intro to psychotherapy

Question 1

what is psychotherapy

Answer 1

Treating mental health concerns to improve ability to function and to improve quality of life

Question 2

Does Therapy Work?

Answer 2

The average treated person is better off than 75-80% of untreated counterparts

Question 3

Four Historical-Cultural Perspectives

Answer 3

1. Biomedical Perspective: cause of mental illness is biological
2. Religious/Spiritual Perspective: cause of mental illness is spiritual unrest
3. Psychosocial Perspective: cause of mental illness is our beliefs about ourselves, including in relation to others
4. Feminist and Multicultural Perspective: cause of mental illness is social and cultural oppression

Question 4

Biomedical Perspective

Answer 4

cause of mental illness is biological

Question 5

Religious/Spiritual Perspective

Answer 5

cause of mental illness is spiritual unrest

Question 6

Psychosocial Perspective

Answer 6

cause of mental illness is our beliefs about ourselves, including in relation to others

Question 7

Feminist and Multicultural Perspective

Answer 7

cause of mental illness is social and cultural oppression

Question 8

evidence Based Treatments (EBTs)/Empirically Supported Treatments (ESTs)

Answer 8

approaches designed to treat specific mental disorders or other client problems, that have received
numerous and varied research support
* some more strong than others

Question 9

Efficacy research

Answer 9

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

Question 10

Effectiveness research

Answer 10

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

Question 11

is technique important to therapy?

Answer 11

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

Question 12

lamberts common factors model

Answer 12

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

Question 13

What Factors Are Linked to Therapy Producing
Worse Outcomes Than No Therapy?

Answer 13

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

Question 14

Potentially Harmful Therapies

Answer 14

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

Question 15

Key Areas of Ethics in Therapy

Answer 15

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.

Question 16

Multiple Relationships and Conflicts of Interest

Answer 16

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.

Question 17

Self-Care:

Answer 17

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.

Question 18

ideological purity

Answer 18

using one therapy model only, can close off alt. way of treatment, not typically done anymore

Question 19

eclecticism

Answer 19

using a specific theory for a patient, case by case basis.

Question 20

integration

Answer 20

combining 2 or more theoretical approaches to maximize effectiveness

Question 21

Feminism

Answer 21

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

Question 22

Patriarchy

Answer 22

consists of social hierarchies where male attributes are privileged and female attributes are
undervalued.

Question 23

Feminism: What and Why

Answer 23

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

Question 24

Intersectionality

Answer 24

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

Question 25

Broverman et al. (1970) studied how psychiatrists, psychologists, and social workers judged healthy males, healthy females, and healthy adults

Answer 25

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)

Question 26

Feminist theory says

Answer 26

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

Question 27

Feminist Therapy

Answer 27

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)

Question 28

Empowerment (4)

Answer 28

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.

Question 29

Feminist Therapy Overarching goals

Answer 29

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

Question 30

Case Formulation (Treatment Goal Planning)

Answer 30

1. Learning to deal more effectively with sadness, grief, and anger within the context of a repressive emotional environment. 2. 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. 3. 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. 4. 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. 5. Expanding Josh’s limited emotional vocabulary through consciousness-raising.

Question 31

Multicultural and Sociocultural Orientations

Answer 31

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).

Question 32

Culture

Answer 32

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?

Question 33

Multicultural Therapy

Answer 33

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?

Question 34

Sociocultural Counseling/Therapy

Answer 34

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

Question 35

Members of dominant social groups (as client or therapist) may experience

Answer 35

Fear of being perceived as racist Feelings of having no right to dialogue on race Reactions of anxiety, helplessness, and feeling misunderstood

Question 36

Members of non-dominant social groups (as client or therapist) may experience

Answer 36

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

Question 37

Clients from minority groups are

Answer 37

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

Question 38

Efficacy and effectiveness of multicultural therapy

Answer 38

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

Question 39

What does multicultural competence look like? Privileged and marginalized counselors are

Answer 39

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.

Question 40

Multicultural and social justice competent counselors:

Answer 40

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.

Question 41

Privileged and marginalized counselors intervene with, and on behalf, of clients by:

Answer 41

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.