Clinical Psychology Flashcards
Psychodynamic Psychotherapies - Characteristics
Human behavior motivated by unconscious processes
Early development on adult functioning
Insight into unconscious processes = key component of psychotherapy
General principles apply to everyone
Conflicts affect personality development
About internal conflict
Freudian Psychoanalysis - Personality Theory
id, ego, superego
focus on sexual and aggressive forces
5 psychosexual stages of development (oral, anal, phallic, latency, genital)
Anxiety - essential in Freud’s personality theory; alert ego to an impending internal or external threat
Defense mechanisms (occur as a result of ego unable to ward off danger through realistic/rational means) – repression, reaction formation, projection, displacement, sublimation
id
Freudian Psychoanalysis - Personality Theory
At birth
Pleasure principle
ego
Freudian Psychoanalysis - Personality Theory
At 6mos
Reality principle
Postpones gratification of id’s instincts
superego
Freudian Psychoanalysis - Personality Theory
4 or 5yo
internalization of society’s values & standards;
permanently block id’s impulses
Freud’s 5 psychosexual stages of development
oral (0-1yo) anal (1-3yo) phallic (4-6yo) latency (6yo to puberty) genital (puberty to death) (OAPLG)
during each stage, the id’s libido (sexual energy) is focused on a different part of body
over-or-under gratification of one’s sexual needs in each stage is assoc. with a different personality outcome
Repression
most “basic” defense mechanisms
1st line of defense; core defense
occurs when id’s drives and needs are excluded from conscious awareness (maintained in the unconscious)
e.g., Jane forgets a traumatic experience
Reaction formation
Avoiding an anxiety-evoking impulse by expressing its opposite
e.g., turning hate into love
Projection
Occurs when a threatening impulse is attributed to another person/external source
e.g., you might hate someone, so you solve the problem by believing that they hate you
Displacement
Satisfying an impulse with a substitute object (e.g., safe & vulnerable substitute)
e.g., someone who is frustrated by the boss may go home and kick the dog
Sublimation
Satisfying an impulse with a substitute object in a socially acceptable way
e.g., sport (putting one’s aggression into sth constructive)
Freudian Psychoanalysis - View of Maladaptive Behavior
unconscious, unresolved conflict occurring during childhood
Freudian Psychoanalysis - Therapy goals & Techniques
Goal: Bringing unconscious into conscious awareness & integrate repressed material into personality
Improvement via: insight & awareness, working through, & catharsis
Techniques:
Analysis (targets: free associations, dreams, resistances, transferences) via 4 processes:
confrontation, clarification, interpretation, & working through
Confrontation
Preconscious
Making statements or questions to help patient see behavior in a new way
Get client to elaborate & see things in a different light
Clarification
Conscious
Clarify patient’s feelings and restating remarks in clearer terms
Interpretation
Unconscious to conscious
More explicitly connecting current behavior to unconscious processes
Free association, dreams, resistances, transferences
Working through
an aspect of improvement in psychoanalysis (in addition to catharsis & insight)
final & longest stage
allows patient to gradually assimilate new insights into his/her personality
Ongoing confrontation and interpretation?
Transference & Countertransference
Transference:
Freud - client toward therapist (projection of earlier relationships; e.g., displacement)
Modification - an attempt to imbue that behavior with personal meaning; client’s reaction to therapist behavior (new behavior; interpret & help patient see how their current behavior is influenced by the past)
Countertransference:
Freud- therapist toward client (counter-productive from Freud’s perspective; e.g., displacement)
Modification - potential source of information about patient and importantly contributes to the curative process
Freudian Psychoanalysis
Role of unconscious instinctual (esp sexual) forces
Human beings are determined by: irrational forces unconscious motivations needs and drives psychosexual events
Adler’s Individual Psychology
Attention to social factors
Behavior as largely motivated by one’s future goals (teleological approach), rather than by past events
Teleological approach
Adler
Behavior as largely motivated by one’s future goals
Adler’s Individual Psychology - Personality Theory
Key concepts: Inferiority feelings Striving for superiority Social interest Style of life
Style of life
The specific ways a person chooses to compensate for inferiority and achieve superiority
one’s style of life is well-established by 4 or 5 yo
Influenced by birth order, early family relationships, innate social interest, inferiority feelings, & striving for superiority
Healthy style of life: reflect optimism, confidence, concern about welfare of others
Mistaken style of life: self-centeredness, competitiveness, striving for personal power, lack of social interest (leads to substance abuse, antisocial behavior)
Adler’s Individual Psychology - View of Maladaptive Behavior
mental disorders = a mistaken style of life (as opposed to a healthy style of life)
Adler’s Individual Psychology - Therapy Goals & Techniques
Goal: Help client achieve a more adaptive style of life (incorporate teleological approach; set future goals)
“lifestyle investigation”: information about family constellation, hidden goals, and basic mistakes (distorted beliefs and attitudes)
Establish a collaborative relationship, identify & understand client’s style of life and its consequences
Jung’s Analytic Psychotherapy
Adopted a broader view of personality dev than Freud
Libido as general psychic energy
Behavior = both past events & future goals/aspirations
Jung’s Analytic Psychotherapy - Personality Theory
Personality as consequence of both conscious & (personal & collective) unconscious factors
consists of 2 attitudes (extraversion & introversion) & 4 psychological functions (thinking, feeling, sensing, & intuiting)
Dev as throughout the lifespan (esp mid & late adulthood), similar to Erikson
Key concept = individuation (integration of conscious and unconscious aspects of psyche that leads to dev of a unique identity)
Dev of wisdom later in life (outcome of individuation)
Conscious ego - Thoughts, perceptions, ideas (how it’s similar to Freud’s)
Personal unconscious
experiences that were unconsciously perceived or were once conscious but are now repressed or forgotten
Collective unconscious
repository of latent memory traces that are passed down from one generation to the next
Universal to all people, to all time periods, to all cultures
includes archetypes
Archetypes
“primordial images” that cause people to experience or understand a certain phenomena in a universal way
includes: self, persona (public mask), shadow (dark side of personality), & anima (feminine) and animus (masculine) aspects of personality
Emotionally charged symbols; thought to be derived by our ancestors to continually repeating events
Jung’s Analytic Psychotherapy - View of Maladaptive Behavior
Symptoms as “unconscious messages” to the individual that sth is awry with the individual
Jung’s Analytic Psychotherapy - Therapy Goals & Techniques
Goal: Bridge the gap between the conscious & the (personal and collective) unconscious
Techniques:
- Interpretations (esp dreamwork)
- Transference as projection of personal & collective unconscious (thus, crucial part of therapy)
- Here-and-now
Object Relations Theory
Basic inborn drive = object-seeking (relationship to others; innate need to connect)
Emphasis on early relationship with objects, esp internalized mental representations (introjects) of self & objects
Object - mental representation of the person & feelings toward the person (e.g., mom, dad)
Splitting comes from object relations (all good or all bad; lack of resolution –> maladaptive behavior) –> Borderline Personality Disorder (mellow after 40yo)
Melanie Klein, Ronald Fairbairn, Margaret Mahler, & Otto Kernberg
Object Relations Theory - Personality Theory
Dev of object relations occurs during separation-individuation phase (4 to 5 mos of age) - Mahler
Differentiation
Practicing
Reapproachement
Object constancy
First, takes steps toward separation through sensory exploration (4mos)
Followed by, period of conflict between independence & dependence
Finally, by 3 yo, dev a permanent sense of self & object (object constancy) & able to perceive others as both separate & related
Separation-individuation phase (Mahler) - Leads to separate identity and object relations
Object Relations Theory - View of Maladaptive Behavior
Problems during separation-individuation process
Inadequate resolution of splitting (all good or all bad, instead of both good and bad)
Inability to tolerance ambivalence
e.g., patient with Borderline Personality Disorder
Object Relations Theory - Therapy Goal & Focus
Goal: Bring “maladaptive unconscious relationship dynamics into consciousness” so that dysfunctional internalized object representations can be replaced with more appropriate ones
Focus:
Splitting
Projective identification
Other defense mechanisms that maintain dysfunctional object relations
Humanistic and Constructivist Psychotherapies - Characteristics
Assumption that one must understand his/her subjective experience (as each person in unique)
- present, here-and-now
- focus on awareness and responsibility
Focus on current behaviors
Belief in the one’s inherent potential for self-determination & self-actualization
Therapy as an authentic, collaborative, & egalitarian relationship
Rejects ax techniques & diagnostic labels
Client’s perceived reality as indiv/socially constructed. Thus, focus of therapy on process of meaning creation than on accuracy or rationality of meanings
Person-Centered Therapy - Personality Theory
An innate “self-actualizing tendency” = source of motivation & guides people toward positive, healthy growth
Self must be unified, organized & whole to become self-actualized
Person-Centered Therapy - View of Maladaptive Behavior
self = disorganized (due to incongruence btw self & experience)
incongruence –> anxiety (self being threatened) –> alleviate anxiety via denial or distortion –> counter to self-actualization
e.g, worth (child finds out that positive regard from her parents is conditional rather than unconditional)
Person-Centered Therapy - Therapy Goal & Focus
Goal = help client achieve congruence between self & experience
Techniques = right environment by therapist will achieve congruence btw self & experience
“right environment” = 3 facilitative conditions
- unconditional positive regard (respect)
- genuineness (congruence)
- accurate empathic understanding
Avoid use of directive techniques
Do not view transference as necessary
Do not assign diagnostic labels
3 Facilitative conditions
- unconditional positive regard (respect)
- genuineness (congruence)
- accurate empathic understanding
Gestalt Therapy (Perls) - Personality Theory
each person is capable of assuming personal responsibility for his/her own thoughts, feelings, and actions and living as an integrated “whole”
Personality = consists of self & self-image
(which aspect dominates depends on early interactions with the environment)
To satisfy needs, person must interact with environment and point of contact with environment is the boundary
Self vs. self-image (Gestalt)
self = promotes individual’s inherent tendency for self-actualization and live as a fully integrated person
self-image = “darker side” of personality; hinders growth and self-actualization by imposing external standards
Gestalt Therapy - View of Maladaptive Behavior
Neurotic (maladaptive) behavior occurs due to abandonment of self for the self-image and lack of integration
Stems from disturbance in the boundary between self & external environment –> interferes with persona’s ability to satisfy one’s needs and maintain homeostasis
4 boundary disturbances: introjection, projection, retroflection, confluence
4 Boundary Disturbances (Gestalt)
- Introjection (likely to show up)
- When one accepts accepts/facts from environment w/o understanding or assimilating them
- trouble distinguishing “me” vs “not me”
- overly compliant
- should’s vs shouldn’t
- take on behavior of someone’s else without assimilate to our own; impedes growth & unique identity - Projection
- disowning aspects of self by assigning them to other people
- thinking what other might be thinking
- other people - Retroflection
- doing to oneself what one wants to do to others
- working against our need - Confluence
- absence of boundary/intolerance of differences btw self and environment
- going with someone else’s need other than our own
Gestalt Therapy -Therapy Goals & Techniques
Goal = help client become a unified whole by integrating various aspects of self
Awareness (as primary curative factor): full understanding of one’s thoughts, feelings, & actions in the here-and-now
*awareness & integration
Techniques: Empty-chair technique Role-play Guided fantasy (imagery) Dream work "I" statements
- transference = counterproductive; avoid diagnostic labels; historical events important only when directly impinge upon one’s current functioning (confusion between fantasy & reality)
(e. g., I’m your therapist, not your mother)
Existential Therapy
e.g. Logotherapy (Frankl)
Emphasis on personal choice & responsibility for developing a meaningful life
Assumes that people are in a constant state of evolving & becoming
Existential Therapy - View of maladaptive Behavior
Inability to cope authentically with ultimate concerns of existence - death, freedom, existential isolation, meaninglessness
Existential Therapy - Therapy Goals & Techniques
Goal= help clients live in more committed, self-aware, authentic, & meaningful ways
Therapist-client relationship = most important therapeutic tool
Reality Therapy (William Glasser) - Personality Theory
Based on choice theory; focus on how people makes choices that affect the course of their lives
5 innate needs as source of motivation: Love & belonging (most important) Survival Power Freedom Fun
Success identity vs Failure identity
Success vs Failure Identity (Reality Therapy)
Success ID = when one fulfills needs in a realistic manner that doesn’t infringe on the rights of others to fulfill their needs
Failure ID =inability to satisfy one’s needs or does so in irresponsibly ways
Reality Therapy - View of Maladaptive Behavior
Failure identity underlies most forms of mental & emotional disturbance
Mental illness = result of individual’s choices
e.g., a person is depressed because he or she chooses to, as he may believe that doing so will help him obtain attention from others or allow him to avoid unpleasant activities
Reality Therapy - Therapy Goals & Techniques
Goal = help clients identify responsible & effective ways to satisfy one’s needs and develop a success identity
Techniques:
Questioning, encouragements, explore & eval behaviors, develop and commit to a realistic plan of action
focus on one’s ‘total behavior” (though focus on one’s behaviors & beliefs)
Rejects medical model, transference as detrimental
Stresses conscious processes, emphasize value judgments
Personal Construct Therapy (George Kelly) - Personality Theory
Focuses on how client experiences the world
Assumes people choose the ways that they deal with the world & there are alternative ways for doing so
Psychological processes = determined by the way one “construes” (interpret, perceive, predict) events
Involves the use of personal constructs
Personal Constructs
Are bipolar dimensions of meaning (e.g., happy/sad; friendly/unfriendly)
Begin in infancy
No two people have the same set of personal constructs
People act as scientists who continually test their personal constructs and revise them as needed
Personal Construct Therapy - View of Maladaptive Behavior
Result of inadequate personal constructs
Rejects medical model of mental illness; instead, replace it with description of anxiety, hostility, and other mal. beh.
anxiety - occurs when one doesn’t have constructs to help him or her determine how to behave in various situations
hostility - when one continues to rely on constructs despite invalidating evidence and tries to force people, objects, or events to fit those constructs
Personal Construct Therapy - Therapy Goals and Techniques
Goal = Help client identify & revise or replace maladaptive personal constructs so that client can make sense of his/her experiences
Use of ax techniques:
Repertory grid
Self-characterization sketch
Treatment strategies:
Fixed-role therapy
Therapist & client as mutual experts & co-experimenters
Repertory Grid
An assessment technique used in personal construct therapy
Client identify people who have various roles in his or her life and the ways in which those individuals are similar or different
Self-characterization sketch
An assessment technique used in personal construct therapy
When client describes him/herself from the perspective of someone who knows the client well
Fixed-role Therapy
A treatment strategy used in personal construct therapy
Help clients “try on” and adopt alternative personal constructs
e.g., client experimenting other ways of experiencing life by acting out in his/her daily life the role of a fictional character who is psychologically different from the client
Brief Therapies
time-limited (6 to 30 sessions)
Focus on current concerns; problem-focused
Therapist adopts an active role
Interpersonal Therapy (Lerman & Weissman) - View of Maladaptive Behavior
Related to problems in social roles & interpersonal relationships tat are traceable to a lack of strong attachments early in life
Interpersonal Therapy - Therapy Goals & Techniques
Goals:
- Symptom reduction
- education, instill hope, pharmacotherapy (if needed) - improving interpersonal functioning
- target 4 areas:
unresolved grief,
interpersonal role disputes,
role transitions,
interpersonal deficits
-communication analysis, CBT, social skills, modeling, role-playing
Solution-focused Therapy - View of Maladaptive Behavior
Focuses on solutions rather than problems
View of maladaptive beh.: Understanding the etiology of problem behavior is irrelevant and focus on solutions to problems
Solution-focused Therapy - Therapy Goals & Techniques
Client as the expert; therapist acts as a consultant who poses different questions
Identify strengths & resources to help resolve presenting problems
Miracle question
Exception question
Scaling question
Formula tasks: ID positive aspects –> lead to solutions
The Transtheoretical Model (Prochaska & DiClemente) -View of Maladaptive Behavior
Analysis of 10 major approaches to therapy that led to 10 empirically supported change processes
Originally dev. as an intervention for cigarette smoking & other addictive beh but has applied to weight control, treatment complaince, IPV, financial management
View of Maladaptive Behavior - focus on factors that facilitate behavior change
6 Stages of Change (Transtheoretical Model)
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Termination
Progression through the stages is not linear
Interventions = most effective when matching someone’s stage of change
Identifies decisional balance, self-efficacy, & temptation as mediating variables affecting motivation at various stages
Goal: Help patient move to the next stage of change
Precontemplation
Little insight/ denial/ uninformed/ unsuccessful in previous attempts
Strategies: empathy, acceptance, support
Contemplation
Aware of need for change (maybe I have a problem?)
Action within 6 mos, but not committed to change
Aware of both pros & cons
May be ambivalent about change and remain in this stage for extended period
Strategies: Consciousness raising (e.g., increase awareness of healthy behavior) & support; self re-evaluation (e.g., self-appraisal); emotional arousal (about positive behavior whether positive or negative)
Preparation
Plans to take action within 1 mo
Has a realistic plan of action for modifying his/her behavior
Identify effective change strategies
Action
Taking concrete steps to change behavior
Making public commitment to change
Will respond to specific strategies (e.g., systematic desensitization)
Maintenance
Maintaining a change in behavior for at least 6 mos
Taking steps to prevent relapse
Will respond to specific strategies (e.g., systematic desensitization)
Termination
Feels he or she can resist temptation
Confident there is no risk for relapse
Decisional balance
the strength of perceived pros and cons of the problem behavior
role in all stages, but particularly important during contemplation stage
Motivational Interviewing - View of Maladaptive Behavior
*Use during pre-contemplation or contemplation stage
Dev. for those ambivalent about changing their behavior
Derived from Roger’s client-centered therapy & Bandura’s notion of self-efficacy
View of Maladaptive Behavior: Focus on factors that impede an individual’s ability to change that behavior
Motivational Interviewing - Therapy Goals & Techniques
Goal: Enhance client’s intrinsic motivation to alter his or her behavior
4 general principles:
- express empathy
- develop discrepancies between current beh & personal goals/values
- Roll with resistance
- support self-efficacy
Techniques (OARS):
- open-ended question
- affirmations
- reflective listening
- summaries
Family Therapies
General Systems Theory:
• family is a system of interrelated components, and a change in one family member causes change in other family members.
• All family systems are open (vs. closed) to some degree.
• Family systems tend to maintain a state of equilibrium
(homeostasis).
Cybernetics:
• A system receives information through positive and negative
feedback loops.
Identified patient
Negative Feedback Loop (Cybernetics)
Reduces deviation, maintains status quo
e.g., thermostat
Positive Feedback Loop (Cybernetics)
Disrupts the system
Amplify change and deviation
In therapy, positive feedback promotes appropriate change in a dysfunctional family system
Double-bind Communication
Bateson; dev of schizophrenia
“Do that and you’ll be punished” and “don’t do that and you’ll be punished” - with one injunction being verbally expressed and the other nonverbally
Communication/Interaction Family Therapy
Mental Research Institute (MRI) by Don Jackson, Virginia Satir, Jules Riskin, Jay Haley & others
How specific communication styles affect family interactions & relationships
Assumptions
- All behavior is communication
- Communication has a “report” and “command” function. Problems arise when report and command functions are contradictory
- Communication patterns are either symmetrical or complementary
Symmetrical Communications
Equal between communicators
May escalate into a “one-upsmanship”
Complementary Communications
Inequality and max difference between communicators
e.g., one participant to assume the dominant and the other the submissive role
Communication/Interaction Family Therapy - View of Maladaptive Behavior
Accepts a circular model of causality;
Symptom as both a cause and effect of dysfunctional communication patterns (e.g., blaming, criticizing, mindreading, overgeneralizing)
Extended Family Systems Therapy (Bowen)
Extends beyond the nuclear family & general systems theory; Describes the function of extended family and its members
Key concepts:
Differentiation of self
emotional triangle
family projection process/Multigenerational transmission process
Differentiation of self
Ability to separate intellectual vs emotional functioning
Lower differentiation = more likely to be “fused” with emotions that dominate the family
Undifferentiated family ego mass = family member who is highly emotionally fused
Emotional triangle
A third being recruited to increase stability and reduce tension when a two-person system experiences stress
Lower differentiation = greater an emotional triangle is formed
Family projection process
Process by which parental conflicts and emotional immaturity are transmitted to children
Extended Family Systems Therapy (Bowen) - View of Maladaptive Behavior
Result of multigenerational transmission process
Progressively lower levels of differentiation are transmitted from one generation to the next
Extended Family Systems Therapy (Bowen) - Therapy Goals & Techniques
Goal = to increase differentiation of all family members
Therapy techniques:
- typically involves only two family members (therapist as the third)
- may also work with family member who displays the greatest differentiation (can motivate others to self-differentiate)
- use of genogram (go back at least 3 generations)
- questioning (as a key technique)
Structural Family Therapy (Minuchin)
All families have an implicit structure = determines how members relate to each other
E.g., of family structures
- power hierarchies
- family’s subsystems (e.g. husband-wife; parent-child)
- boundaries (e.g., overly rigid/disengaged or too diffuse/enmeshed)
Key concepts:
Boundaries (disengaged/enmeshed)
Rigid triads (detouring, stable coalition, triangulation)
Rigid triads
Boundary problems (Minuchin’s structural family therapy)
- Detouring = when parents focus on child either by overprotecting or blaming child for family’s problem (e.g., scapegoating)
- Stable coalition = when parent and child form a coalition and “gang up” against the other parent
- Triangulation /unstable coalition = when each parent demands the child to side with him or her against the other parent (child being pulled in two directions)
Structural Family Therapy (Minuchin) - View of Maladaptive Behavior
Result of inflexible (or diffuse) family structure –> inability to adapt to stress
Structural Family Therapy (Minuchin) - Therapy Goals & Techniques
Long-term goal: restructuring the family (& unbalance family homeostasis)
Short-term goals: symptom relief
Techniques:
- Joining
- blend with family, includes:
a) *tracking (Id & use family’s values, themes & life events in conversations)
b) *mimesis (adopting family’s affective & communication style) - Evaluate family structure (like Bowen’s genogram)
- construct a family structural map to clarify family interaction patterns
- evaluate family’s structure (transactional patterns, power hierarchies, & boundaries) - Restructuring the family
- Use of *enactment & reframing to unbalance family’s homeostasis
- manipulate mood, esculate stress
Strategic Family Therapy (Jay Haley) - View of Maladaptive Behavior
Emphasize role of communication in maladaptive behavior, esp. how it’s used to exert control in a relationship
Symptom = interpersonal phenomenon
(“represents a strategy, adaptive to a current social situation, for controlling a relationship when all other strategies have failed”)
Strategic Family Therapy (Jay Haley) - Therapy Goals & Techniques
4 stages: social, problem, interaction, goal-setting
Therapists: assume an active, take-charge role/ use of directives such as paradoxical intervention
Paradoxical Interventions (Strategic family therapy)
Helps alter the behavior of family members by:
Helping them see a symptom in a different way, recognize they have control over their behaviors, or use their resistance in a constructive way
Ordeals = are unpleasant asks that client has to perform whenever a symptom occurs
Restraining = encouraging family not to change
Positioning = exaggerating the severity of symptom
Reframing = relabeling a symptom to give it a more positive meaning
Prescribing the symptom = instructing family member to deliberately engage in the symptom
Milan Systemic Family Therapy (Mara Selvini-Palazzoli)- View of Maladaptive Behavior
Results when a family’s pattern becomes so fixed that members are no longer able to act creatively or make new choices about their lives
Premise = family system is a circular patterns of action & reaction
Milan Systemic Family Therapy (Mara Selvini-Palazzoli) - Therapy Goal & Techniques
Goal = to help family members see their choices and assist them in exercising their prerogative of choosing
Techniques (designed to help members understand their relationships & problems in different ways, which then paves way to see new solutions & make new choices)
*Use of therapeutic team
- Hypothesizing (testing hypotheses and revise as necessary)
- Neutrality (ally of entire family)
- Paradox (use of counterparadox/double-bind & positive connotation/reframing)
- Circular Questions (help members recognize differences & similarities in their perceptions)
Behavioral Family Therapy - View of Maladaptive Behavior
Based on operant conditioning, social learning theory, & social exchange theory
All behaviors, including maladaptive ones, are learned and maintained by its antecedents & consequences
Behavioral Family Therapy - Therapy Goal & Techniques
Goal = alter environmental factors (antecedents & consequences) that are maintaining problematic behaviors
Techniques =
- Focus on observable behaviors
- Ongoing assessment of behaviors
- Increasing or decreasing target behaviors through contingent reinforcement
- Focus on improving communication & problem-solving skills
Recent trend to focus on maladaptive cognitions as well
Object Relations Family Therapy - View of Maladaptive Behavior
Result of both intrapsychic & interpersonal factors
Primary source of dysfunction = projective identification (when family member projects old introjects onto another family member and then reacts to that person)
Object Relations Family Therapy - Therapy Goal & Techniques
Goal = resolve each member’s attachment to family introjects (i.e., interpreting transferences, resistances, etc)
Therapists recognize multiple transferences in therapy
Group Therapy (Yalom) - 3 Formative Stages
- First Stage - Orientation, hesitant participation, search for meaning, dependency (reliance on therapist; toward advice giving & problem-solving)
- Second Stage - Conflict, Dominance, Rebellion
- social pecking order (anxiety, resistance, transition stage, hostility toward leader) - Third Stage - Development of Cohesiveness
Group Therapy (Yalom) - Therapeutic Factors & Therapist’s Role
Therapeutic Factors (group therapy as a social microcosm)
- Most important: interpersonal input, catharsis, self-understanding, & cohesiveness
- Least: Re-enactment, guidance, identification
Therapist Role
- creation & maintenance of group
- culture building (technical expert & participant/model)
- activation & illumination of here-and-now
Group Therapy (Others)
Concurrent group & individual therapy (neither necessary nor beneficial)
- Prescreening can reduce premature termination (10-35% drop out during 12 to 20 sessions)
- Preview orientation
Good candidate:
- primary problems = interpersonal issues
- motivated to change
- has a positive view of group therapy
- prefers to get involved in therapy slowly
- finds peer support & feedback beneficial
- is psychologically & verbally sophisticated
Feminist Therapy - View of Maladaptive Behavior
Symptoms are considered:
1: to be related to nature of traditional feminine roles or conflicts
2: “survival tactics” or means of exercising personal power
3: arbitrary labels that society has assigned to certain behaviors to exert social control
Feminist Therapy - Therapy Goals & Techniques
Goals: empowerment or helping women become more self-defining & self-determining
Techniques:
- Striving for an egalitarian relationship
- Avoiding labels
- Avoiding revictimization
- Involvement in social action
Self-in-relation theory (Feminist)
Gender differences can be traced to differences in mother-daughter & mother-son relationship
- males are taught to separate from mother, whereas females are taught to remain attached to mothers
- thus, females define themselves in relation and males in separation
Complementary & Alternative Medicine
- Hypnosis
- acute stress, anxiety, obesity, insomnia, chronic pain, recover repressed memory - Acupuncture
- unblocks flow of qi along pathways/meridians
- release of endorphines; alteration in blood flow
- useful to reduce certain pain, manage chemo-induced nausea and vomitting - Reflexology
- applying pressure to re-establish balance and promote healing
- restores energy flow
- stress & anxiety, pain, premenstrual syndrome, others
Community Psychology
Stresses prevention over treatment
Types: primary, secondary, tertiary
Techniques:
- Education
- Preventative health care
- Health Belief Model (health behavior can be modified by targeting people’s knowledge and/or motivation to act)
- Health Locus of Control Model (enhance one’s health behaviors by promoting patient’s sense of personal responsibility & control)
Primary prevention
Group/ All members of an identified group or population
Aim at decreasing incidence of new cases
- Stop it before it starts
- Reduce prevalence
E.g., all students at Jollity High
Secondary prevention
Self/Individual
- Screen & intervene
- Early detection
E.g., suicide hotline; crisis intervention
*Reduce severity of mental disorders
Tertiary prevention
Decrease after effects & risk of relapse
- Education & Rehab
- Reduce duration & consequences of dx & chronicity
e.g., rehabilitation, halfway houses, AA
Consultation - Stages
Entry
Diagnosis
Implementation
Disengagement
Mental Health Consultation
consultant, consultee(s), or client/program
- Client-centered case consultation:
- work with consultee to work more effectively with client - Consultee-centered case consultation:
- enhance consultee’s performance (focus on skills, knowledge, abilities, objectivity) - Program-centered administrative consultation
- working with administrators (consultees) to solve problems in an existing program - Consultee-centered administrative consultation
- help administrative- level personnel improve professional functioning
Eysenck (1952)
Effects of psychotherapy are small and nonexistent; nothing more than spontaneous remission
People who don’t receive therapy do better (72%) than those with similar problems who receive eclectic therapy (66%) and psychoanalytic (44%) therapy
- do better within 2 years
- only 66 and 44% show substantial decrease
Smith, Glass, & Miller (1980) meta-analysis
1st to use meta-analysis to psychotherapy outcome research
Mean effect size = .85
Average therapy client is better off than 80% of those who need therapy but remain untreated
Lambert and Bergin (1994)
Therapy is not due to any unique or specific techniques but common factors such as catharsis, positive relationship with therapist, behavioral regulation, cognitive learning and mastery
Howard et al. (1986) - Dose-dependent effect
Relationship btw treatment length and outcome “levels off” at ~26 sessions
Dose dependent effect: 75% of clients show marked improvement at 26 sessions and 85% at 52 sessions
Howard et al (1986) - Phase model
Benefits of therapy vary depending on the phases
3 Phases:
- Remoralization - first few sessions (due to increased hopefulness)
- Remediation - focus on symptom relief - ~16 sessions
- Rehabilitation - “unlearning troublesome, maladaptive habitual behaviors & est. new ways of dealing with various aspects of life” (behavior & personality change)
Efficacy vs. Effectiveness
Efficacy:
- clinical trials (under well-controlled conditions)
- less useful
- limited generalizations
- good internal validity
- useful for est. whether or not a treatment has an effect
- in lab; structured session format
Effectiveness:
- correlational or quasi-experiental
- best for assessing clinical utility (tmt’s generalizability, feasibility, cost-effectiveness)
- better external validity
- conducted in clinical and other applied settings
Research on Psychotherapy with Members of Diverse Populations
- While smaller proportion of Af-Am receive mental health services, a disproportionate share in emergency room, psychiatric inpatient setting, treatment for illicit drug
- ethnic & cultural minority groups are more likely to terminate therapy prematurely
- Ethnic matching reduced premature termination for Asian, Hispanic, & White Americans, but Af-Am; outcomes assoc with improved treatment outcomes for Hispanic American clients only
- People with a strong commitment to their culture are more likely to prefer an ethnically similar counselor
- Other factors such as education, similarity in values and worldview - are more important than race, culture, etc for many members of culturally diverse groups
Interventions for older adults
Most common problems: anxiety, severe cog impairment, & depression
More heterogeneous than other age groups
Gatz et al (1998):
- behavioral & environmental interventions
- memory and cognitive retraining
- cognitive, behavioral, & brief psychodynamic therapies
- interventions most effective when tailored to specific needs and circumstances (e.g., incorporating caregivers & family members into an intervention)
Interventions for IPV victims
20.4% (female) vs 7% (male)
Younger, heterosexual, American Indian/Alaska native, yearly incomes < $10,000
Interventions:
- emphasize self-determination
- appropriate to women’s needs
- ensure safety & increase her self-esteem & sense of empowerment & control
- separate services for victims & perpetrators?
Diagnostic Overshadowing
When the presence of one diagnosis (e.g., Intellectual Disability or LD) causes a clinician to attribute all of a client’s symptoms to that diagnosis and overlook the possibility of a co-diagnosis
Alloplastic vs Autoplastic interventions
Alloplastic:
-make changes to the environment
Autoplastic:
-changing the individual
Therapist Distress
Suicidal statements = most stressful type of client behavior
Lack of therapeutic success = single most stressful aspect of their work
Issues related to confidentiality = most frequently encountered ethical/legal dilemma
Psychiatric Hospitalization
Admission rates to state & county psychiatric hospitals = higher for men
Marital status: (highest to lowest) Never married > married or divorced/separated > widowed
Race/ethnicity: Whites represent largest numbers
Age: 25-44 yo for men and women
Diagnosis: schizophrenia (most common) for inpatients in the 18 to 44 age; age 65 (organic disorder, then affective disorder)
- more women than men for outpatient admissions
- whites represent 70% of admissions to both inpatient and outpatient mental health programs
Diverse Populations - African Americans
Therapy: multisystems approach or extended family system
Gender roles = flexible; egalitarian; adopt multiple roles
Family = an extended kinship network (including church)
Emphasize interconnectedness;
group welfare > individual needs
Diverse Populations - American Indians/Alaskan Natives
Therapy: Build trust & credibility by showing respect and familiarity with their culture; network therapy; incorporate traditional healing practices
Collateral social system that includes family, community, tribe (emphasis on extended family & tribe)
Adopt a spiritual and holistic orientation of life; emphasizes on harmony with nature
Time = personal & seasonal rhythms; present-oriented (than future-oriented)
Diverse Populations - Asian Americans
Therapy: prefer a directive, structured therapy approach; expect therapist as a knowledgeable expert, given concrete advice, and as authority figure
Somaticize their psychological problems
Avoid open expression of emotion
Greater emphasis on family & community; adopt a hierarchical family structure & traditional gender roles
Emphasize harmony, interdependence, & mutual loyalty
Diverse Populations - Hispanic/Latino Americans
Therapy: Utilize an active, directive, solution-focused approach; incorporate traditional healing practices
May somaticize their psychological problems
Gender role = clearly defined (patriarchal; sex roles = inflexible; parent-child bond is often stronger than husband-wife and other family relationships)
Family welfare > individual welfare (allegiance family over other concerns)
Consider discussing intimate personal details with strangers = highly unacceptable; problems be handled within family/other natural support system
Consider impact of religious & spiritual factors
Internalized homophobia
when LGBT individuals “accept heterosexual society’s negative evaluations of them and incorporate these into their self-concepts”
consequences = low self-esteem, self-doubt, self-hatred, sense of powerlessness, denial of one’s sexual orientation, self-destructive behavior
Therapy = ID & correct cognitive distortions, training in assertiveness & coping skills, activating social support systems
“Coming out”
lesbian and bisexual women who come out report higher levels of self-esteem & positive affec, lower levels of anxiety,
higher degree of outness = associated with lower levels of psychological distress for lesbian & bisexual women
Cultural Competence
- Awareness
- aware of own assumptions, values, & beliefs - Knowledge
- understand worldviews of culturally diverse clients - Skills
- Use therapeutic modalities & interventions that are appropriate for culturally different clients
Two critical processes critical when working with diverse clients: credibility & giving
Indegenous Healing
Share 3 characterisitcs:
- Rely on community & family networks
- Religious & spiritual practices of the community are integrated into the healing process
- Healing process = conducted by a traditional healer or other respected member of community
Examples
Curanderismo
Ho’oponopono
Sweat lodge ceremony
Acculturation
Degree to which a member of a culturally diverse group accepts and adheres to the values, attitudes, behaviors of his/her own group and the dominant (majority) group
Integration
Assimilation
Separation
Marginalization
Integration
Biculturalism
Best mental health outcome
High in both (minority & dominant) cultures
Assimilation
High in Majority
Low in minority
Separation
Low in Majority
High in Minority
Marginalization
Low in both (minority & dominant) cultures
Worst outcome; neither here nor there
Worldview
How a person perceives his/her relationship to nature, other people, institutions, and so on
Impacted by one’s cultural background & experiences
Determined by 2 factors-
Locus on control
Locus of responsibility
White middle-class therapists: INTERNAL control & responsibility
African-American: EXTERNAL control & responsibility
- Members of minority groups
- increasingly likely to exhibit INTERNAL control & EXTERNAL responsibility
Cultural encapsulation (Wrenn, 1985)
When therapists exhibit:
Limited worldview
Rigid, sterotyped views
No cultural differences
Emic vs Etic
Emic = me in my culture; culture-specific theories
Etic = theory is universal; a universal orientation
High- vs. Low-Context Communication
High-context = grounded in situation, group understanding, nonverbal cues, slow to change, unify a culture
Low-context = relies primarily on explicit, verbal message; change rapidly and easily
Consequences of Oppression
- Internalized oppression
- Conceptual incarcerations = adopting a White Protestant worldview & lifestyle
- Split-self syndrome = polarizing oneself into “good” and “bad” components
Playing it cool & Uncle Tom syndrome = ways in which Af-Am disguise negative feelings to protect self from being harmed or exploited
Cultural vs Functional Paranoia
Cultural = healthy reaction to racism Functional = unhealthy condition
Ridley’s model
- Intercultural nonparanoiac discloser (low in both)
- functional paranoiac (high functional, low cultural)
- healthy cultural paranoiac (low functional, high cultural)
- confluent paranoia (high in both)
Sexual Stigma
“shared knowledge of society’s negative regard for any nonheterosexual behavior, identity, relationship or community”
-create power differential between hetero and homosexuals
Heterosexism
cultural ideologies, which are “systems that provide the rationale and operating instructions” that promote and perpetuate antipathy, hostility, & violence against homosexuals
Sexual prejudice
negative attitudes that are based on sexual orientation, whether the target is homosexual, bisexual, or heterosexual
Racial/Cultural Identity Development Model
Atkinson, Morten, & Sue (1993)
5 stages that people experience as they understand themselves in terms of own culture, dominant culture, & oppressive relationship between the 2 cultures
Stage 1: Conformity Stage 2: Dissonance Stage 3: Resistance & Immersion Stage 4: Introspection Stage 5: Integrative Awareness (CDRIII)
Conformity
Stage 1 of Racial/Cultural Identity Dev Model
“White is good”
Positive attitudes toward dominant cultural values
Depreciate one’s own culture
Dissonance
Stage 2 of Racial/Cultural Identity Dev Model
Confusion & conflict; question treatment of white toward other groups
Resistance & Immersion
Stage 3 of Racial/Cultural Identity Dev Model
- Actively reject dominant society
- Appreciate attitudes toward self and members of their own group
Introspection
Stage 4 of Racial/Cultural Identity Dev Model
Uncertainty about rigidity of beliefs in Stage 3; conflicts btw loyalty and responsibility toward one’s group and feelings of personal autonomy
Integrative Awareness (Stage 5 of Racial/Cultural Identity Dev Model)
“multicultural; let’s all get along”
Experience a sense of self-fulfillment with regard to cultural identity
Strong desire to eliminate all forms of oppression
Adopt a multicultural perspectively
Black Racial Identity Development Model
(Cross, 1971)
“race salience”
Stage 1: Pre-Encounter Stage 2: Encounter Stage 3: Immersion-Emersion Stage 4: Internalization (PEIEI)
Pre-Encounter
Stage 1 of Black Racial Identity Development Model
Race & racial identity have low salience
Adopt mainstream identity;
Negative beliefs about Blacks –> low self-esteem
Assimilation, miseducation, self-hatred identities
Encounter
Stage 2 of Black Racial Identity Development Model
Exposure to a single significant race-related event(s) –> greater awareness and interest in developing a Black identity
Question dominant culture’s treatment of other groups
Immersion-Emersion
Stage 3 of Black Racial Identity Development Model
Race & racial identity = high salience
Dev. black identity
Immersion
- idealizes Blacks & Black culture
- rage toward Whites
- guilty & anxiety about previous lack of awareness of race
Emersion
- intense emotions subside
- rejects all aspects of White culture & internalize a Black identity
Internalization
Stage 4 of Black Racial Identity Development Model
Race = high salience
Adopt one of 3 identities
1) pro-Black, non racist orientation
2) biculturist (Black identity with another salient cultural identity)
3) multiculturalist (Black identity with two or more other salient cultural identities)
White Racial Identity Development Model
(Helms)
Two phases:
- Abandoning Racism (Statuses 1-3)
- Contact
- Disintegration
- Reintegration - Development a nonracist White identity (Statuses 4-6)
- Pseudo-Independence
- Immersion-Emersion
- Autonomy
Contact
Status 1 of White Racial Identity Dev Model
Little awareness of racism
Behaviors reflect racist attitudes & beliefs
IPS = Obliviousness & Denial
Disintegration
Status 2 of White Racial Identity Dev Model
Increase awareness of race & racism –> confusion & emotional conflict
IPS = suppression of information & ambivalence
Reintegration
Status 3 of White Racial Identity Dev Model
Attempts to resolve moral dilemmas by idealizing White society and denigrating members of minority groups
IPS: selective perception & negative out-group distortion
Pseudo-Independence
Status 4 of White Racial Identity Dev Model
Personally jarring event(s) –> cause one to question own racist views
Acknowledge role that Whites have had in perpetrating racism
Interested in understanding racial/cultural differences but only does so on intellectual level
IPS = selective perception & reshaping reality
Immersion-Emersion
Status 5 of White Racial Identity Dev Model
Explores what it means to be White, confronts own biases, begins to understand White privilege
Experiential & affective understanding of racism & oppression
IPS = hypervigilance & reshaping
Autonomy
Status 6 of White Racial Identity Dev Model
Internalizes a nonracist White identity
Appreciation of and respect for racial/cultural differences & similarities
Seeks out interactions with members of diverse groups
IPS = flexibility & complexity
Homosexual Identity Development Model
(Troiden, 1988)
Stage 1: Sensitization/Feeling Different
Stage 2: Self-Recognition/Identity Confusion
Stage 3: Identity Assumption
Stage 4: Commitment/ Identity Integration
Sensitization/Feeling Different
Stage 1 of Homosexual Identity Development Model
Characteristic of middle childhood
Feels different from peers (e.g., different interests than same-gender classmates)
Self-Recognition/Identity Confusion
Stage 2 of Homosexual Identity Development Model
Onset of puberty
Attraction to people of the same sex
Attribute feelings to homosexuality -> turmoil & confusion
Identity Assumption (Stage 3 of Homosexual Identity Development Model)
Becomes more certain about one’s homosexuality
Deal with realization by various ways
- trying to “pass” as heterosexual
- align self with homosexual community
- act in ways consistent with stereotypes about homosexuality
Commitment/Identity Integration
Stage 4 of Homosexual Identity Development Model
Adopt a homosexual way of life
Public disclose of one’s homosexuality
Telepsychology
Telephone Text Emails Chats Interactive tele-video conferencing tech virtual reality
Can cover crisis intervention, homebound patients, assessments & consultations, conduct therapy
Healthcare systems
3 approaches to healthcare
- Private model
- Beveridge model (public funds)
- Bismarck model (mix of public & private funds)
Triangular Model
Where organizational policies & prof knowledge form the foundation with the supervisor relationship at the core with the ultimate emphasis on providing service to clients
