Clinical Psychology

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CBT

  • cognitive distortions (Beck)
  • arbitrary inference, selective abstraction, overgeneralization, magnif/minim, personalization, dichotomous thinking
  • depression vs. anxiety (Beck)
  1. depression (cognitions- hopelessness, low s-e, failure) anxiety (anticipation of danger/harm)
  2. depression (negative themes) anxiety (uncertainty of future events question)
  3. both display demoralization, self-absorption, reduced cog capacity for pblm solving and task performance

RET vs Beck

  • RET holds irrational thoughts lead to maladaptive beh, CT holds thoughts are dysfx when they interfere with normal cog processing (can be rational); RET more beh focus; RET therapist more likely to challenge pt’s dysfx beliefs in CT pt encouraged to test out these beliefs on his/her own
  • Stimulus Control
  • narrowing: restricting target behavior to limited set of stim (e.g., fat person- only eat at kitchen table at mealtimes)
  • cue strengthening: linking beh that’s targeted for increase to specific cue or set of cues (e.g., student who rarely studies encouraged to study in certain, specified location, stim with that location will come to trigger study beh)
  • competing responses: identifying and eliminating responses that block desirable behs, or encouraging responses that block undesirable behs (e.g., poor studyer asked to id interference to studying- talking; targeted for elimination)

Stress inoculation Training

  1. cognitive preparation (ed as to how his/her faulty cog prevent appropriate and adaptive coping)
  2. skills acquisition (learning and rehearsing new skills, such as relaxation)
  3. practice (application of learned to real or imagined situations)

research shows useful in remediating aggressive beh and impulsive anger

paradoxical intention

Instructing clients to “do or wish for the very things they fear”- to circumvent anticipatory anxiety; used to treat insomnia

Client-Centered therapy

Carl Rogers

  • congruence: genuineness of therapist (words/actions)
  • incongruence comes about from conflict btwn self-concept and person’s experiences
  • self-actualization tendency: what guides/motivates us or capacity for natural growth, for constructive change, or for self-understanding; goal of therapy is to realize this capacity for self-actualization
  • client’s maladjustment due to discrepancy btwn real self and ideal self
  • therapist providing unconditional positive regard, empathy, genuineness results in change in client

Transactional Analysis

Erik Berne

  • aims to simplify client’s understanding of unhealthy interactions
  • goal is to get people to understand their patterns of behavior and to let their adult ego state take ctrl of transactions while integrating 3 ego states

Theory of Personality

Ego states

assumes 3 distinct ego states: child, parent, adult

Strokes

recognition of others (+/-); how transactions occur bwn ego states at 2 levels (social and covert)

Scripts

  • life plan:
  • developed through interactions with parents and others;
  • giving/receiving strokes- pattern; if unhealthy- maladaptive beh

life positions

  • I’m Ok, you’re Ok;
  • I’m Ok, you’re not Ok,
  • I’m not OK, you’re OK;
  • I’m not OK, you’re not OK

Transactions

  1. complementary: original communication met with appropriate response
  2. crossed: original communication elicits inappropriate ego state
  3. ulterior: confusion b/c one of communicators giving a dual message; basis of games (series of ulteriors)

Family therapy

Systems Theory

  • family is system of interacting relationships and transactional patterns
    • open system (open to outside influence)
    • closed system (resistant to change)- want to avoid this (goal of therapy)
  • properties of a family system:
  1. wholeness: all parts of system interrelated, if one part changes, all others do
  2. non-summativity: whole is greater than the sum of its parts
  3. equifinality: same end result occurs for the family no matter where one enters the system
  4. equipotentiality: one cause can lead to different results
  5. homeostasis: tendency for a system to restore the status quo in event of change/disruption of system (disruption- positive feedback)
  6. negative feedback: correct deviations in status quo to maintain homeostasis
  7. positive feedback: creating deviations in status quo to maintain homeostasis

Communication/Interaction Therapy

  • behavior is form of communication (verbal and non verbal); encourage positive communication btwn family members

double-bind communication

sometimes 2 aspects of same communication contradict each other (“I love you” while pushing child off lap)

metacommunication

report level is intended verbal statement, command level is implicit non-v message (metacommunication)

symmetrical or complimentary communication patterns

(former is = but more competition and conflict; other involves dominant/nondominant roles)

pseudo hostility

superficial bickering to avoid real conflicts; mystification: use denial to mask what’s really going on

Extended Family Systems Therapy

  • Bowen’s: incorporates members of extended family; encourages differentiation of self in all family members (primary goal)
  • 8 interlocking constructs:
  1. differentiation of self: ability to separate one’s intellectual & emotional fx; less able to do this- more fused with other family members
  2. triangulation: triad that causes conflict
  3. nuclear family emotional system: mech family uses to deal with tension and instability
  4. family projective process: projection of parental conflicts and general family dysfx onto children
  5. emotional cutoff: methods kids use to remove selves from emotional ties to their parents (avoidance of emotional involvement leads to lack of self-differentiation)
  6. multigenerational transmission process: escalation of family dysfx through several generations, leads to severe dysfx
  7. sibling position: birth order influences family fx: older children are expected to be responsible of younger
  8. societal regression: impact of societal stress on family system
  • Use genograms and triangulation techs

Minuchin’s structural family therapy

  • views family as an organism or structure
    • when structure’s dysfx processes maintained, family is underfunctioning
    • goal is to disrupt these processes and push family structure toward better fx’
    • improve family process with improve individual in family
  • family system
    • family is, rather than individuals
    • family structure (how family members relate to each other, sets of rules, values, etc.)
    • subsystems (parent-child relationship)
  • Boundaries: (enmeshment: overly unclear, diffuse boundaries- dependence; disengagement: overly rigid boundaries- isolation)
    • parent/child conflicts:
    • triangulation: each parent demands child to side with him/her against other
    • detouring: spouses reinforce deviant beh in child b/c it takes focus off of pblms they are having with each other
    • stable coalition: could join (one parent with child against other parent)
  • goals of therapy:
    • restructure family (inflexible)
    • joining (therapist blends with family system via mimesis- adopts family’s style/lang and tracking- id with family values and hx)
    • creates a family map (specific patterns in general family system can be assessed)
    • restructures the family via
      • enactment- use of role-playing to understand relationships/situations and then changed
      • reframing- family beh relabeled in more positive light
      • blocking- force family to act as they normally do to adopt new interactional patterns

Strategic family therapy

  • Jay Haley;
  • focuses on strategies a therapist uses to restructure a family’s problematic system
  • therapy seen as power struggle btwn client/family and therapist
  • therapist is to adopt strategy to reduce/eliminate family’s sx beh patterns
    • paradoxical interventions (instructing pt to engage in sx beh)
    • reframing (relabeling a beh to make it more amenable to therapeutic change)
    • circular questioning (intv tech to learn more about patterns in family relations)

Object-Relations Family Therapy

  • Psychodynamic principles
  • Interprets current relationships btwn family members
  • Focus on:
    • Transference
    • Early parent-child relationships
    • Insight is core for family change

Group Therapy

  • pioneers: Adler, Burrow, Moreno, Yalom
  • composition of group: most therapist want hetero/homogeneous balance
  • dev level, gender, IQ (most important), stability, size
  • stages of group therapy
  1. group members hesitant to divulge info; dep on leader for communication and approval; concerned with rules, structure, purpose of group
  2. members est place in group; communication becomes hostile and critical (esp toward therapist)
  3. members begin to trust each other and therapist more (cohesive)
  • role of group leader
    • knowledgeable about group dynamics; handle/manage conflicts
    • handle multiple transferences and countertransferences
    • encourage participation from all members
  • benefits of co-therapist
    • complement/support each other
    • broaden range of possible transferential relationships
    • M/F team advantages
  • benefits of group therapy
    • Increased sense of hope
    • Development of social skills
    • Universality (others have similar problems)
    • Sharing of info
    • Sense of cohesiveness and togetherness
  • confidentiality in group therapy
    • although not legally required for members, crucial for effective dev of group
  • group/indiv therapy both might be OK with borderlines and narcissistics

Psychoanalytic theory

Traditional Psychoanalysis

  • ego defense mech: keep unacceptable impulses from reaching consciousness
    • anxiety results if d.mech break down and fail to control

“psychic excitation” (entry of unconscious impulses into consciousness)

  • id governs primary process thinking (unconscious) and fx according to pleasure principle; bio drives: self-preservation instincts, libido, aggressive drives
  • ego governs secondary process thinking or conscious mental process; reality principle
  • superego: conscience, comes from internalization of societal and parental restrictions
  • goal of classical psychoanalysis:
    • engender insight into unconscious and
    • strengthen ego so behavior is more reality based;
    • improvement:
      • catharsis,
      • repeated interpretation leading to insight,
      • working through (assimilation of insights into personality)
    • parallel process: phenomenon where counselor responds to his/her supervisor in way that parallels manner in which a client responds to the counselor
  • reaction formation (OCD); displacement (phobias)
  • therapeutic alliance (allows pts to id with therapist as someone who can help replace id with ego)- switched to working alliance
  • four therapeutic steps: confrontation, clarification, interpretation, working through
  • Freud (Little Hans fear of horses- Oedipal complex, phallic stage)

Additional Psychodynamic Therapies

Jung’s Analytical Psychology

  • extroversion (disposition to fine pleasure in external things)
  • introversion (turning inward of the libido)
  • turn from extroversion of youth to introversion of adulthood mid life (40); associated with mid-life crisis/transition
  • personal unconscious contains repressed material while collective unconscious consists of archetypes (universally shared predispositions toward feeling, thinking, and perceiving)
  • used same processes as Freud: dream interpretation, associations, transference analysis
  • unconscious exists on 2 levels: individual/personal unconscious (arises from repression), collective conscious (arises from universally inherited neural patterns, and archetypes)

Adler’s Individual Psychology

  • pathological beh represents maladaptive and defensive attempts to overcompensate for feelings of inferiority
  • When a child adopts compensatory patterns of behavior as a defense mechanism, a socially-maladaptive life-style is the result if excessive; neurotic, psychotic, delinquent
  • goal of therapy is to help client replace mistaken style of life
  • masculine protest: every child experiences feelings of inferiority which motivate child to grow, dominate, and be supportive
  • organ inferiority: inferiority cmplx dev in connection with particular body part
  • goal of therapy: replace “mistaken style of life” with healthier/more adaptive one; like Freud- interpretation of dreams, resistances, transferences; also used role-plays (help pt dev new behs)
  • STEP and STET applications (Systematic Training for Effective Parenting/ Teaching)

neo-Freudians

(emphasize social, cultural determinants of personality)

Sullivan

  • emphasized importance of relationships through lifespan
  • parataxic distortions deals with current acquaintances as if they were significant others from past, causes neuroticism; – like transference
  • 2nd parataxic mode involves private/autistic symbols, person sees causal connections btwn events that aren’t actually related (helps dev self and reduce anxiety)
  • syntaxic mode involves symbols with shared meaning; emergest at end of 1st year of life (underlies lang acquisition)
  • 1st: prototaxic mode involves discrete unconnected momentary states (before lang dev; 1st few mos; SZ associated with this)
  • role of cognitive experience in personality dev; 3 modes of cog exp

Horney

  • focused on early relationships
  • certain parental behaviors (indifference, overprotection, rejection) cause child to experience basic anxiety (feelings of helplessness and isolation in hostile world)
  • defend against anxiety: movement toward others movement against others, movement away from others; healthy person uses all 3, neurotic- only 1

Fromm

  • focus on effects of societal structures and dynamics on personality
  • 5 Cs styles: receptive, exploitative, hoarding, marketing, productive (last allows person to realize his/her true human nature)

Ego Analysts

-Anna Freud, Hartmann -focus more on ego’s role in personality dev and pathology -ego-defensive fxs: resolution of conflict -ego-autonomous fxs: adaptive, non-conflict laden fxs (learning, memory, speech, perception) -non-defensive fx of ego & pathology results when ego loses its autonomy from id -re-parenting, focus on therapy -psychopathology occurs when ego loses its autonomy from the id

Object relations theory

  • As most psychodynamic based theories argue insight is core requirement for change (family change)
  • look at transferences resulting from early mother-child relationship in relation to current relationships btwn family members
  • Mahler, Winnicott, Kernberg, Fairbairn
  • focus on internal representations of self/others (introjects)
  • emotionally impoverished childhood env leads to pblms related to formation of introjects- leading to Itra/interP difficulty (splitting, unstable self-image)
  • psychological birth (occurs in 3rd year)- Mahler; self id and level of ego strength available to maintain representation of another person (object)
  • Kohut known for his work on narcissism: child dev grandiose self when child’s natural self-love (narcissism) is undermined by parent’s failure to satisfy child’s needs
  • re-parenting: focus of therapy

Cultural/ethnic considerations

-Latino’s and A-A stress family/extended family unit, less so individualism -A-A: more non-verbal, emotional, concrete, like structured, time-limited therapy

Cross’s model of Psychological Nigrescence (Identity development of blacks)

  1. pre-encounter: Euro-A worldvw (blame A-A for own pblms)
  2. encounter: personal/social event dislodges worldvw, search for A-A id
  3. immersion-emersion: struggles to destroy old id and clarify new; reject W, accept B
  4. internalization: resolves conflict btwn old/new worldvws: ideological flexibility, psych openness, self-confidence; moves toward non-racism
  5. internalization-commitment: able to integrate new id into old group, commitment to political actions to improve A-A condition

Latinos: patriarchal, family/sex roles rigid, personal approach to therapy

  • Cuento therapy focuses on using Spanish folktales in txt process
  • research shown that can impair formation of successful therapy interactions:
  • lang differences, class-bound values (middle class), and cultural-bound values (normal/abnormal)

Native Americans

  • Therapy is recommended to be non-directive, open, accepting
  • respect importance of elder tribe members, medicine people, legends
  • network therapy works (therapist serves as catalyst)

Asian-Americans

  • social/family roles well-defined and rigid
  • therapy not encouraged within the culture (address mental health issues in the family)

Gay/Lesbians

  • McLaughlin’s 8 stages of “homosexual identity formation”
  1. isolation
  2. alienation and shame
  3. rejection of self
  4. passing as straight
  5. consolidating a self id
  6. acculturation
  7. integration of self and public id
  8. pride and synthesis

Approach to therapy with diverse populations

  • eclectic orientation implies greater flexibility (good for ethnic groups)
  • informal approach also good with Latino’s (characteristic of culture)
  • need to focus on acculturation issues for any client from different culture
  • Views that impact therapeutic relationship:
  1. racial/cultural identification (degree to which client id with their cultural/racial background;
    1. The stronger the identification, stronger the desire for racially similar therapist, similar to MID model)
  2. attitude similarity (attitude similarity might be more critical than race)
  3. therapist sensitivity (racially sensitive/aware- helps therapeutic alliance)
  4. The presenting issue may determine whether racial/cultural identification is an important issue for therapy.
  • therapist’s sensitivity to cultural issues and level of ID with own cultural group are better predictors of efficacy than same ethnic group (pt/therapist)
  • etic approach: looking at cultures from outside using universally accepted means of investigations
  • emic approach: studying a culture from inside and seeing it as its own members do; should take this approach in therapy

Cultural encapsulation (Wrenn)

Model for therapist

  1. defines world in terms of own cultural beliefs/stereotypes
  2. minimizes/ignores cultural variations among clients
  3. unaware of own cultural biases
  4. defines counseling in dogmatically-accepted tech/strategies

Berry’s acculturation model (modes)

  1. integration: high retention of minority culture, high maintenance of mainstream culture
  2. assimilation: low retent. of minority culture, high maint. of mainstream culture
  3. separation: high minority culture, rejection of mainstream culture
  4. marginalization: low minority culture, low mainstream culture

The last two modes are more stressful

Hall’s communication styles

  • High-context c. (Af, As, L, NA; verbalizations shortened without loss of meaning, non-v messages)
  • Low-context c (W; verbalizations stressed and elaborate codes)

Minority Identity Development Model

  • 5 stages of id dev in oppressed minority group:
  1. conformity: to dominant cultural values; neg to own; prefer majority therapist
  2. dissonance: cultural confusion/conflict, challenge 1; prefer minority therapist
  3. resistance and immersion: actively rejects majority group and endorses minority, distrust, hatred strong; own race therapist
  4. introspection: conflict btwn personal autonomy and rigid constraints of 2
  5. synergistic articulation and awareness: resolves conflict; sense of self-fulfillment of cultural id; race of therapist doesn’t matter

Janet Helms identity development model for Whites

  • (similar to Minority Identity Development model); four interaction patterns: parallel, regressive, progressive, crossed:
  1. contact: limited contact with people of color; unaware of race/ethnic differences
  2. disintegration: increase contact leads to greater awareness of inequalities; emotional, psych, and moral confusion/conflicts
  3. reintegration: resolve conflicts- adopt W is superior and minorities inferior
  4. pseudo-independence: dissatisfaction with reintegration and re-examine beliefs
  5. immersion-emersion: embrace White identity, don’t reject minority, attempt to determine how they can feel proud of race without being racist
  6. autonomy: internalize non-racist White identity, realistic, understand strength/weaknesses of race, seek out cross-racial interactions

Gestalt theory/therapy

  • goal is to engender full awareness of self, env, and self-env interaction
  • leads to integration of whole/gestalt self
  • I statements, dream analysis, empty chair tech, here-and-now
  • Treat transference as fantasy and get client to focus on “here-and-now”

Boundary Disturbances

  • introjection: assimilating info, beliefs, and values without really understanding them (e.g., accept individualism without thinking about them b/c accepted by our culture).
  • projection: like in PA
  • retroflection: substitution of self for env, does to self what they’d like to do to others; chief mech underlying isolation
  • deflection: avoidance of contact or awareness by being vague, indirect , overly polite
  • confluence: boundary btwn self/env becomes too thin/permeable (doesn’t experience self as distinct)
    • merge self into beliefs, attitudes, feelings of others
  • isolation: more severe form of confluence, nonexistence boundary btwn self/env; importance of others for self is lost
  • all healthy unless person unaware they are doing it

Fritz Perl (theory of personality)

  • emphasizes boundary disturbances (such as introjection, defection, confluence)
  • results in person who is less ctrl by self, and more by self-image
  • consistency of self (promotes actualization, growth, awareness) and self-image (imposes external standards on self and impairs self-actualization and growth)
  • person’s interactions w/env determine which part of personality exerts most ctrl

Existential psychotherapy

  • focuses on individual and ultimate concerns of existence (death, isolation, meaningless, ultimately responsible for own lives)
  • normal or “existential anxiety” and neurotic anxiety (latter being when person tries to evade normal anxiety, loss of subjective sense of free will and inability to take responsibility for one’s own life)
  • goal of therapy is to reduce neurotic anxiety and to dev authentic/intimate relationship btwn therapist and client

Reality therapy

  • 1st developed by Glasser who was working with delinquent adolescents
  • psych problems are thought to be due to inability to responsibly/adequately meet one’s basic needs
  • Key issues are survival, belonging (affiliation), power, fun, freedom
  • success when failure identity is replaced by success identity
  • like Adler, applied to schools/institutions:
    • Schools Without Failure (SWF) program

Crisis Intervention, Brief Psychotherapy, Solution-focused therapy

Stages of crisis intervention

  • formulation (id of specific crisis and client’s rxns to it)
  • implementation (assessment of client’s life prior to crisis, setting of specific ST goals, implements of tech to achv these goals)
  • termination (progress in achieving these goals assessed)

Brief psychotherapy

  • time limits (<25 sessions);
  • therapeutic alliance (primary change strategy) in addition to
  • ability to stay focused on primary pblms,
  • willingness to adopt an active role,
  • flexibility in choice and application of intervention strategies;
  • selection of clients (acute onset sxs; good premorbid fx, high motivation, relate well to others)

Solution-focused therapy

  • goals:
    • move client toward a solution orientation
    • Change complaint narratives to solution narratives
  • techniques
    • exception question (ask when pblm wasn’t there- self-fulfilling prophecy);
    • scaling question (rate situation to see how problem is perceived by others);
    • formula tasks (rx for change);
    • miracle question (visualize goal);
    • skeleton key (unlocking solutions);
    • narratives and lang games

Psychometric issues

  • empirical criterion keying: choosing items for a test on basis of items’ ability to distinguish btwn grps (MMPI-2, Strong-Campbell Interest Inventory e.g.s)
  • MMPI-2
    •  ? >30- questionable;
    • T score of more than 60 for ? Responses- invalid profile
    • K (correction, suppressor V): person’s psychological defensiveness and guardedness (high- defensive)
  • Special scores on Rorschach:
    • contamination and inappropriate logic (most serious, psychopathology; 2/more impressions fused into single response, strained reasoning to justify stated characteristics);
    • deviant verbalizations (incorrect words or redundancies)
    • R has larger validity coefficients than MMPI with Exner system
    • The data comprising the Exner norms has been questioned
  • Strong-Campbell Interest Inventory
    • more valid for predicting occupational choice or satisfaction than job success
    • (based on Holland’s theory and research)- broken down into occupations;
    • predictive validity (0.30)
    • Occupational Themes: RIASEC
      • realistic
      • investigative
      • artistic
      • social
      • enterprising
      • conventional
  • Kuder Vocational Preference Record
    • Indication of interest in 10 broad areas: outdoor, mechanical, computational, scientific, persuasive, artistic, literary, musical, social services, clerical
    • based on broad categories and content validity (not empirical criterion keying- how it differs from SCII)
    • recently dev a child version (grades 6-12)

Potpourri

  • Howard’s research on # of therapy session/therapy outcome
  • 3 phases:
    • remoralization (1st few sessions; improve feelings of hopelessness and desperation);
    • remediation (symptomatic relief, about 16 sessions);
    • rehabilitation (3rd phase, gradual improve in various aspects of fx)
  • suicide risk Factors:
    • 15-24 age
    • primary prevention (intervention before onset of pblm)
    • client Vs thought to be best predictors of therapy outcome (high intelligence, openness, low defensiveness, high ego strength, high anxiety tolerance, moderate expectations about therapy).
    • therapist Vs thought to be good predictors of therapy outcome (therapist competence)
  • Treatments Vs: therapeutic alliance
    • paraprofessionals and professionals are equally effective in txt of certain pblm domains;
    • txt for kids/adolescents as effective as txt for adults;
    • therapy for elderly depressed effective
  • txt duration to effectiveness (linear up to 26 sessions, levels off)
  • treatment effect size of 0.85
    • average client at end of therapy is better off than 80% of controls
    • 66% of treated individuals compared to 34% of controls show improvement as a result of psychotherapy