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Who Seeks Treatment?

15% of U.S population in a given year We will limit ourselves to 4 types: Most common presenting problems • Psychodynamic-Unconscious conflicts and motivations • Anxiety and Depression • Humanistic-Importance of self-esteem, self understanding, support in moving toward positive Women more than men mental health People with Medical insurance • Behavioral-actions learned through basic learning People with higher levels of education principles can lead to serious maladaptive behavior However, many people still do not seek help • Cognitive-habitual ways of thinking affect our moods because of the stigma attached to treatment and our interactions with others

Psychoanalysis

Freud’s psychodynamic approach has had a strong influence in our understanding of psychotherapy. Freud began career treating patients with Hysteria • Demonstrated that physical symptoms had Psychogenic causes. The Case of Anna O. • Patient fixated psychic energy as a result of unconscious conflicts • Anna’s understanding of her problems led to cure.

Psychoanalysis- Psychoanalysis Source of Problem: • Unresolved conflicts from early childhood (first five years) • Primary talk • The conflicts are unconscious and unknown to the patient • Takes a long time and is expensive. • Patient develops symptoms which indicate the conflict exists • The therapist is in control and decides whether Basis for recovery: patient improving. • Insight into the unconscious source of current feelings and • “Good” patients tend to be intelligent, drives that give rise to maladaptive behavior . articulate, and motivated, also rich. • Therapist’s job is to uncover source of the hidden conflicts and liberate the affect that supports them (). Techniques to gain access to unconscious conflicts : • Free and resistances • Dream interpretation • , acting toward therapist as though source of conflict

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Humanistic Approach to Psychotherapy Client (person) Centered Therapy called his therapy Client Centered, in Humanistic Psychotherapy grew out of: contrast to the hierarchical doctor/patient • A reaction to non-democratic and authoritarian relationship emphasized by Freud. psychodynamic approach of Freud. Source of problem • Existential Philosophy which stresses that each person • Rogers saw low self esteem as a major problem as a result of must decide for themselves what is a full and a Self Concept that was Incongruent with what was their meaningful life Ideal self Concept. Humanistic Approach assumes: • Parents who treated their Conditional positive regard by • Every person inherently good and naturally strives and withholding their love if child didn’t meet their expectations is capable of developing their own inherent human created incongruence. This could be real or imagined. potential. • Incongruence prevents self-actualization because an • Need for positive self-regard to be able to make individual has a a need to distort reality to hide shortcomings positive choices (actualizing your potential) in order to feel worthy of affection. Defensive maladaptive adaptive behavior leads to problems with others, and prevents optimal development.

Client Centered Therapy

Basis for recovery • Healing of the client comes with Unconditional Positive Regard: The granting of love and approval regardless of an individual's behavior allows realize their human potential. • Being able to accept oneself as you actually are (achieving congruence) leads to an openness to change and becoming a fully functioning person.

Rogers Client Centered Therapy Mirroring: Clarifying Feelings Main Therapeutic Techniques: "I thought I'd have something to talk about--then • Providing an environment for the client to discover the reality it all goes around in circles. I was trying to of their condition by helping client to clarify their feelings, and supporting change. think of what I was going to say. Then coming • Requires special Characteristics of therapist for acceptance: in here it doesn't work out....I tell you, it – Unconditional positive regard seemed that it would be much easier before I – Empathy came." – Genuineness • Mirroring. Therapist actively listens and repeats or rephrases thoughts and feelings expressed by client to help them “ become aware of what they are actually feeling. To reflect Rogers: You thought you would have more to the reality they are saying is there. say before you came here”

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Rogerian Reflections Rogerian Reflections

"I tell you, I just can't make a decision: I don't "I find myself and my thoughts getting back to know what I want. I've tried to reason this the days when I was a kid, and I cry very easily. thing out logically--tried to figure out which The dam would break through." things are important to me." Rogers: “When you think about the time when Rogers: “It seems confusing to you and you you were a child you feel yourself becoming don’t know what to do.” emotional.”

Mirroring causes both the therapist and the patient to gain greater insight into underlying conflicts in the self-concept.

Client: Let's put it this way. My stepfather and I are not on the happiest terms in the world. Therapist: But part of what really makes for difficulty is the fact that you and your stepfather, as you say, are not... the relationship Behavior Therapy isn't completely rosy. Client: Let's just put it this way, I hate him and he hates me. It's that way. Behavior Therapy a reaction to the vague and Therapist: But you really hate him and you feel he really hates you. non-scientific approach of other . Client: Well, I don't know if he hates me or not, but I know one thing, I don't like him whatsoever. Therapist: You can't speak for sure about his feelings because only he knows exactly what those are,but as far as you are • Reaction against medical model. Patient not “sick” but concerned... has learned to respond in maladaptive ways Client: ... he knows how I feel about it. Therapist: You don't have any use for him. • Application of principles of operant and classical Client: None whatsoever. And that's been for about eight years now. conditioning for therapeutic effect. Therapist: So for about eight years you've lived with a person whom you have no respect for and really hate. • Unlike any of the other therapies, behavior therapy is Client: Oh, I respect him. “ ” Therapist: Ah. Excuse me. I got that wrong. not talk therapy. Client: I have to respect him. I don't have to, but I do. But I don't love him, I hate him. I can't stand him. Source of problem: Therapist: There are certain things you respect him for, but that doesn't alter the fact that you definitely hate him and don't love him. Client: That's the truth. I respect anybody who has bravery and courage, and he does. • The environmental contingencies of reinforcement and Therapist: ... You do give him credit for the fact that he is brave, he has guts or something. punishment that support the maladaptive behavior. Client: Yeah. He shows that he can do a lot of things that, well, a lot of men can't. • Symptom oriented. Symptoms are learned responses Therapist: M-hm, m-hm. Client: And also he has asthma, and the doctor hasn't given him very long to live. And he, even though he knows he is going to die, not indicators of a “disease.” Get rid of symptom and he keeps working and he works at a killing pace, so I respect him for that, too. disease is gone. Symptom substitution, no problem Therapist: M-hm. So I guess you're saying he really has... Client: .. .what it takes. • Insight into past childhood conflicts not important.

Behavior Therapy Behavioral Cure for Bedwetting

Therapeutic Techniques: Developed by Hobart Mowrer in 1940s • Change contingencies that support maladaptive behavior and reinforce new responses to replace them. • Because it is a science based therapy it is very concerned with immediate, measureable results.

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Systematic Desensitization Systematic Desensitization

Systematic Desensitization is used to extinguish Systematic desensitization for phobic reactions fear behavior to phobic stimuli. • Uses anxiety hierarchy and counteract emotion through reciprocal inhibition. • Problem in phobias is that fear of reinforced by avoidance behavior. • Very successful in treatment of phobias. Anxiety hierarchy and reciprocal inhibition 0 Beginning a new course 10 A professor announces a quiz in two weeks 30 A professor announces a major exam in three weeks 45 Reading the material to be given on the exam 55 A fellow student asks you if you know the material 70 Studying with other students several days before the exam 80 Hearing students talk about things that you don’t know 90 Walking down the hallway to the exam room 100 Looking at the exam and finding a question you don’t know the answer to.

Techniques in Behavioral Therapy Implosion Therapy

Implosion or flooding therapy. • A sudden and large-scale exposure to the object under controlled conditions • Assumption is that the sympathetic nervous system cannot maintain a panic state for very long and that the level of arousal will decline, extinguishing the fear. Technology has changed methods • Digital Reality helmets can expose patients to objects that create fear (snakes, spiders), and situations that create fear (heights), in a very safe effective manner.

Other Techniques in Behavior Therapy

Aversion Therapy • Conditioning negative reactions to serious maladaptive behavior or to inappropriate stimuli. • Punishment Unlike other therapies, behavior therapy does not require insight into one’s problems or client’s cooperation. This means people can be given “therapy” against their will.

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Extinction of Self Destructive Behavior Aversion Therapy

Aversion therapy associates a punisher with the behavior that is to be avoided or suppressed.

Techniques in Behavioral Therapy Enforcing Treatment

Example: 47 year old chronic Schizophrenic. Three behaviors were a Method: problem. • Therapist Targets Behaviors or Actions they seek to • Stealing food change. • Wearing excessive clothing (25 pounds) • Hoarding towels. • Patients get tokens (poker chips, gold stars, or stamps) Procedures: for engaging in socially desirable or productive • Timeout. Removed from the dining room. Eliminated in 2 weeks. Weight down behaviors. Tokens taken away for undesirable behaviors. to 180 in fourteen months. • Excessive Clothing. Had to meet predetermined weight in order to receive meal. • Tokens can be used to immediately reinforce behaviors, 23 lbs at first. Then decreased two per week. Got to 3 lbs in 11 weeks. and exchange them later for tangible rewards. • Towel hoarding. Kept 19-29 towels in her room. Tried to make it aversive. Given 7 per day first week. Then by 3rd week raised to 60. At 624 towels she • Work well in psychiatric hospitals and sheltered care started removing towels, until she got down to 1.5 and maintained. facilities – First week: "Oh you found it for me thank you“ – Second: "Don't give me no more towels I have enough“ • Lack of generalizability to real world is a problem. – Third: "Take them towels away, I can't sit here all night and fold towels.“ Where will tokens come from? – Fourth: Get these dirty towels out of here. – Fifth: "I can't drag anymore of these towels, I just can't do it.

Cognitive Therapies Aaron Beck’s Cognitive Errors All or none thinking • If a situation is less than perfect you see it as a total failure. Cognitive therapies focus on person’s ingrained Overgeneralization • You see a single event as a never ending pattern of defeat by using the thoughts and beliefs that create maladaptive words ALWAYS or NEVER. negative feelings. Mental filter • You pick out a single negative detail and dwell on it exclusively. A word -Aaron Beck of criticism erases all the praise you receive. • seeks to improve people’s functioning by changing how Magnification and minification • You exaggerate the importance of your problems and shortcomings and they think and believe about situations that affect them minimize your strengths. negatively. Emotional reasoning • You assume that your negative emotions accurately reflect reality. “I feel guilty. I must be a rotten person.” Labeling • Instead of saying you made a mistake you attach a negative label to yourself: “I’m a loser.” Personalization and blame • You hold yourself personally responsible for events you can’t control. If it rained for the picnic you planned, it is your fault.

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Beck: Root of Depression is Negative Thinking Cognitive-Behavioral Therapy

Rational-emotive therapy- • Like Beck Ellis emphasizes that thoughts precede emotions, and that unpleasant feelings are a result of irrational thoughts. • Biggest difference is that these therapists tend to have a more “in your face” style of confronting you when you engage in negavitve thinking. • More likely to arrange “homework” to ensure changes in your behavior.

Cognitive and Rational-Emotive Therapies

Source of Problem • Person has developed habitual ways of thinking negatively about the self that does not match reality, leading to depressive thoughts and feelings. Both therapies apply learning principles. • Sets clear goals and procedures for changing behavior. Therapeutic Techniques: – Identify negative cognitions and examine them against reality – Challenge the person to test them, require explanations, express disbelief and disapproval of irrational beliefs. Confrontive. – Replace negative cognitions with more accurate perceptions – Homework. Both theorists require homework to practice new ways of dealing with difficult situations.

Cognitive Restructuring Exercise Exercise

Situation: Situation: • Having a long difficult assignment due the next day. • Breaking up with a person you love. Negative: Negative Cognition: • "I can't go on. He/she was everything to me. • "I'll never get this work done by tomorrow." Positive Alternatives: • "I really hoped our relationship would work but it is not Positive alternatives: the end of the world." • "If I work real hard I may be able to get it all done for • "Maybe we can get back together sometime in the tomorrow." future." • "This is going to be tough but it is still possible." • "I'll just have to try to keep myself busy and not let it bother me." • "It will be a real challenge finishing this assignment for tomorrow." • "If I met him/her, there is no reason why I won't meet someone else."

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Determining If Psychotherapy Works

Evaluating Psychotherapy more complex than it looks. Can we use a before treatment and after treatment assessment of people in therapy • Problem of regression to mean. Most people look for help when they are feeling their worst. The passage by itself is likely to show an improvement. Comparing people who decide to use Psychotherapy and those who do not. • Those who decide on psychotherapy are obviously different why else would they decide on psychotherapy; maybe more motivated to change.

The Effectiveness of Psychotherapy Effectiveness of Psychotherapy

The use of an Experimental and Control group. If we control for things on the previous slide is Experimental Group that enough for us to determine effectiveness? • Those who receive therapy Experimental Control group • People who receive therapy • Those not receiving therapy Control group Important things to control for • People who do not receive therapy • Random assignment of groups Placebo Control • Who decides if patient improved? • People who are not treated but think that they are – Patient – Therapist – Disinterested third person who doesn't’t know who was treated

Testing Effectiveness of Psychotherapy Creating Placebo Controls

In Placebo control, the person has the expectation they One way to do this has been to have people are being treated. without any training in psychotherapy counsel Giving a public presentation students with problems. ______• Very difficult problem to solve, but with this in mind Group Percent “significantly improved” what do you make of the findings that in comparing all the mainstream types of therapy they are pretty much ______the same? Self Report Objective Physiological • Or that therapists with advanced degrees do not seem to of anxiety behavior indices matter, Desensitization 100 100 87 • Or that how much experience therapist has had seems Insight 53 60 53 to be irrelevant. No-Trt control 7 24 28 This question is getting at whether Placebo control 47 73 47 has special insights into what works in therapy.

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Choosing a Therapist and Therapy

Even though it has been difficult to determine the effectiveness of therapy we do know that effective therapists • Are seen by their clients as genuine, warm, and caring. • Are considered to be people the client trusts and can work with Effective Therapies • Behavior therapies seem to be more effective in curing phobias • Cognitive therapies most effective in curing anxiety and depressive disorders.

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