonin, norepinephrine, or both => But, mechanisms of action still unclear
Four major categories:
- Monoamine Oxidase Inhibitors (MAOIs)
- Tricyclics (TCAs)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
*SSRIs and SNRIs are recommended as the first-line medz options for depression
- Take time to reach beneficial levels
-Benefits most pronounced for severe depression - Effects minimal or non-existent at mild and moderate levels of sx severity
- 30-50% of patients do not respond favorably to antidepressants -> Many discontinue use within 3 months of starting medication (not getting better + side effects)
SSRIs + Issues with Prescription
Most widely-used class of antidepressants => Act by inhibiting reuptake of serotonin ex: Prozac, Zoloft, Paxil, Luvox
- Some demonstrated efficacy for depression but also for OCD, panic dx, and eating dx
- Side effects mild compared to earlier classes => Nausea, diarrhea, headache, tremors, sleepiness,
sexual problems - Not fatal in overdose (unlike TCAs)
- No evidence that they’re more effective than other antidepressants
Study: Effectiveness of Antidepressants
- Meta-analysis concluded that “virtually all of the variation in drug effect size was due to the placebo characteristics of the studies”
- Result of positive expectancy for improvement and natural course of dx (spontaneous remission)
Issues with Antidepressant Prescription
- Can help to alleviate acute symptoms, but seldom helpful in long-term
- Evidence mostly supports use with only severe depression
- Yet frequency of prescription is incredibly high and increasing over time
- Publication bias => Studies that show positive effect are more likely to get published (Unpublished studies show smaller effect sizes) *Recall influence of pharmaceutical companies (“me too” drugs)
