intro to psychotherapy Flashcards
what is psychotherapy
Treating mental health concerns to improve ability to function and to improve quality of life
Does Therapy Work?
The average treated person is better off than 75-80% of untreated counterparts
Four Historical-Cultural Perspectives
- Biomedical Perspective: cause of mental illness is biological
- Religious/Spiritual Perspective: cause of mental illness is spiritual unrest
- Psychosocial Perspective: cause of mental illness is our beliefs about ourselves, including in relation to others
- Feminist and Multicultural Perspective: cause of mental illness is social and cultural oppression
Biomedical Perspective
cause of mental illness is biological
Religious/Spiritual Perspective
cause of mental illness is spiritual unrest
Psychosocial Perspective
cause of mental illness is our beliefs about ourselves, including in relation to others
Feminist and Multicultural Perspective
cause of mental illness is social and cultural oppression
evidence Based Treatments (EBTs)/Empirically Supported Treatments (ESTs)
approaches designed to treat specific mental disorders or other client problems, that have received
numerous and varied research support
* some more strong than others
Efficacy research
nvolves tightly controlled experimental trials with high internal validity
* Randomized controlled trials (RCTs) are the gold standard for determining treatment efficacy
* RCTs statistically compare outcomes between randomly assigned treatment and control groups
* In medicine/psychiatry, the control group is usually administered a placebo pill, and treatment is considered
efficacious if the active medication relieves symptoms at a rate significantly higher than the placebo
* In therapy, treatment groups are generally compared with a waiting list or attention-placebo control group
(receives the same amount of interpersonal interaction but from a layperson, not trained therapist using any
techniques)
* To control for confounds, RCTs require that participants meet specific inclusion and exclusion criteria
* Empirically supported treatments generally receive that support from efficacy studies, but some modalities of
therapy lend themselves better to being studied in this way than others
* Efficacy studies do not reflect psychotherapy as practiced in the field
Effectiveness research
considers the outcome of psychological treatment as it is delivered in
real-world settings
* Effectiveness research focuses on external validity
* Effectiveness research can be scientifically rigorous, but it doesn’t involve random
assignment to treatment and control conditions
* Similarly, inclusion and exclusion criteria for clients to participate are less rigid and more like
actual clinical practice, where clients come to therapy with a mix of different symptoms or
diagnoses
* The purpose is to evaluate counseling and psychotherapy as it is practiced in the real world
is technique important to therapy?
In research studies, different theory-based techniques didn’t produce significantly different
outcomes on average
* Research shows that different therapy approaches include common therapeutic factors, and
it is these factors that account for most of the positive change that occurs in psychotherapy
lamberts common factors model
Techniques (~15%): the actual methods and strategies employed by therapist to work with the
client toward change in their behavior and/or beliefs
* Different techniques used within different modalities
* How well the techniques are used matters
* Expectancy (~15%): What a client believes will happen
* Patient education can help
* Placebo effect can occur
Therapeutic Relationship (~30%): relationship between therapist and client
* Bordin (1979) described three dimensions of the working alliance:
1. A positive interpersonal relationship between therapists and clients
2. The identification of agreed-upon therapy goals
3. Therapists and clients collaboratively working together on therapeutic tasks linked to the identified goals
* Bordin’s model has strong research support
* (We’ll also learn about human factors therapists can bring to the equation when we cover Carl Rogers later
in the semester)
* The therapeutic relationship is the most powerful therapeutic factor over which therapists can
directly exert control
Extratherapeutic Factors (~33-40%): client factors that can contribute to success of therapy
* *Motivation
* Severity of disturbance
* Capacity to relate to others
* Resilience
* Insight
* Emotional intelligence
* Presence/absence of supportive others
* Ability to commit to treatment/lack of barriers
What Factors Are Linked to Therapy Producing
Worse Outcomes Than No Therapy?
Therapist Factors
* Client Factors
* Lack of fit between client and therapist
* Beutler (2009) wrote: “The fit of the treatment to the particular patient accounted for the strongest
effects on outcomes of all variable classes at one year after treatment” (p. 313)
* Implications?
* Intervention Factors
* Potentially Harmful Therapies (Lilienfeld)
* For some of these, whether they are helpful or harmful depends on the level of skill and competence
of the therapist providing the intervention; for others, they just have a high rate of being harmful
Potentially Harmful Therapies
Examples of PHTs:
* Critical incident stress debriefing
* Facilitated communication
* DID-oriented therapy
* Grief counseling for individuals with normal bereavement reactions
* Recovered-memory techniques
* Boot-camp interventions for conduct disorder
* DARE (Drug Abuse Resistance Education) programs
* Scared straight interventions
* Attachment therapies (eg, rebirthing)
* The seriousness of PHT is a reminder of how the importance that ethical therapists stay attuned to research
findings identifying treatment approaches that have heightened risks
Key Areas of Ethics in Therapy
Beneficence and Nonmaleficence: It’s not enough to want to help, you also have to take reasonable precautions to avoid
inadvertently causing harm
Competence: practitioners must have adequate knowledge and skills to perform specific professional services.
* Determining competence includes having awareness of both what you are well-versed in and what you do not know
enough about to deliver services around.
Informed Consent: refers to clients’ rights to know about and consent to the ways you intend to work with them.
* Clients have a right to know about their therapist’s training status, the particular treatment approach(es) being used,
how long therapy is likely to last, and potential benefits and harm associated with therapy.
Confidentiality: information clients share with therapists is private and not shared without the client’s permission, with
limited and specific exceptions.
* Exceptions
* It is of utmost importance to honor confidentiality because it is imperative to the client trusting their therapist, any
therapist, and the therapeutic process.
Multiple Relationships and Conflicts of Interest
having more than one type of relationship with the client that could
potentially cause conflict
* From APA ethics code: A psychologist refrains from entering into a multiple relationship if the multiple relationship
could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing
his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the
professional relationship exists.
* Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are
not unethical.
* Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or
other interests or relationships could reasonably be expected to:
(1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists, or
(2) expose the person or organization with whom the professional relationship exists to harm or exploitation.
Self-Care:
Neglecting oneself is an occupational hazard of mental health professions
* Lead by example
* Therapists need to be able to be functional themselves in order to continue to
benefit others. Psychotherapists who don’t do so get burned out, provide
substandard care, develop their own psychological problems, and/or act
unethically.
ideological purity
using one therapy model only, can close off alt. way of treatment, not typically done anymore
eclecticism
using a specific theory for a patient, case by case basis.
integration
combining 2 or more theoretical approaches to maximize effectiveness
Feminism
The belief that human beings are of equal worth and that the pervading patriarchal social
structures which perpetuate a hierarchy of dominance, based upon gender, must be resisted and
transformed toward a more equitable system
Patriarchy
consists of social hierarchies where male attributes are privileged and female attributes are
undervalued.
Feminism: What and Why
Feminists are critical of social hierarchies and the use of power to oppress (Enns, 2004)
Feminist therapy is also diversity-oriented. If women can be oppressed, so can other non-dominant
perspectives
* Therefore, feminist theory is concerned with amplifying voices that have been traditionally silenced
or ignored– female or otherwise
Intersectionality
we have multiple social identities that interact with each other, creating a whole
that’s more complex than and different from the sum of its parts
* Implications for discrimination: people with multiple identities outside of the dominant socially
valued identity experience multiple forms of discrimination and oppression
* Intersectionality may also contribute to why some people uphold a patriarchy that benefits them in
some ways but not in others– i.e., proximity to power
Broverman et al. (1970) studied how psychiatrists, psychologists, and social workers judged healthy
males, healthy females, and healthy adults
Healthy males and healthy adults were essentially identical (male is the default for what constitutes
healthy)
* You couldn’t both have feminine and be considered a healthy adult (feminine traits are undervalued
as a whole; however, women who show masculine traits are also demeaned– a bind for men and a
double bind for women)
Feminist theory says
let’s question with a critical eye ideas of dysfunction and deviance, as well as
question if behaviors that are dysfunctional or deviant come from within, or come about as a natural
reaction to being treated poorly in society
Feminist Therapy
Is not mutually exclusive from/can be used in conjunction with other therapies
* Without feminist awareness, clients might continually try to change themselves to survive in
patriarchal, sexist environments.
* Empirical research supports that this “taking of responsibility” will add stress and distress
* Denial of sexism is linked to higher distress (like gaslighting)
* Improving psychological health involves stopping blaming oneself for not being heterosexual,
white, male, or for being the wrong kind of male
* Focuses on empowerment to combat ways clients have been disempowered
Psychological connection with others via meaningful relationships produces psychological growth
throughout our lives
* Valuation of independence over interdependence is patriarchal
* Relational Cultural Therapy is based on a model of human development that places connection at
the center of growth
* supported by research evidence (therapy and brain imaging studies)
Empowerment (4)
Somatic power: Healthy power involves feeling security with and acceptance of one’s body as it is, rather
than trying to control one’s body to substitute for areas one cannot control or in order to feel more
accepted by society.
2. Intrapersonal power: Healthy power is linked to self-understanding, clarity of purpose, and emotional
awareness, rather than trying to control what others think or primarily focusing on what matters to others.
3. Interpersonal/social-contextual power: Healthy power involves confidence in one’s ability to help oneself
and contribute meaningfully to others, rather than becoming passive in the face of feeling undervalued and
resulting in helplessness, hopelessness, or isolation.
4. Spiritual/existential power: Healthy power involves feeling free to embrace whatever way of making
meaning that resonates with you, rather than self-blaming as inherently flawed for feelings of
meaninglessness and disconnection.
Feminist Therapy
Overarching goals
Helping clients see the patterns and social forces that have diminished their sense of power and
control
* Honoring the client’s experience in the world and their values as valid
* Encouraging clients to reclaim power, authority, and direction in their lives
* Allowing clients to experience this shared power in the therapy relationship
* Facilitating growth via meaningful relationships and interconnectedness
Case Formulation (Treatment Goal Planning)
- Learning to deal more effectively with sadness, grief, and anger within the context of a repressive emotional
environment. - Coming to an understanding that his beliefs and views of emotional expression were not in his best
interest, but instead, foisted upon him by toxic cultural attitudes about how boys and men should
experience and express emotion. - Developing trust and confidence in himself—despite not having a father figure or a mother who could
provide him and his sisters with a consistently safe and stable home environment. - Learning to talk about what he really feels inside and pursue his life passions whatever they might be
instead of reflexively pursuing culturally “manly” activities. - Expanding Josh’s limited emotional vocabulary through consciousness-raising.
Multicultural and Sociocultural Orientations
Are not mutually exclusive from/can be used in conjunction with other therapies
Theoretical approaches must have the capacity to serve client from a diverse spectrum, or cease to be relevant
Like feminist theory, consider social forces as a major contributor to psychopathology
Like feminism, social justice “involves addressing issues of equity, power relations, and institutionalized oppression” (Goodman, 2011, p. 4) and the belief that all people should be able to live “with dignity, self-determination, and physical and psychological safety” (p. 4).
Culture
a context that we are surrounded by, that is infused into various aspects of daily experiences, and shapes our norms and values
Those in majority cultures often have less awareness of their cultural underpinnings
E.g., what is dominant American culture?
Suburban culture?
How does your culture influence your life and day to day experiences?
How does intersectionality influence your life and day to day experiences?
Multicultural Therapy
Uses modalities and defines goals consistent with the life experiences and cultural values of diverse clients
Conducting counseling in a way that’s consistent with the client’s life experiences and cultural values. Their perspective comes first; the therapist’s theoretical orientation comes second, and is integrated in.
Implications for understanding diagnosis and assessment in light of their cultural limitations
One potential problem in applying cultural/racial knowledge is the tendency for practitioners to assume everyone from a particular group holds the same cultural values
DISCUSS: How do we address this?
Sociocultural Counseling/Therapy
Recognizing that, where misalignment is present between the client’s cultural values or identities and those which are valued in the dominant culture, this will contribute to the client’s distress and/or sense of dysfunction
Should be addressed in treatment goals
Acknowledging people from within the same culture are not necessarily familiar with the experience of others who have different social identity markers
Curiosity, not dismissiveness
“What would the world be like if different cultures had encountered each other with questions instead of answers?” (Thomas Merton, 1974) apply to our interactions
Considering this– and having conversations around this– can be challenging and uncomfortable
Members of dominant social groups (as client or therapist) may experience
Fear of being perceived as racist
Feelings of having no right to dialogue on race
Reactions of anxiety, helplessness, and feeling misunderstood
Members of non-dominant social groups (as client or therapist) may experience
Fear of being seen as a representative for an entire group
Worry about distancing for addressing uncomfortable truths
Reactions of anxiety, helplessness, and feeling misunderstood
Clients from minority groups are
more likely to drop out of therapy before completion of goals, suggesting therapy relationship factors are contributing to clients not feeling comfortable or understood enough to continue the work
When issues regarding race and ethnicity were considered important but were not included in their care, clients were less satisfied with treatment. Ethnic minority clients generally felt that these elements were more important than did White clients.
“Across three of the four outcome variables (access, quality of care, and general satisfaction), racial match and provider history of discrimination/prejudices added significantly to the predictive power of the model.”
Racial/ethnicity matching has had mixed results in research findings, from no to small effects
Efficacy and effectiveness of multicultural therapy
Multicultural approaches can be difficult to define and even more difficult to quantitatively evaluate.
Problems associated with empirical validation of culturally sensitive treatments, related to our metrics for quantifying problems/diagnoses and outcomes being generally from a Western lens
Lack of investigation into culturally relevant factors within existing data
What does multicultural competence look like?
Privileged and marginalized counselors are
aware, knowledgeable, skilled, and action-oriented in understanding how client and counselor privileged and marginalized statuses influence the counseling relationship.
Multicultural and social justice competent counselors acknowledge and maintain knowledge about how, for themselves and their clients:
their privileged and/or marginalized statuses provides advantages/disadvantages in society.
their privileged and/or marginalized statuses influence their assumptions, worldviews, values, beliefs, and biases.
learning about privilege and marginalization may sometimes be an uncomfortable or unfamiliar experience.
Multicultural and social justice competent counselors:
acknowledge their strengths and limitations in working with clients from privileged and marginalized groups.
are open to learning about their and their clients’ cultural background as well as their privileged and marginalized statuses.
seek out formal and informal opportunities to engage in discourse about historical events and current issues that shape the worldview, cultural background, values, beliefs, biases, and experiences of privileged and marginalized clients.
attend professional development trainings to learn how stereotypes, discrimination, power, privilege, and oppression influence privileged and marginalized clients.
At the community, institutional, policy, and global levels this is more labor intensive, and may or may not align with your personal career goals.
It’s okay to know where you are capable of investing your energy, and it’s okay to have a life outside of your work. Still, one can:
Stay current on national and world politics and events.
Seek out professional development to learn about how privileged and marginalized clients influence, and are influenced by, national and global policies and affairs.
Privileged and marginalized counselors intervene with, and on behalf, of clients by:
employing evidenced-based interventions that align with the cultural worldview of clients.
assisting clients in critically analyzing conclusions they have drawn about themselves and others based on their privilege and oppression.
assessing the impact of historical events and current issues on the presenting problems expressed by clients.
assisting clients with developing self-advocacy skills that promote social justice.
examining the relationships privileged and marginalized clients have with family, friends, and peers that may be sources of support or non-support.
assist clients in developing communication skills to discuss issues of power, privilege, and oppression with family, friends, peers, and colleagues.
