Full Yeat Flashcards
How to define psychotherapy?
By task or goal:
- to help patients cope with trauma
- to enable them to reach their best self
- to equip them with skills to better deal with life’s challenges
- to teach them ways to regulate emotional ups and downs
How to define psychotherapy cont’d?
By setting or technology – modes of action
- two people in a quiet room, free of distractions
- boundaries: times regular; comfortable chair or couch
- say anything do nothing
- talk vs. pen-and-paper homework
Research perspective in psychotherapy
- interpersonal (not-self help)
- based on psychological principles (not medical)
- therapist is trained, patient has a problem, mental disorder
- remedial for disorder, problem
- individualized for same
How has the case been made for psychotherapy’s scientific status
- gap between clinical practice and research
- psychiatry–ambivalent relationship to psychotherapy
- clinical psychology – evidence based treatment/therapies
- therapeutic practice – highly individualized, taught by means of apprenticeship model
Each system of therapy is structured around
model of mind/modal patient
theory of psychopathology – what causes someone’s distress
distinctive technology – talk and therapist’s self vs. worksheets/homework
theory of therapeutic action – what alleviates suffering?
ideal/expected outcome – what does successful treatment look like?
The pyschodynamic mind
dynamic - interaction and conflict between parts of mind
neither entirely rational or knowable
internally divided (id, ego, superego); (conscious and unconscious)
Theory of psychopathology for psychodyamic
Illness - when we cannot reconcile unconscious desires (id, unconscious) with conscience, sense of who we are (superego, ego)
sex and aggression - sources of conflict with society
Desire is dangerous; society demands repression of sexuality; individual - seeks sexual pleasure
aggression must be checked – we can’t get what we want
constant battle between parts of mind
Theory of therapeutic action for psychodynamic
talk, relationship-transference
The cognitive behavioral mind
We understand reality with “schemas” (cognitive frameworks that help us organize and interpret information)
Focus on mental representation of the world and “reality”
- usefully allows us to process vast amounts of information quickly
- at the same time allows us not to see what doesn’t fit in the schema
CBT Therapeutic action
Focus on the present not the past
Identify distorted thinking
Distinguish thoughts from reality
Understand the effect cognition has on feelings
Change inaccurate beliefs
Restructure patterns of thought, schemas
Cognitive errors
distortions/irrational beliefs
examples: Overgeneralizing, Selective Abstraction, excessive responsibility, self-references, dichotomous thinking
The cognitive therapist’s approach
Initial thought about a situation
What is the negative thinking behind initial thought
What is the source of the negative belief
Challenge your thinking
Consider the consequences of continuing to think this way
Magic
recast as the therapeutic alliance
Lumpers
common factors – commonalities more important in accounting for outcomes than differences
Splitters
dominant in research literature
Allegiance effect: allegiance of researchers strongly influences therapy outcome
- Studies by advocates of treatment usually favor that treatment
- allegiance effect: much stronger than differences among treatment
Common factors
common factors: patient engagement, affective experiencing, and the therapeutic alliance
Magic of words
Freud (1905): “Words are the essential tool of mental treatment”
Transference
- Makes the relationship legible to science
Freud: patterns laid down in childhood produce “what might be described as a stereotype plate (or several such, which is constantly repeated in the course of a person’s life”
responding to another person as if they were someone from your past
3 people involved
Therapeutic Alliance
- makes the relationship legible to science
refers to the direct human relationship between the therapist and the patient
used to refer to the part of the patient that wants to work with the therapist
Repetition and Enactment
When something we do not want to know or understand about ourselves plays out over and over in our lives
Projection
Being unaware of unwanted/unacceptable feelings in yourself and mistakenly seeing them in other people instead
Behaviorism
all behaviors learned through interaction with environment
psychology is a branch of experimental natural science
focus should be on observable behaviors, not internal states – can’t see thus can’t measure
all behaviors conforms to the model of stimulus-response
Behavior-therapy basics
Aaron Beck
CBT creator
“Man has the key to solving and understanding his psychological disturbance”
CBT
CBT envisioned as radical alternative to dynamic therapies and revision of behaviorism
developed in the 1950s
- hopeful–supplant psychoanalysis and dynamic therapies
- commitment to methodological rigor
Beck’s basic principles of CBT
- mental disorders are thinking disorders
- thoughts influence mood
- if patients can be taught to restructure thoughts, mood will improve
Beck’s model of depression
depressed patients experience streams of negative thoughts–called them automatic thoughts
3 categories: negative thoughts about themselves, the world, and the future
Dialectical perspective
“Contradictory truths do not cancel each other but stand side by side”
Linehan: dialectical perspective
How to understand the meaning of the patient’s behavior in the present
Individuals both accept themselves as they are AND accept that they need to change (acceptance and validation)
developed for people with BPD
BPD (borderline personality disorder )
- emotional hyper-reactivity and resultant dysregulation
- intolerance of aloneness
- chaotic interpersonal relationships
Why does attachment matter?
Independence is predicated on attachment
Ainsworth studies show that babies can have a close attachment to mother (secure base) that allows them to explore b/c they know that their mother will be there to soothe them
What is group therapy?
Key assumptions:
- people act differently in groups vs. individual
- groups are greater than the sum of their parts
- groups have structure
Basic characteristics of group therapy
- one or two leaders, 6 - 12 members
- meets 1/2 times a week
- open or closed
- usually strangers, screened by group leaders
- outpatient or inpatient
Why group over individual therapy?
- cost effective
- support from others with similar problems
- focus is one the here-and-now – people’s patterns become evident in group process (Yalom calls this phenomenon “the group as social microcosm”)
Where does group therapy have its origins?
Encounter groups at Esalen Institute and California Dreaming
Freud and the group
Hypothesis: crowds held together by power of some kind (eros)
Individuals in groups animated by love of the other – individual gives up self for group
Wilfred Bion (psychoanalyst) on groups
Groups form around external reality task.
Developed perspective in work w/ mlitary/veterans in military psychiatric hospital
Psychiatrist in such situation must act as commanding officer – how to sustain authority and have close emotional relationship with men
What happens in a group?
- people come together as a group for the purpose of preserving the group
- fear over disintegration of the group
B.W. Tuchman model of group forming
Forming: stage of information exploration and exchange in which individuals’ identities are revealed
Storming is the stage of conflict in which desired roles, positions and status are declared, and competition occurs over conflicting demands
Norming is the stage negotiation and resolution, during which time stable solutions to conflicting demands are achieved
Performing is the “steady state” of the group in which, having done the initially necessary social-emotional work, attention can be focused on task performance with only social-emotional maintenance being acquired
Yalom’s perspective on group therapy
perfect setting for interpersonal issues “the group forms a social microcosm”
To what do patients attribute the success of group work?
Yalom: “Discovering and accepting previously unknown/unacceptable parts of myself”
“Being able to say what was bothering me instead of holding it in”
“Other members honestly telling me what they think of me”
Yalom: some factors influencing change in group therapy
- instillation of hope
- universality - not alone
- imparting information–educate
- altruism–able to help others
- corrective recapitulation of primary family group
- development of socializing techniques
Content vs. process
content is what they say, process is how they say it
Managers vs. leaders
managers (competence, control) (stability, order)
leaders (inspiration, vision) (tolerance of chaos)
Attitudes toward goals: managers take an impersonal, passive outlook; goals arise out of necessities, not desires. Leaders take a personal, active outlook; and shape rather than respond to ideas. Set the direction of the company
Conceptions of work: Managers negotiate and coerce, avoid risk, and balance opposing views. Leaders develop fresh approaches to problems, increase options, and seek risk when opportunities appear promising
Relations with others: Managers prefer working with people but maintain minimal emotional involvement. Leaders relate to others directly, intuitively, empathetically; focus on the substance of events
Sense of self: managers feel part of the organization. Leaders feel separate from the organization and their sense of self comes from struggles to profoundly alter human and economic relationships
Barriers to treatment – external and internal
external: non-internal reasons like financial constraints, lack of therapists
internal: reasons relating to one’s internal self such as the stigma, culture
Disparities for POC
Research studies show discrimination at the point of entry: black people are less likely to get a call back from a therapist
Many therapists are known to exhibit a preference for patients they perceive as being young, attractive, verbal, intelligent, and successful (YAVIS)
Cultural competency
Understanding help-seeking behaviors
Specific manifestations of distress
turn to “culturally endorses coping strategies”
For example: clients with few resources face logistical issues (transportation, childcare); and can’t miss work, mistrust of mental health system, stigma
What is self-help?
actions taken by self
Conversion therapy
Aim–change sexual orientation or gender identity
Method–aversion, behavioral exposure (nausea inducing drugs, electric shock)
historically (chemical castration)
Discredited–ineffective, cannot change orientation; harmful (suicide, depression) seen as torture
Freud and psychoanalysis on homosexuality
Psychoanalysis “opposed to any attempt at separating off homosexuals from the rest of mankind as a group of a special character”
“All human beings are capable of making a homosexual object choice and have in fact made one in their unconscious
“From the point of view of psychoanalysis the exclusive sexual interest felt by men for women is also a problem that needs elucidating and is not a self-evident fact based upon an attraction that is ultimately of a chemical nature”
Homosexuality an achievement not a given
Freud petitioned on behalf of civil rights for homosexuals
Sexology
scientific study of human sexual behavior
origins in the late 19th century
Sexological principles
- curiosity, lack of overt moralism
- normative, but homosexuality is not a disease or crime
- interested in variation
Who is a therapist?
Shedler: there is no such thing as a licensed therapist. Legit professionals state their specific profession: psychiatrist, psychologist, etc.
Ethics of practice
Confidentiality: laws protecting/laws mandating reporting of abuse
- record-keeping (subpoenas)
Boundary violations:
non-sexual (dual relationships (must wait a couple years but generally not recommended even after termination), gifts, barter)
sexual
Boundary violations: short history
boundary violations – term not used till 1980s and 90s
malpractice suits brought by patients–rare before 1975
states began to criminalize therapists’s sexual exploitation of clients in early 1980s
Singularity–therapist must
listen w/o judgment
side with patient against family, friends, co-workers
discover and ameliorate traumas
identify strengths and work on weaknesses
reflect back our best selves
support us through thick and thin
Toll of being a therapist
Isolation
mental exhaustion
feelings of helplessness in the face of suffering
burnout
managing worry and concern for patients
affective exhaustion, indirect traumatization
challenges both in private practice and agency setting, dealing w/ insurance, family members, dysfunctional staff
Eliza effect
as users interacted with the chatbot, they had strong emotional reactions. Some users told eliza private thoughts.
Active listening
technique of person-centered therapy
is a widely used communication technique in which the listener repeats, rephrases, and asks for clarification of the statements made by the speaker
Weizenbaum as dissenter
- people did not realize they were talking to a computer
- the relevant issue is ethical…since we do not now have ways of making computers wise, we ought not now give computers tasks that demand wisdom
- wanted to outlaw “all projects that propose to substitute a computer system for a human function that involves interpersonal respect, understanding, and love”
Appeal of chatbots
- people disclose more to a chatbot
- apps don’t judge, they’re neutral
- scalability
- access, convenience
- illusion
- cyberspace
Challenges of internet-delivered CBT
- works best when there is a trained guide/coach to check in over the phone (humans limit scalability and profitability)
- not engaging enough
Woebot combats these challenges b/c its an automated coach that helps you practice good thinking hygiene and “he’s fun to talk to”
Therapy Platforms
platforms market themselves as available on demand for patients but therapists are alarmed by this b/c limit-setting and boundary-setting are a part of therapy
“If you can’t manage to not talk to your therapist for four hours, you are very ill and need a higher level of care”
Cyberspace
term coined in 1984 by William Gibson
“…figurative space, a representational space that must be actively programmed and created…an area or volume between specific boundaries…the reality of cyberspace, like the reality of physical space is an articulated gap [that] creates a space where reality and fantasy can be manipulated to create many desired possibilities.
Cyberspace is where fantasy and reality often collide
the individual can feel control as he manipulates reality
Problem with Eliza
- people believed the computer understood them
- troubled by belief that program would replace human psychotherapists
- asked in 1978: what are the limits people ought to impose on the application of computation to human affairs?
What is psychotherapy?
- interpersonal (not self-help)
- based on psychological principles (not medical)
- therapist is trained; patient has mental disorder, problem, complaint
- remedial for disorder, problem, complaint
- individualized for same
Argument against chatbots
it doesn’t teach you to function in the world and relate to others. It teaches you how to indulge in a narcissistic fantasy
research shows that only 6% of apps backed by evidence of efficacy
The bond
what patients want–interpersonal
Argument for Woebot
it hinges on alliance, users were able to develop a bond w/ woebot
As it stands today, rules-based AI is more suitable for healthcare than generative AI
Termination
a. psychologists terminate therapy when it becomes reasonably clear that the patient no longer needs the service, or is being harmed by continued service
b. psychologists may terminate therapy when threatened by the client
c. except where precluded by the actions of clients, prior to termination, psychologists provide pre-termination counseling and suggest alternative service providers as appropiate
Insecure attachment
Insecure attachment is characterized by a lack of trust and a lack of a secure base. People with an insecure style may behave in anxious, ambivalent, or unpredictable ways. When adults with secure attachments look back on their childhood, they usually feel that someone reliable was always available to them.
Family therapy
Families all have:
- structure
- boundaries
- alliances
- coalitions
- triangulations
Decenter problem and symptom bearer
Behavior is not individual but sustained by the system
Explore family patterns that maintain symptom
Explore what each brings from the past that influences present
What are family members doing that helps maintain the identified patient’s symptoms?
