Clinical/Counseling Psychology An art & a science…..
Clinical & Counseling Psychologists…. • ….work with people who are struggling with psychological disorders • ….help people to make changes that they want to make in their lives
What happens in therapy differs depending on… • …the problem: For some specific disorders, research has determined which approaches work best • e.g., cognitive-behavioral therapy is the “treatment of choice” for depression & for panic disorder • …the therapist: different therapists have different orientations or may take an eclectic approach. An eclectic therapist may combine ideas from the various therapies as she deems appropriate for the client and the problem.
What happens in therapy differs depending on… • …the problem • …the therapist • …the client: Just as some client’s problems may fit more with one approach than others, the client’s personality may fit more with one approach than with others. Both therapist and client need to decide together what approach is best.
The different treatment approaches are based on the various approaches to personality, so you’ve heard them before….
Treatment approaches include: • Behavioral • Cognitive • Freudian (Psychodynamic) • Humanistic • Systems approaches • Biological approaches
Behavioral treatment approach • Remember the behavioral approach says that people behave in the way that their environment has taught them to behave, e.g., through rewards & punishments, modeling, etc. • So the behavioral approach • Attempts to change the way the environment reinforces particular behaviors • Works at applying learning principles to help people to learn new behaviors.
Techniques of the Behavioral Approach • Systematic desensitization—This is a technique used specifically with phobias. Your book gives a very clear description of systematic desensitization on pp. 569-570. Make sure you read it.
Techniques of the Behavioral Approach • Systematic desensitization—helps the client to pair relaxation with a previously feared stimuli • Aversive therapy—(almost the opposite of systematic desensitization!)—has the client pair some aversive stimuli (e.g., nausea, pain, disturbing images, etc.) with some behavior that he/she is having difficulty giving up. • For example, a person trying to quit drinking might take a drug that makes her nauseous whenever she drinks alcohol. • A person trying to stop being so self-critical might be told to wear a rubber band around his wrist and snap it while thinking “No!” each time he thinks a critical thought.
Techniques of the Behavioral Approach • Both systematic desensitization and aversive therapy make use of classical conditioning learning principles. Remember in our brief discussion of classical conditioning earlier, we talked about it as associational learning—learning that occurs when things get paired together. • systematic desensitization “teaches” the client a new thing by pairing relaxation with something they fear • Aversive therapy “teaches” a new thing by pairing a bad experience with some behavior they want to eliminate
Techniques of the Behavioral Approach • Systematic desensitization • Aversive therapy • Behavior Modification programs—These approaches try to increase positive behavior and decrease negative behavior by using reinforcements and punishments in the most effective ways based on learning principles the behaviorists have discovered from research.
Behavior Modification programs • For example, therapists might work with the parents of a troubled child to help them set up a behavior mod program targeting their child’s behavior. The therapist will try to help the parents identify in what ways the undesired behavior is being reinforced and eliminatethat reinforcement & help them develop ways to reinforce desiredbehavior • Another special example of a behavior modification program is a token economy. This sort of program is described in your textbook on p. 572.
Behavioral Approach • Basically, a behavioral therapist assumes that any undesired behavior happens for a reason, and is going to search for the reinforcement or association that is maintaining that behavior and find ways to eliminate it so as to help the client to change their behavior in the way that they want to change it.
Humanistic Perspective • Remember the quote that we looked at when we began the humanistic perspective: “At their core, people are good. If people can learn to accept themselves as they are, then they can grow into their full potential. “ • Remember that this approach also emphasizes free will as a significant factor in determining our behavior. • Following these ideas, the humanistic approach to therapy is going to emphasize acceptance of the client and is going to give the client a lot of control over what happens in the therapy session.
Humanistic treatment approach • Humanistic therapy is sometimes titled a “client centered” or “patient centered” approach. In humanistic therapy, the therapist is nondirective, meaning that she allows the client to direct the session rather than directing it herself. • Remember the humanist approach sees us as having the potential to be healthy if we are just given positive regard and allowed to be ourselves. So the therapist’s job in humanistic treatment is to provide unconditional positive regard for the client. The therapist provides an environment in which the client feels safe to reveal the true self and say whatever he/she feels.
The “Tools” of a Humanistic Therapist • An environment of unconditional positive regard. Carl Rogers sometimes called this acceptance/ If you can’t remember what unconditional positive regard is, you can go back and read the definition of this on p. 488 of our textbook. • Active listening & “Mirroring” the client’s responses back to him so that the client can “listen to himself’ better • Empathy—working at seeing the world from the client’s perspective • Genuineness—The humanists thought that the character of the therapist really mattered. The therapist needed to truly engage and care about the client.
The Humanistic Approach • Read the excerpt from a therapy session on p. 568 in your textbook to get a sense of how this sort of therapy “feels.”
Cognitive treatment approach • Look at the example of a cognitive therapist working with a client given on pp. 573-574 of your textbook. What do you notice about this? How does it seem different from the example of the humanist approach? • You’ll want to notice (among many other things) that the therapist in the example focuses on how the client thinks about things and how those thoughts & perceptions affect the client. This is how you know that the therapist is taking a cognitive approach.
Cognitive treatment approach • Remember the cognitive perspective sees our thoughts as the cause of our personality and behavior. Thus if clients are having problems it is because they are thinking of things wrongly. • Cognitive therapists sometimes call these problematic ways of thinking “faulty cognitions.” Albert Ellis, a well known cognitive therapist, calls this “stinking thinking.” • Some cognitive therapists can be very confrontational—working at convincing clients that they are thinking about things wrongly; others may take a more gentle approach…
Cognitive-Behavioral Treatment • Often in contemporary therapy, therapists combine the cognitive & behavioral approaches. They will look for both the cognitive & environmental factors that trigger the problem behavior. They often ask the client to record-keep. • For example, if a client is experiencing panic attacks, a cognitive behavioral therapist might ask the client to keep a notebook in which she records each panic attack she experiences. She may be asked to keep track of what she was thinking before, during and after the attack, as well as what was going on in the environment (either reinforcers or associations—sometimes called “triggers”) before, during & after. Then the therapist works with the client to interpret this information to work at making needed changes in how she thinks, as well as in her environment.
Freudian (or Psychodynamic) treatment approach • Remember what the Freudian approach says about the cause of behavior • The cause of much of behavior in Freudian theory lies in the unconscious, so the therapist needs to figure out what is going on in the client’s unconscious. • The goal of Freudian therapy is sometimes summarized as “making the unconscious conscious”
What techniques does a Freudian therapist use to try to get at the client’s unconscious? • Free Association—you may remember that we talked about how Freud had used hypnosis to get at the unconscious but then eventually gave this up because he felt it wasn’t needed. Instead, he started using a technique called free association in which the patient was asked to say whatever came to mind.
What techniques does a Freudian therapist use to try to get at the client’s unconscious? • Free Association • Analysis of Transference—Transference, according to Freud, was a feeling that the client projected upon the therapist based on unresolved past relationships—early childhood relationships. For example, Freud hypothesized that if the client’s father was cold & withholding & judgmental, then the client would respond to the psychoanalyst as if HE were cold & withholding & judgmental. So by “analyzing” the transference was one way to discover what childhood realities were influencing current behaviors.
What techniques does a Freudian therapist use to try to get at the client’s unconscious? • Free Association • Analysis of Resistance • Analysis of Transference—Freudian analysts typically want to present a “blank slate” to the patient early in therapy. This is one of the reasons why in traditional therapy, the patient was asking to sit on a couch facing away from the analyst so the patient couldn’t even see the analyst’s facial expressions! This way, whatever the client projects onto the therapist is seen as a sign of unresolved unconscious childhood conflicts.
What techniques does a Freudian therapist use to try to get at the client’s unconscious? • Free Association • Analysis of Transference • Dream analysis—Freud thought that dreams were “the royal road to the unconscious”! So he often encouraged patients to tell him about their dreams and then interpreted them as conveying something about the patient’s unconscious
What techniques does a Freudian therapist use to try to get at the client’s unconscious? • Free Association • Analysis of Transference • Dream analysis • NOTE: Through all these approaches, the goal is for the psychoanalyst to develop an interpretation of the patient’s behavior and what is going on in her unconscious. Once the therapist is confident of his interpretation, he shares it with the patient, thus working toward the goal of “making the unconscious conscious”!!!
Freudian (or Psychodynamic) treatment approach • Read the example of a psychodynamic therapy session on p. 566. What do you notice about the interaction between the therapist & client? • The therapist is taking a very directive approach. Notice that the therapist talks more than the “patient” (client). Earlier in psychodynamic therapy, the therapist (sometimes called psychoanalyst) listens to the client’s dreams, free associations, etc. It is the therapist’s job to listen to what the client says & to interpret it. The vignette on p. 566 is an example of the therapist making an interpretation. • Notice also that the therapist’s interpretation involves disturbing feelings with which the client is not in touch. This is a very psychodynamic interpretation (because it focuses on the unconscious)
Systems approach to treatment • Remember from our earlier discussion of the systems approach that this approach believes that the only way to make sense of a person’s behavior is to understand it in the context of the system in which it occurs, e.g., in the family • So according to this approach, if an individual has a problem, it may be a problem of the entire system. For example, it may be the entire family that has to change; not just the person who is displaying symptoms!
Systems approach • One of the main techniques of the systems approach is family therapy, but some systems therapists will work with a lone individual at sorting out her role within her family and making changes to it that might make her feel better about her life. • Systems therapists look for patterns in the family in which the “symptoms” are embedded or look for the purpose that the “symptoms” may serve within the system
Biomedical treatment approaches 1. Psychopharmacology—(psychotropic drugs) this is the most common biomedical approach & we’ve already discussed several examples before—Prozac for depression & antipsychotic drugs to treat schizophrenia. • Research has demonstrated that when treating depression, the combination of antidepressant drugs and psychotherapy is more effective than either antidepressant drugs OR therapy alone.
Biomedical treatment approaches 1. Psychopharmacology 2. Electroconvulsive Therapy (ECT)—ECT involves the administration of electrical shock to a depressed individual. The patient is given a series of weekly treatments. • Patients first receive a general anesthetic and muscle relaxant and then electrical shock is administered via an electrode. Figure 42.2 on p. 595 of your book illustrates the procedure • 80% of those receiving ECT recover from their depression after three treatments • There are sometimes side effects however—including memory loss for the treatment period—and so ECT is typically only used In severe depression that does not respond to medication (esp. when the risk of suicide is high).
Biomedical treatment approaches 1. Psychopharmacology 2. Electroconvulsive Therapy (ECT) 3. Psychosurgery—previously referred to as “lobotomy”—most drastic and least used procedure—removes or destroys brain tissue to try to change behavior. For example, we talked about how sometimes in severe epilepsy, the corpus callosum will be severed in an attempt to control the seizures.
Effectiveness of therapy • You’ll notice from your textbook reading that there are multiple ways to try to evaluate the effectiveness of therapy: clients’ reports, therapists’ reports and controlled experiments (called “outcome research” in your textbook)
Effectiveness of therapy • In general, research evidence suggests that therapy is effective but doesn’t find “one clear winner” among these approaches. Because of this, there has been some interest in discovering commonalities among therapies—things that different approaches share in common. You can read about this on pp. 585-587 in your textbook.
Effectiveness of therapy • Research targeting specific disorders, however, does sometimes find “winners.” In other words, some approaches work better for particular disorders. • The research question “What therapy is best?” may not be the best question to ask. Instead, researchers are beginning to ask “What therapy is best for this particular disorder for this particular type of client?”
Effectiveness of therapy • It’s also important to remember that clients are individuals, and so even if research suggests that a particular approach is best for a particular disorder, that does not mean that the approach is going to work with the particular client with which the therapist is working. What it does mean is that it makes sense for the therapist to try the most highly recommended treatment first (unless there are other compelling reasons) and if that doesn’t work, to then try other approaches which just might end up being more effective for that particular client • This is why I think it is best to think of psychotherapy as not just a science, but also an art.
Preventative mental health • Since many psychological disorders are “understandable responses to a disturbing and stressful society”, one way we might prevent psychological disorders is to make changes in those societal factors that contribute to people developing mental health problems. • Preventative mental health is an approach that attempts to do just that. Those involved in preventative mental health (such as community psychologists) attempt to alleviate poverty, racism, sexism, unemployment and other societal factors that interfere with people’s good mental health.
If you are interested…. • ….in clinical/counseling psychology, you may want to consider taking the upper-level courses Abnormal Psychology and Therapeutic Psychology the next time they are offered!