Psychotherapy Summary

Week 1: Why do we need psychotherapy research? 2

Chpt. 1 (Current Psychotherapies): Introduction to 21st-Century Psychotherapies 2
Chpt. 1 (Cooper): The Challenge of Research 2
Chpt. 3 (Cooper): Does Orientation Matter? The Great Psychotherapy Debate 3

Week 2: Psychoanalysis 5

Week 3: Family Therapy 10

Week 4: Humanistic and Experiential Psychotherapies 17

Week 5: Cognitive Behavioral Therapy 24

Behavior Therapy 24
Cognitive Therapy 29

Week 6: Outcomes of Research and Techniques 34

Outcomes of Counselling and Psychotherapy 34
Technique and Practice Factors 35

Week 7: Client, Therapist and Relationship Factors 39

Client Factors 39
Therapist Factors 41
Relational Factors 44
Multicultural Theories of Psychotherapy 46

Extra Chapter: Positive Psychotherapy 51

Week 1: Why do we need psychotherapy
research?

Chpt. 1 (Current Psychotherapies): Introduction to 21st-Century

Psychotherapies

Studying the unconscious: (18th century)

- Leibniz (the role of subliminal perceptions in our daily life; dynamic forces that
operate unconsciously)
- Mesmer (hypnotherapy)

19th Century:

- Fechner (measured the intensity of psychic stimulation needed for ideas to cross the
threshold from the unconscious to full awareness)
- Helmholtz (unconscious inference e.g. automatic, fast processing)
- Carus (therapist transference = when the client projects feelings about someone else
onto the therapist)
- Nietzsche (self-deception, sublimation, repression, conscience and neurotic guilt)

21st century:

- Positive psychology (self-actualization)

- Issues:
- Treatment efficacy (some diagnoses are only treatable by a certain form of
therapy, irrespective of the therapist)
- Therapist aptitudes (some therapists achieve clinical success when they
treat a certain kind of disorder but not when they treat another one)
- Diagnosis and diagnostic coding (necessary to choose the right treatment)

Chpt. 1 (Cooper): The Challenge of Research

Limitations:
- Research shows generalities, not specifics
- No certainties, only probabilities
- Cultural differences

Research-informed therapy, instead of research-directed

Chpt. 3 (Cooper): Does Orientation Matter? The Great
Psychotherapy Debate

- Eysenck did a study in which he compared the therapeutic effects of different

interventions (24 groups) and found there were no significant differences between
them
- Empirically supported treatments = therapeutic practices that have been shown to be
efficacious with a particular group of clients

For example:
- Depression (non-directive counselling, problem-solving therapy, psychodynamic
therapy, process-experiential therapy, interpersonal therapy; mainly CBT and
mindfulness-based cognitive therapy)
- Bipolar disorder (CBT, family-oriented interventions and psycho-education)
- Specific phobias (CBT, exposure)
- Social phobia (social skills training, exposure, CBT (internet-delivered))
- Panic disorder (CBT, exposure, bibliotherapy)
- GAD (anxiety management, CBT, applied muscle relaxation)
- OCD (exposure and response-prevention techniques, CBT)
- PTSD (CBT, psychodynamic treatments)
- Anorexia nervosa (cognitive-analytic therapy, psychodynamic psychotherapy and
family therapy)
- Bulimia nervosa (CBT, interpersonal therapy)

Issues:
- Discrete psychological illnesses do not necessarily exist (e.g. comorbidity)
- Empirically supported treatments are not necessarily generalizable
- Lack of evidence is not the same as counter-evidence
- Researchers biases (e.g. researcher allegiance effects = the tendency for
researchers to find results that support their own beliefs, expectations or
preferences)

- Bona fide therapy = a therapeutic practice delivered in good faith (the practitioner is
trained in and committed to sound psychological principles)
- Dodo bird verdict = the assertion that different bina fide therapies are about
equivalent in their efficacy and effectiveness
- Ignores that different clients may benefit from very different types of therapy
- Many studies do show that there are therapies that are more effective than
others
- Some therapies receive more resources and are more well-researched
- non-specific/common factors = aspects of the therapeutic process that are common
to most therapeutic relationships
- specific/model factors = well-defined actions on the part of the therapist that are
associated with a particular therapeutic orientation
Lambert’s Pie: findings that suggest the different influential forces involved in outcome
effects of therapy

- This lead researchers to investigate the key factors of therapeutic effectiveness

(principles of therapeutic change)
- Aptitude-treatment interaction paradigm = the assumption that clients with
particular qualities and characteristics will do better in some forms of therapy
than others
Week 2: Psychoanalysis
- Founding father = Sigmund Freud

Basic principles

1. Unconscious motivation (all human beings have wishes, fantasies or

tacit/subliminal knowledge that guides their actions)
2. Interest in facilitating awareness of unconscious motivation; increasing choice
3. An emphasis on exploring the ways in which we avoid painful or threatening
feelings, fantasies or thoughts (defenses)
4. An assumption that we are ambivalent about changing and an emphasis on the
importance of exploring this ambivalence
5. An emphasis on using the therapeutic relationship as an important vehicle of change
6. An emphasis on using the therapeutic relationship as an arena for exploring clients’
self-defeating psychological processes and actions
7. An emphasis on helping clients to understand the way in which their own
construction of their past and present plays a role in perpetuating their self-defeating
patterns

Basic concepts

The Unconscious
- Freud: ego (keeps aspects from experience deriving from the more primitive,
instinctually based aspect of the psyche aka id out of awareness)
- Others: it is problematic to speculate about the nature of hypothetical psychic
agencies such as the ego and the id
- Any experience or action reflects a particular type of compromise between an
underlying wish vs. a fear of the consequence of achieving it

1. Our experience and actions are influenced by psychological processes that are not
part of our conscious awareness
2. These unconscious processes are kept out of awareness in order to avoid
psychological pain

Fantasy
- People’s fantasies play an important role in their psychic functioning and the way in
which they relate to external experience, especially in their relationships with other
people (shape our experience)
- Vary in the extent that they are part of conscious awareness
- Serve various psychic functions: need for regulation of self-esteem, need for a feeling
of safety, regulating affect and the need to master trauma (motivate our behavior)
Primary and Secondary Processes
- Primary process = primitive form of psychic functioning that begins at birth and
continues to operate unconsciously throughout the lifetime
- No distinction between past, present and future
 - Different feelings and experiences can be condensed into one image or
symbol, feelings can be expressed metaphorically and identities of different
people can be merged
- Secondary process = psychic functioning associated with consciousness
- Foundation for rational, reflective thinking

Defenses
- Defense = an intrapsychic process that functions to avoid emotional pain by pushing
thoughts, wishes, feelings or fantasies out of awareness

1. Intellectualization (maintaining emotional distance from distressing thoughts and

feelings while talking about them)
2. Projection (when a person attributes a threatening feeling or motive he is
experiencing to another person)
3. Reaction formation (when someones denies a threatening feeling and proclaims
they feel the opposite)
4. Splitting (when an individual attempts to avoid their perception of the other as good
from being contaminated by negative feelings, they might split their cognitive
representation of the other person)

Transference
- the redirection to a substitute, usually a therapist, of emotions that were originally felt
in childhood
- Therapeutic relationship provides an opportunity for the client to bring the memory of
the relationship with the parent or other significant figure from the past to life through
the relationship with the therapist

One-person vs two-person psychology

- Freud viewed the therapist as a neutral blank canvas that the patient would project
their issues onto (one-person psychology)
- Nowadays therapist and client are viewed as co-participants who engage in an
ongoing process of mutual influence at both conscious and unconscious levels
(two-person psychology)

History

1. Freud:
- Anna O. (patient of Freud; would experience relief from symptoms after talking freely
about painful and traumatic experiences and recovering painful memories that had
been dissociated)
- Hysterical symptoms were the result of suppressed emotions that had been
cut off at the time of the trauma (these emotions then expressed themselves
in the form of physical symptoms)
- Hypnosis could help clients recover memories of the trauma and experience
the associated affect (resulting in a cure)
- Free association (clients are encouraged to attempt to suspend their self-critical
function and verbalize thoughts, images and associations and feelings that are on the
edge of awareness)
 - Seduction theory (sexual trauma always lies at the root of psychological problems)
- Over time, Freud began to theorize that sexual feelings are present during
early infancy and give rise to sexually related wishes and fantasies that are
puched out of consciousness because they were experienced as too
threatening
- Recovered memories of sexual trauma were actually the product of
reconstructed fantasies rather than real sexual trauma
- Drive theory (Psychosexual theory)
- Freud developed a belief that all thinking and action were fueled by a type of
psychic energy (linked to sexuality) e.g. libido
- Pleasure principle = as infants, we reduce tension by resorting to sexual
impulses and therefore we have the same drive to do this as we grow up
(sexual experiences have become associated with tension reduction)

- Structural theory (e.g. id, ego, superego)

- One goal of analysis traditionally has been to help individuals become more
aware of the overly harsh nature of their superegos so they become less
self-punitive
- In america: rise of ego psychology (aka classical psychoanalysis; adherence
to drive theory of motivation and psychosexual model of development,
therapist as blank screen; process of gaining insight into one’s own
unconscious conflicts)
- Object relations theory
- England
- Concerned with the way in which we develop internal representations of our
relationships with significant others

2. Jung:
- Delayed response times to emotionally charged words reflect the unconscious
functioning of emotional complexes (affectively charged ideas that are repressed
because they are emotionally threatening)
- Believed Freud was mistaken in his view that sexuality is the most important
motivational principle and that his view of the unconscious was one-sided and failed
to recognize the more creative and growth-oriented aspects of the unconscious
processes. Also believed Freud failed to recognize the importance of spiritual and
transpersonal aspects of the human psyche
- Developed analytical/Jungian psychology

3. Other:
- Interpersonal psychoanalysis
- Relational psychoanalysis
- Modern conflict theory
- Kleinian theories e.g. containment
- Lacanian/post-lacanian theory

Personality Theories

1. Conflict Theory
 a. Intrapsychic conflict
b. Different personality or character styles can be understood as resulting from
the compromise between specific underlying core wishes and characteristic
styles of defense that are used to manage these wishes e.g. displacement,
projection and behavioral avoidance
2. Object Relations Theory
a. Internal representations (internal objects) influence the way in which people
perceive others, establish relationships and choose partners
b. Internalization = how internal models are established
c. Attachment theory (Bowlby) = the earliest relationships infants have with
their caregivers are characterized by certain types of attachment and become
the blueprint for attachment later in life
d. Projective identification (Klein) = the intrapsychic process through which
feelings that originate internally are experienced as originating from the other
e. Fairbairn
3. Developmental Arrest Models
a. Self psychology (Kohut) = psychological problems emerge as a result of the
failure of caregivers to provide an optimal environment
i. Optimal disillusionment
ii. Attunement

Psychotherapy

- Psychodynamic psychotherapy = forms of treatment that are based on

psychoanalytic theory but lack some of the defining characteristics of psychoanalysis
- Specific therapeutic stance that involves:
- An emphasis on helping clients become aware of their unconscious
motivation
- Refraining from giving the client advice or being overly directive
- Attempting to avoid influencing the client by introducing one’s own belief and
values
- Maintaining a certain degree of anonymity by reducing the amount of
information one provides about one’s personal life or feelings and reactions in
the sessions
- Attempting to maintain the stance of the neutral and objective observer rather
than a fully engaged participant in the process
- A seating arrangement in which the client reclines on a couch and the
therapist sits upright and out of view of the client
- Therapeutic alliance = having a good relationship with client (trust in the therapist,
degree to which one feels understood by the therapist)
- Goals of therapy tend to be symptom reduction and personality change
- Countertransference = the therapist’s counterpart to the client’s transference (a
function of their own unresolved conflicts; obstacle to therapy) aka any reaction to a
client in therapy
- Resistance = the tendency for an individual to resist change or act in a way that
undermines the therapeutic process
- Intersubjectivity = the ability to hold onto one’s own experience while at the same
time beginning to experience the other as an independent center of subjectivity
- Enactment = client and therapist play complementary roles in relational scenarios
(neither is fully aware); influenced by each person’s schemas
- Intervention tools: empathy, interpretations, clarification
- Termination (agreed upon by client and therapist, agreement upon certain number of
final sessions, summarize entire process to finish productively)
- Mechanisms: making the unconscious conscious (to increase choice), emotional
insight, creating meaning, increasing and appreciating limits of agency, containment
(cultivating the ability to tolerate and process painful or disturbing feelings in a
nondefensive fashion), rupture and repair (model for understanding how the process
of working through misunderstandings and disruptions in relatedness that take place
between client and therapist can contribute to a change in the client’s implicit
relational knowing)
Week 3: Family Therapy
- Reciprocal causality = focus is placed on family as a system (context); behavioral
sequences, what is taking place and how each participant influences and is
influenced by other family members (dysfunctional or impaired family unit)
- The symptomatic person is just expressing the family’s dysfunction

Key Concepts

- Family structure (how it arranges, organizes and maintains itself at a particular cross
section of time)
- Family processes (the way it evolves, adapts or changes over time)
- Family as a living system (complex, durable, causal network of related parts that
together constitute an entity larger than the simple sum of its individual members)
- Organization (the way that the units within the system consistently relate to
each other; a change in one part influences another part and thus changes
the entire system)
- Wholeness (cannot examine individual parts, have to assess it as a whole;
greater than the sum of its parts)
- Circular causality = reciprocal action occur within a relationship network by means of
interacting loops (any cause is seen as an effect of a previous cause and becomes in
turn the cause of a later event)
- Family homeostasis = maintaining equilibrium or undertakes operation to restore that
equilibrium whenever the balance is upset or threatened (when a crisis/disruption
occurs, some family members may try to maintain or regain a stable environment by
activating family-learned mechanisms to decrease the stress and restore internal
balance)
- Negative feedback (attentuating effect, restoring equilibrium)
- Positive feedback (leads to further change by accelerating the deviation)

- Subsystem = organized components within the overall system and they may be
determined by generation, sex, or family function
- Each family member will belong to several subsystems at the same time e.g.
daughter, sister; play different role in each interaction
- In certain dysfunctional situations, family members may split into separate
long-term coalitions e.g. males vs. females, parents vs. children, father and
daughter vs. mother and son
- Specific subsystems:
- Spousal (any issues between partners will result in scapegoating the children
or forming alliances with one parent against the other; presenting a positive
model of marital interaction)
- Parental (when effective, provides childcare, nurturance, guidance, limit
setting)
- Sibling (learn to negotiate, cooperate, compete and eventually attach to
others)
 - Boundaries = invisible lines that separate a system, subsystem or an individual from
outside surroundings
- Protect the system’s integrity, distinguish between those considered insiders
and outsiders
- Rigid (overly restrictive, permitting little contact among the members of
different groups) e.g. disengaged families; members feel isolated from each
other
- Diffuse (overly blurred so that the roles are interchangeable and members are
overinvolved in each other’s lives) e.g. enmeshed families
- Closed system = when boundaries are not easily crossed, the family is insular, not
open to what is happening around it, suspicious of the outside world
- Open system = open to new experiences, able to alter and discard unworkable or
obsolete interaction patterns

- Second-order cybernetics = acknowledged the effect of the therapist on their

observations; by helping define the proble, the observer influences goals and
outcomes

Gender Awareness and Culture Sensitivity

- Gender sensitive outlook (being careful not to reinforce stereotyped sexist and
patriarchical attitudes or class differences)
- Pay more attention to differences in power, status and positive within families
and in society in general
- Culturally sensitive therapy (therapist must remain alert to the fact that how they
counsel a family is influenced by cultural values, attitudes, customs, religious beliefs
and practices and beliefs regarding what constitutes normal behavior)

Other Systems

- Object relations family therapy = help family members uncover how each has
internalized objects from the past, usually as a result of an unresolved relationship
with one’s parents and how these imprints from the past (introjects) continue to
impose themselves on current relationships
- Unconscious relationship seeking from the past as the primary determinant of
adult personality formation

History: Important Figures

- Freud: recognized the importance of family conflict in forming a neurotic individual,

did not involve family in therapy
- Adler: stressed the importance of family constellation on individual personality
formation; central role of family in formative years (family interactive patterns are the
key to understanding a person’s current relationships)
- Sullivan: speculated on the role that family played in the transitional period of
adolescence, thought to be the typical time for the onset of schizophrenia
 - General systems theory: challenged the traditional reductionist view in science that
complex phenomena could be understood by carefully breaking them down into a
series of less complex cause and effect reactions
- Family group therapy: involve entire families in the therapeutic process, believing the
kinship groups provide more real situations and provide a greater opportunity for
powerful and longer-lasting system changes as a result of family-level interventions

History: Development

- Double-bind communication patterns: when a child habitually receives

simultaneously contradictory messages from the same parent and is forbidden to
comment on the contradiction
- Related to schizophrenia research (did not receive the necessary nurturance
as children and failed to achieve autonomy as adults; parents were poor role
models)
- Marital skew = extreme domination by one emotionally disturbed partner is
accepted by the other, who implies to the children the situation is normal
- Marital schism = parents undermine their spouses, threats of divorce, each
parent fights for the loyalty of their children
- Family emotional system: viewpoint that emphasizes reciprocal functioning
- Pseudomutuality = a false sense of family closeness in which the family gives the
appearance of taking part in a mutual, open and understanding relationship without
really doing so
- Psychodynamics of family life (first text about this therapy; argued for family sessions
aimed at untangling interlocking pathologies, thus endorsing systems view that
problems of any one family member cannot be understood apart from those of all
other members)
- Treating delinquency/behavioral problems in adolescents: functional family therapy
and multisystemic therapy

Approaches to family therapy

1. Object Relations Family Therapy

- Need for a satisfying relationship with some object e.g. another person is the
fundamental motive of life
- Introjects = memories of loss or unfulfillment from childhood; people
unconsciously relate to one another in the present largely based on
expectations formed in childhood

2. Experiential Family Therapy

- Growth experience derived from an intimate interpersonal experience with an

involved therapist
- Help family members be more honest, more expressive of their feelings and
needs, better able to use their potential for self-awareness to achieve
personal and interpersonal growth
 - Symbolic experiential family therapy (building self-esteem, learning to
communicate adequately and openly)
- Emotion-focused couples therapy (based on attacgment theory, attempts to
change a couple’s negative interactions while helping them cement their
emotional connection to each other.)

3. Transgenerational Family Therapy

- Individual problems arise and are maintained by relationship connections with

family members
- The people with the strongest affective connections with the family are most
vulnerable to personal emotional reactions to family stress (fusion)
- The degree to which an individualized, separate sense of self independent
from the family occurs is correlated with the ability to resist being
overwhelmed by emotional reactivity in the family (differentiation)
- More differentiation = less likely the individual will experience personal
dysfunction
- The least differentiated will likely marry someone who is also undifferentiated
and will have dysfunctional children who will also marry undifferentiated
people (and so on for generations)
- Contextual therapy (the patterns of relating within a family are passed down
from generation to generation; the key to understanding both individual and
family functioning)

4. Structural Family Therapy

- Focus on how families are organized and on what rules govern members’
transactions
- Symptoms are viewed as conflict diffusers, diverting attention from more basic
family conflicts

5. Strategic Family Therapy

- Designing of novel strategies to eliminate undesired behavior

- Paradoxical interventions (force clients to abandon symptoms)
- Systemic family therapy (children use their symptoms to defeat their parents
in a power struggle for the sake of the other)
- Circular questioning (help family members examine their family belief
system)

6. Cognitive-Behavioral Family Therapy

- Behavioral perspective: Maladpative or problematic behavior can be

extinguished as the contingencies of reinforcement for that behavior are
altered
- Cognitive restructuring, overcoming dysfunctional beliefs (schemas) learned
early in life
 - Negative schemas affect automatic thoughts and emotional responses
to others and call for cognitive restructuring to modify or alter faulty
perceptions

7. Social Constructionist Family Therapy

- Challenge mechanistic model (systems thinking)

- Our perceptions are not exact duplications of the world but a point of view
seen through the limiting lens of our assumptions about people
- The view of reality each of us constructs is mediated through language and is
socially determined through our relationships with others and with the
culture’s shared set of assumptions
- Culture, etc. must be addressed in determining a family’s functioning level
- Requires collaboration between therapist and family members without
preconceived notions of what constitutes a functional family or how a
particular family should change
- Therapist and family members examine together the belief systems that form
the basis for the meaning they give to events; consider new alternatives

8. Narrative Therapy

- Our sense of reality is organized and maintained through the stories by which
we circulate knowledge about ourselves and the outside world
- How the problem affects the family (not how family produced the problem)
- Externalization = viewing the problem as outside themselves rather than as
an internal part of their identity
- Help liberate families from feelings of hopelessness and explore alternative
stories/narratives

Personality Theories (depends on the perspective/approach)

- Family life cycle: certain predictable marker events or phases occur in all families,
regardless of structure, composition or cultural background, compelling each family
to somehow deal with these events

Other Concepts

- Family Rules: interactions follow organized, established patterns (norms, boundaries

of permissible behavior); regulate and stabilize family system
- Redundancy principle = a family’s usually restricted range of options for
dealing with one another

- Family Narratives and Assumptions: held worldview shared by the family system, has
implications for behavior
- Linking experiences together to justify how and why they do what they do
- Depend on cultural background

- Pseudomutuality and pesudohostility:

 - When families are absorbed with fitting together at the expense of developing
their separate identities
- Quarrelling or bickering between family members is a way of maintaining a
connection without becoming either deeply affectionate or deeply hostile to
one another

- Mystification: parental efforts to distort a child’s experience by denying what the child
believes is occurring

- Scapegoating: when a particular individual is held responsible for whatever is wrong

with the family (will carry the pathology for the family)

Psychotherapy Theories

Basic premises:

1. People are products of their social connections, and attempts to help themmust take
family relationships into account
2. Symptomatic or problematic behavior in an individual arise within a context of
relationships, and interventions to help that person are most effective when those
faulty interactive patterns are altered
3. Individual symptoms are maintained externally in current family system transactions
4. Conjoint sessions (focus on interpersonal processes)
5. Assessing family subsystems and the permeability of boundaries within the family
and between the family and the outside world offers important clues regarding family
organization and susceptibility to change
6. Traditional psychiatric diagnostic labels based on the individual psychopathology
often fail to provide an understanding of family dysfunctions and tend to pathologize
individuals
7. The goals of family therapy are to change maladaptive or dysfunctional family
interactive patterns or help clients construct alternative views about themselves that
offer new options and possibilities for the future

- Monadic outlook: therapy based on characteristics of a single person

- Dyadic outlook: based on a two-person interaction
- Triadic model: based on interactions between two or more people

- First-order changes = changes within the system that do not alter the organization of
the system itself
- Second-order changes = fundamental changes in a system’s organzization and
function

Psychotherapy techniques

- Reframing: relabeling problematic behavior by viewing it in a new light that

emphasizes its good intentions
- Therapeutic double binds: directing family members to continue to manifest their
presenting symptoms intentionally
 - Enactment: role-playing efforts to bring the outside family conflict into the session
- Family scultping: placing other members in physical arrangement in space to
demonstrate how they view their place in the family
- Circular questioning: asking several members of the family the same question
- Cognitive restructuring: change unrealistic expectations/beliefs
- Miracle question: what would happen if a miracle took place and they found this
problem that they brought to therapy to be solved?

Mechanisms of Psychotherapy

1. Structural change: actively challenge ongoing transactional patterns that handicap

optimal functioning
2. Behavioral change: strategies, paradoxical tasks
3. Experiential change: openness, honesty, communication, ask about what they need
from one another, self-exploration and feeling the feelings that have been
suppressed
4. Cognitive change: attach new meanings to experiences
Week 4: Humanistic and Experiential
Psychotherapies
- Founding father = Carl Rogers
- Rogerian hypothesis = advances the idea that individuals are most able to
access their own creative resources when provided a relationship offered by a
genuine, congruent therapist who is experiencing unconditional positive
regard and warm acceptance, and is empathically receptive to the client’s
own perceived realities

Key Concepts

- The person (claim of the sovereignty of personhood)

- Actualizing tendency (organisms are motivated to maintain and enhance themselves;
moral goodness)
- Nomothetic (universal level of analysis; human beings are deeply the same and tend
to respond in similar ways to similar situations)
- Idiographic (specific level of analysis; human beings are vastly different. No person’s
circulatory system is exactly the same as another person’s)
- Organismic valuing process = individuals select goals based on inner nature, internal
rationality, and individual decision making.
- Congruence = state of wholeness and integration within the experience of the person
(the capacity to symbolize experiencing in conscious awareness and to integrate
those experiences within our concepts of self)
- Interactive therapeutic relationship (client propels the process/co-constructs therapy)
- Nondirective attitude (trust in client’s inherent growth tendency and right to
self-determination; therapist cannot contradict the client or decide the course of
therapy)
- Moral compass of the client guides the process
- Self-concept = positive self regard
- Locus of evaluation = shifting the basis of standards and values from other people’s
judgements to their own inner experience (internal locus of evaluation implies more
intrinsic motivation)
- Experiencing =e.g. Thinking, sensing, perceiving, feeling, remembering, etc. the
subjective experience of the individual is the primary indicator of behavior

Other Theroretical Approaches

- Pre-therapy
- Experiential or focusing-oriented therapy
- Emotion-focused therapy

Positive Psychology

- Founded by Martin Seligman

 - Desirability to focus on clients’ strengths as the engine of change (strength, potential
and resilience)
- Client is an agent of change, capable of self-righting (restoring oneself to health and
balance)
- Two overlaps between humanistic therapy and positive psychology:
- “Fully functioning person” = state of optimal functioning and well-being
- Applying scientific methods to the phenomena observed in the process of
psychotherapy

Feminist Therapy

- Deconstructing and challenging social role expectations, economic subordination,

political disempowerment, violence against women as a strategy of social control and
intimidation
- Exposing diagnostic categories oppressive to women, practices in therapy that
reinforced male authority and the nonexistent evidentiary base for essentialist
formulations of women’s biological nature
- Addresses ethics and advocates more than one-to-one models of change (many
women’s problems are rooted not in their psyches but in the social structures that
oppress them)
- Aim to develop innovative ways to work with other women (+ transwomen, gender
queer, etc.)
- Therpists integrate and adapt psychoanalytic, interpersonal, humanist, systems and
topical approaches such as trauma therapy
- Focus on intersectionality

Cognitive-Behavioral Therapy (ethically problematic from the client-centered perspective)

- Dodo bird verdict = the idea that all therapies are equally effective
- Dysfunctional cognitive schemas sustain maladaptive behaviors
- Challenge core beliefs
- No agency of the client, they must receive wisdom from the therapist

History

- Rogers gave a presentation at the University of Minnesota; “Some Newer Concepts

in Psychotherapy” (which is known as the birth of client-centered therapy)
- Expanded into a book titled Counseling and Psychotherapy (describes the
generalized process in which a client begins with a conflict situation and
predominant negative attitudes and moves towards insights, independence
and positive attitudes)
- Lead to more research and developments in the field of psychotherapy
- Lead to acceptance of psychotherapy as a primary professional function of
clinical psychologists
- “The Necessary and Sufficient conditions of Therapeutic Personality Change”:
congruence, unconditional positive regard and empathic understanding
 - “Third force” in psychology e.g. the exquisitely rational nature of behavior and growth
of human beings, challenge to determinism or behaviorism and psychoanalysis (also
mimicked by Maslow or Kierkegaard)
- Research project performed, hypothesis: hospitalized schizophrenic patients would
respond to a client-centered approach
- Most successful patients were those who had experienced the highest degree
of accurate empathy
- It was the client’s, rather than the therapist’s judgment of the therapy
relationship that correlated more highly with success or failure

- The basic person-centered hypothesis = individuals and groups who have

experienced empathy, congruence and unconditional positive regard will go
through a constructive process of self-directed change

Current Status

- Annual workshops at Warm Springs since 1987 (unplanned meetings of the whole
community and is not organized around papers or workshop sessions; self-directed
group experience)
- 2000: World Association for Person-Centered and Experiential Psychotherapy and
Counseling was founded at the International Forum for the Person-Centered
Approach
- Peer-reviewed journal launch “Person-Centered and Experiential Psychotherapy”
(publishes empirical, qualitative and theoretical articles of broad interest to
humanistic practitioners and researchers)

Theory of Personality

(theory of therapy, personality and interpersonal relationships)

19 propositions:

1. Every individual exists in a continually changing world of experience of which he or

she is the center
2. The organism reacts to the field as it is perceived (for the individual, this perceptual
field is “reality”)
3. The organism reacts as an organized whole to this phenomenal field
4. The organism has one basic tendency and striving to actualize, maintain and
enhance the experiencing organism
5. Behavior is the goal-directed attempt of the organism to satisfy its needs as
experienced in the field as perceived
6. Emotion accompanies and in general facilitates such goal-cirected behavior, the kind
of of emotion being related to the seeking versus the consummatory aspects of the
behavior and the intensity of the emotion being related to the perceived significance
of the behavior for the maintenance and enhancement of the organism
7. The best vantage point for understanding behavior is from the internal frame of
reference of the individual
8. A portion of the total perceptual field gradually becomes differentiated as the self
 9. As a result of interaction with the environment, and particularly as a result of
evaluational interaction with others, the structure of the self is formed
a. An organized, fluid but consistent conceptual pattern of perceptions of
characteristics and relationships of the I or the me together with values
attached to these concepts
10. The values attached to experiences and the values that are a part of the
self-structure in some instances are values experienced directly by the organism and
in some instances they are values introjected or taken over from others but perceived
in distorted fashion as though they had been experienced directly
11. As experiences occur in the life of the individual, they are a. symbolized, perceived
and organized into some relationship to the self. b. Ignored because there is no
perceived relationship to the self-structure or c. denied symbolization or given a
distorted symbolization because th experience is inconsistent with the structure of the
self
12. Most of the ways of behaving that are adopted by the organism are those that are
consistent with the concept of self
13. Behavior may, in some instances, be brought about by organismic experiences and
needs that have not been symbolized. Such behavior may be inconsistent with the
structure of the self, but in such instances the behavior is not “owned” by the
individual
14. Psychological maladjustment exists when the organism denies to awarenes
significant sensory and visceral experiences, which consequently are not symbolized
and organized into the gestalt of the self-structure
15. Psychological adjustment exists when the concept of the self is such that all the
sensory and visceral experiences of the organism are or may be assimilated on a
symbolic level into a consistent relationship with the concept of self
16. Any experience that is inconsistent with the organization or structure of self may be
perceived as a threat. The more of these perceptions there are, the more rigidly the
self-structure is organized to maintain itself
17. Under certain conditions, experiences that are inconsistent with sense of self may
become assimilated
18. When the individual perceives all his sensory and visceral experiences and accepts
them into one consistent and integrated system, they are necessarily more
understanding of others and more accepting of others as separate individuals
19. As the individual perceives and accepts into his self-structure more of his organismic
experiences, he finds that he is replacing his current value system with a continuing
organismic valuing process

- Conditions of worth = the process of introjection of external judgement and evaluation

Other Concepts

- Experience = the private world of the individual

- Reality = whatever is perceived by the individual
- Actualizing tendency = All living organisms are dynamic processes motivated by an
inherent tendency to maintain and enhance themselves; unconditional support of the
therapist, trust in the client’s will to grow
 - Syntropy (all living organisms are evolving toward greater complexity, fulfilling
those potentials that preserve and enhance themselves)
- Fully functioning persons (if the goodness of fit between the person and their
environment were perfect) = understanding out own welfare as dependent on the
health and wellbeing of others, increasingly open to new experience and trusting our
experience as a guide for living
- Nondirective therapy = client has the ability to guide the therapeutic process,
therapist is not the expert
- Self-determination theory
- Internal frame of reference = the perceptual field of the individual (the way the world
appears from a specific reference point and experiences we have accumulated along
with the meanings attached to experience and feelings)
- Self/concept of self/self-structure = organized, consistent, conceptual gestalt
composed of the perceptions of the characteristics of the I or me and the perceptions
of the relationships of the I or me to others and to various aspects of life together with
the values attached to these perceptions
- Symbolization = the process by which the individual becomes aware or conscious of
an experience
- Tendency to deny symbolization to experiences at variance with the concept
of self (e.g. someone who thinks of themselves as honest will not easily admit
to themselves that they are lying)
- adjusted/maladjusted
- Organismic valuing process = individuals freely rely on the evidence of their own
senses to make value judgments
- Fully functioning persons = able to experience all their feelings, are afraid of none of
them, allow awareness to flow freely in and through their experiences

Theory of Psychotherapy

- Core values of the therapist: congruence, unconditional positive regard, and

empathic understanding of the client’s internal frame of reference
- Conditions of the client: two persons in psychological contact, client is in a state of
incongruence (being vulnerable or anxious)

1. Congruence
a. Most basic of the conditions, fosters therapeutic growth
b. Transparent communication
2. Empathic understanding
a. Places the client’s own expression and meanings at the center of the process
as the therapist follows with understanding
b. The client is the author of their own life and the leader of the therapy
c. No specific way to respond (no shallow reiteration of words)
3. Unconditional positive regard
a. Warm acceptance, nonpossessive caring, nonjudgmental openness
b. Therapist accepts the client’s thoughts, feelings, wishes, intentions, theories
and attributions about causality as unique, human and appropriate to their
current experience
Process of Psychotherapy

- Therapist tries to understand the client’s world

- Reassurance and advice giving are not helpful (reflection of the therapist’s own
anxiety)
- Questions and requests should be respected
- Moment of movement
- It is an experience of something at this instant in the relationship
- An experience without barriers, inhibitions or holding back
- Past experience has never been completely experienced
- Experience has the quality of being acceptable and capable of being
integrated with the self-concept

Mechanisms of Psychotherapy

- Acquiring conditions of worth (can result in an incongruent self if the self is constantly
denied or ignored)
- There is a pathological entity inside that needs to be brought into the light of
awareness e.g. inner child, repressed memories, abandonment issues
- Two types of internal contexts: the objective context that is stressed in our
culture as significant and meaningful and the subjective context having little
real-world value

Applications

- Clients are not viewed as instances of diagnostic categories who come into therapy
presenting problems
- Problems are seen as constructs that are generated by process of social and political
influence in the domains of psychiatry, etc.
- Consultation offers the opportunity to examine biases of all types and to progress
toward greater openness and acceptance of clients’ culture, religious values and
traditions
- Trust in the process, more accurate self-appraisals (need to understand the client’s
relationship to the problem)
- Reject the term treatment

1. Play therapy
2. Group process
3. Classroom teaching
4. Intensive group
5. Peace and conflict resolution

Evidence

- Empirically supported treatment = random sampling of subjects and random

assignment to experimental and control groups using double-blind procedures
- Common factors research = the outcome of psychotherapy might be the result of
factors that all therapies have in common e.g. personal characteristics of the
 therapist, resources of the client and the potency of the therapeutic relationship
(dodo bird argument)
- Specificity myth = the belief that specific disorders need specific treatments
Week 5: Cognitive Behavioral Therapy

Behavior Therapy

Basic Concepts

- Behavior = motor behaviors, psychological responses, emotions and cognitions

1. Behavior therapy focuses on changing behavior

a. Decrease frequency of maladaptive behavior
b. Goal: increase flexibility in the client’s behavioral repertoire so that the
individual has a wider range of response options in any given situation
2. Behavior therapy is rooted in empiricism
a. Hypothesis-driven approach in their work
b. Identify variables that contribute to problem behavior, test out assumptions
through a range of behavioral-assessment methods
c. Evidence-based methods to evaluate the effects of their intervention
throughout treatment
3. Behaviors are assumed to have a function
a. Result from patterns of reinforcement and punishment from the environment
b. View behaviors as understandable given the context
4. Behavior therapy emphasizes maintaining factors rather than factors that may have
initially triggered a problem
5. Behavior therapy is supported by research
a. Most researched form of psychotherapy
6. Behavior therapy is active
a. Therapist is directive (gives advice and suggestions)
b. Client actively engaged in course of treatment
7. Behavior therapy is transparent
a. Learn the skills necessary to become their own therapists

History

- Aversion therapy
- Modeling, shaping and reinforcement
- First factor: Classical conditioning
- Second factor: Behaviorism (operant conditioning); reinforcement and punishment
- Third factor: the 1949 Boulder Conference on Graduate Education in Clinical
Psychology; many practitioners left psychoanalysis and joined the behavior therapy
movement

- Systematic desensitization = gradually confronting feared situations in imagination

while simultaneously practicing progressivee relaxation to relax the muscles of th
ebody
- Reciprocal inhibition
 - Nowadays, exposure-based treatments use exposure in real life and it is
rarely paired with relaxation exercises (does not add to the effectiveness)
- Conditioning therapy changed to behavior therapy (Lazarus, 1958)
- Skinner: developed treatments based on operant-conditioning principles, established
the field of applied behavior analysis, developed reinforcement-based programs for
treating substance-use disorders and developed behavioral treatment for reversing
unwanted habits

- Token economy = behavioral problems were managed through reinforcement of

desirable behaviors by providing tokens that could be exchanged for rewards later

Current Status

- Many behavior therapists started using cognitive strategies as well

- Social-cognitive theory, social learning, modeling (Albert Bandura)
- “Third wave” of behavior therapy (acceptance-based behavior therapies)
- Emphasize the importance of accepting unwanted thoughts, feelings and
emotions rather than trying to control or directly change them
- E.g. ACT, mindfulness-based cognitive therapy and dialectical behavior
therapy

Theory of Personality

- Five-factor model (OCEAN)

- Personality is influenced primarily by factors in the environment (reinforcement,
punishment, etc.)
- Behaviorists reject traditional trait approaches to personality and are skeptical about
their ability to predict behavior
- Personality might change depending on the environment
- Importance of stable temperamental characteristics affecting behavior and assume
that these patterns are influence both by and individuals learning history and by
biological makeup

Other Concepts

- Classical conditioning
- Conditioned stimulus
- Unconditioned stimulus
- Unconditioned response
- Conditioned response
- Extinction = presentation of the CS in the absence of the US so that the CR
eventually stops occurring (does not erase the previous learning, just creates
a new association)
- Reinstatement = repairing of the US and CS
- Operant conditioning
- Positive reinforcement (addition of aversive or rewarding stimulus)
- Negative reinforcement (removal of aversive stimulus)
- Punishment (positive/negative)
 - Extinction = behavior stops occurring because it is no longer followed by a
positive consequence
- Discrimination learning = when a response is reinforced or punished in one
situation but not in another
- Generalization = the occurrence of a learned behavior in situations other than
those where the behavior is acquired

- Vicarious learning = observational learning; learning about environmental

contingencies by watching the behavior of others
- Rule-governed behavior = learned contingencies through information that is heard or
read (without experiencing them)

Theory of Psychotherapy

- All behavior is learned through association, consequences, observation or rules

learned through communication and language
- Help clients by providing corrective experiences that lead to changes in behavior
- Structured an active (homework)
- Don’t give as much importance to the therapeutic relationship, but evidence suggests
that a good therapeutic relationship is necessary for different types of psychotherapy
to be effective
- Motivational interviewing

Process of Psychotherapy

- One hour, one client (some sessions may be 90 minutes to two hours if in a group)
- Sessions can occur in other settings as well
- Between 10 and 20 sessions
- Exposure treatment may only need 1 session
- The goal of therapy is to get the client out of therapy
- Clients are taught strategies not only to change problem behaviors but also to
maintain their improvements once treatment has ended
- Ethical concern: the therapy is coercive (clients are forced to do something they don’t
want to do)
- Plan in advance how to encounter situations in outside settings

Mechanisms of Psychotherapy

- Emotional processing theory = fearful associations are stored in memory in a fear

network comprimising a stimulus component, a response component and a meaning
component
- Conditioning experiences cause these components to become associated
with one another so that experiencing any on of these elements make is more
likely that the other components will also be activated
- Exposure works by a. Fully activating the fear network and b. Incorporating
new, corrective information

Effects
 - Anxiety and related disorders:
- Panic disorder (psychoeducation, exposure and cognitive reevaluation)
- OCD (exposure, response prevention)
- Relaxation training
- Specific phobias (Exposure)

- Depression:
- Cognitive reappraisal
- Behavioral activation
- Problem-solving training
- Social-skills training
- Mindfulness treatments

- Substance related disorders:

- Contingency management
- Community reinforcement

- Schizophrenia:
- Token economy
- Social skills training
- Contingency management
- Communication training
- Problem solving training

Treatment

- Behavioral assessment (multiple methods, multiple informants and multiple

situations)
- Identifying target behaviors
- Determining appropriate course of treatment
- Treatment targets e.g. behavioral deficits or behavioral excesses and
problems in the environment
- Functional analysis = identify the variables responsible for maintaining target
behaviors (ABC; antecedents, behavior, consequences)
- Behavioral interviews (development and course of the behavior over time,
direct samples of client’s behavior that might not otherwise be reported)
- Behavioral observation (naturalistic or in an imitated scenario, problem of
reactivity)
- Monitoring forms and diaries (track behaviors as they occur; antecedents as
well as thoughts, emotions, physical sensations, situations encountered,
unwanted urges and consequences)
- Self-report scales = questionnaires that assess behaviors or other domains of
interest
- Psychophysiological assessment e.g. penile plethysmography

- Treatment Planning
- Set a treatment goal (specific and measureable)
- Based on the results of the functional analysis
 - Based on the client’s diagnostic profile

- Exposure-based strategies (best studied and consistently most effective)

- Confronting feared stimuli directly
- In vivo exposure = exposure to fearful situations in real life
- Imaginal exposure = exposure to feared mental imagery
- Interoceptive exposure = purposely experiencing firghtening physical
sensations until they are no longer frightening
- Exposure hierarchy = a list of feared situations ranked (clients start by
practicing the easier items and thengradually move up)
- Modeling by the therapist (demonstrating how to approach a feared situation)

- Response prevention = inhibiting an unwanted behavior in order to break the

association between a stimulus and response

- Operant-conditioning strategies = changing patterns of reinforcement and

punishment in the environment which may include adding reinforcers to increase
desirable behaviors, etc.
- Differential reinforcement = reinforcing the absence of unwanted behaviors
and the occurrence of wanted alternative behaviors
- Contingency management = client’s environment is changed so that
unwanted behaviors are no longer reinforced
- Aversive conditioning = punishment-based conditioning (aversive stimulus is
paired with the behavior that client wants to get rid of)

- Relaxation Training = using strategies for reducing the effects of anxiety and stress
on the body e.g. breathing retraining (to prevent hyperventilation), guided mental
imagery (manage stress and reduce feelings of tension) and progressive muscle
relaxation (reduce feelings of muscle tension in the body)

- Stimulus control = a behavior being under the control of a specific cue or stimulus

- Modeling = therapist modeling how to approach a feared object

- Behavioral activation = therapeutic scheduling of specific activities for the client to

complete in their daily life that function to increase contact with diverse, stable and
personally meaningful sources of positive reinforcement
- Based on the idea that depression is maintained by a lack of
response-contingent positive reinforcement caused by inactivity and
withdrawal which reduce possibilities for reinforcement
- The key to changing how one feels is changing what one does
- Unhelpful short-term coping strategies can keep people stuck in their
depression
- Figuring out what strategies are likely to be helpful for a particular client lies in
understanding events that precede and follow the client’s behaviors
 - Social Skills training = modeling, corrective feedback, behavioral rehearsal and other
strategies to help their clients improve their abilities to communicate effectively and
function better in social interactions
- Identifying social skills deficits in a positive and non judgemental manner

- Problem-solving training = designed to help people solve problems systematically by

teaching them five core steps
- Define the problem
- Identify possible solutions
- Evaluate the solutions
- Choose the best solutions
- Implementation

- Acceptance-based behavioral therapies = accept unwanted emotions rather than

trying to control them
- Mindfulness
- ACT = teaches clients to notice, accept and embrace private events; become
aware of values and take action so that behaviors match values
- Dialectical behavior therapy = CBT + mindfulness techniques

Cognitive Therapy
- Based on a theory of personlity that posits that people respond to life events through
a combination of cognitive, affective, motivational and behavioral responses
- Aims to adjust information processing and initiate positive change in all systems by
acting through the cognitive system
- The patient’s maladaptive conclusions are treated as testable hypotheses
- Behavioral experiments and verbal procedures are used to examine alternative
interpretations and generate contradictory evidence that supports more adaptive
beliefs and leads to therapeutic change

Basic Concepts

- Schemas = people’s perceptions of themselves and others, their goals and

expectations, memories and fantasies, previous learning
- Cognitive shift (selective interpretation/heightened arousal for specific stimuli)
- Core beliefs = predispose people under the influence of certain life situations to
interpret their experiences in a biased way
- Cognitive vulnerabilities (things people are particularly sensitive to)
- Modes = networks of cognitive, affective, motivational and behavioral schemas that
compose personality and interpret ongoing situations

Strategies:

- Collaborative empiricism = views the patient as a practical scientist who lives by

interpreting stimuli but has been temporarily thwarted by their own apparatus that
gathers and integrates information
 - The therapist asks questions to understand the patient’s point of view
- The patient plays an active role in describing how they would like things to be
different
- Guided discovery = discovering what threads run through the patient’s current
misperceptions and beliefs and linking them to relevant experiences in the past
- Socratic dialogue = asking informational questions, listening, summarizing, asking
synthesizing or analytical questions that apply discovered information to the patient’s
original beliefs
- Aim: improve reality testing through continuous evaluations of personal conclusions
- Reduce cognitive distortions and biased judgments
- Approaches to treating dysfunctional modes:
- Deactivate them
- Modify their content and structure
- Construct more adaptive modes to neutralize them

Techniques:

- Skills training e.g. relaxation, assertiveness training, social skills training

- Role playing
- Behavioral rehearsal
- Exposure therapy
- Conscious interpretation
- Highly structured and usually short term (12 to 16 weeks)
- Therapy is meant to change maladaptive assumptions
- Stance of the therapist is active and directive
- Each disorder has its own cognitive content/cognitive profile (cognitive specificity)

History

- Main influences: the phenomenological approach to psychology (aka the individual’s

view of the self and personal world are central to behavior), structural theory and
depth psychology and cognitive psychology
- Founders: Albert Ellis and Aaron Beck

Current Status

- Cognitive triad
- Controlled studies have demonstrated the efficacy of cognitive therapy in the
treatment of panic disorder, GAD, substance abuse, eating disorders, marital
problems, OCD, and schizophrenia
- Lower relapse rates

Theory of Personality

- Personality attributes are seen as reflecting basic schemas or interpersonal

strategies developed in response to the environment
- Cognitive vulnerability (each individual has vulnerabilities and sensitivities that
predispose them to psychological distress)
 - Schemas develop early in life from personal experience
- Two major personality dimensions (social dependence; closeness, nurturance and
dependence and autonomy; independence, goal setting, self-determination and
self-imposed obligations)

Other Concepts

- Theory of causality (there is no specific cause for psychopathology, it is caused by

many different factors)
- Cognitive distortions = systematic errors in reasoning
- Arbitrary inference (drawing a specific conclusion without supporting evidence
or even in the face of contradictory evidence)
- Selective abstraction (conceptualizing a situation on the basis of a detail
taken out of context, ignoring other information)
- Overgeneralization (abstracting a general rule from one or a few isolated
incidents and applying it too broadly and to unrelated situations)
- Magnification and minimization (seeing something a far more significant or
less significant than it actually is)
- Personalization (attributing external events to oneself without evidence
supporting a causal connection)
- Dichotomous thinking (black or white thinking)
- Cognitive model of depression (cognitive triad; negative view of the self, world and
future)
- Cognitive model of anxiety disorders (excessive functioning or malfunctioning of
normal survival mechanisms); cognitive content revolves around themes of danger,
and the individual tends to maximize the likelihood of harm and minimize their ability
to cope)
- Mania (selective perception of gains in life, blocking out negative experiences or
reinterpreting them as positive, unrealistically expecting favorable results from
various enterprises; exaggerated feelings of success)
- Panic disorder (prone to regard any unexplained symptom or sensation as a sign of
some impending catastrophe)
- Phobia (anticipation of physical or psychological harm in specific situations e.g.
evaluation phobias; fear of failure)
- Paranoid states (individual is biased toward attributing prejudice to others; assumes
other people are deliberately abusive, interfering or critical)
- Suicidal behavior (hopelessness and cognitive deficit, difficulties solving problems)
- Anorexia nervosa (distortions in information processing)
- Schizophrenia (complex interaction of predisposing neurobiological, environmental,
cognitive and behavioral factors; creates vulnerability to dysfunctional beliefs)

Theory of Psychotherapy

- Correct faulty information processing and help patients modify assumptions that
maintain maladaptive behaviors and emotions
- Treating beliefs as testable hypotheses
- Therapist asks questions to elicit the meaning, function, usefulness and
consequences of the patient’s beliefs
 - Homework is given between sessions (practice skills and helps therapy proceed)
- Collaborative empiricism (jointly determining the goals for treatment, eliciting and
providing feedback)
- Socratic dialogue (clarify or define problems, assist in the identification of thoughts,
images and assumptions, examine the meanings of events for the patient, assess the
consequences of maintaining maladaptive thoughts and behaviors)
- Guided discovery (patient modifies maladaptive beliefs and assumptions)

Process of Psychotherapy

- Goals of the first interview: initiate a relationship with the patient, elicit essential
information, produce symptom relief
- Establish collaborative framework
- Identify expectations for therapy
- Problem definition (functional and cognitive analyses of the problem)
- Homework focuses on recognizing the connections among thoughts, feelings and
behavior
- Middle of process: shifts to thinking patterns instead of behavior patterns, patient
starts to come up with their own homework
- Ending of treatment: planned for in the first session, maybe followed by one or two
booster sessions to consolidate gains and assist the patient in employing new skills

Mechanisms of Psychotherapy

- Comprehensible framework
- Patient’s emotional engagement in the problem situation
- Reality testing the situation
- The modification of dysfunctional assumptions leads to effective cognitive, emotional
and behavioral change

Treatment

- Patients learn to monitor their negative, automatic thoughts

- Recognize the connections among cognition, affect and behavior
- Examine the evidence for and against distorted automatic thoughts
- Substitute more reality-oriented interpretations for these biased cognitions
- Learn to identify and alter the beliefs that predispose them to distort their experiences

Cognitive techniques:

- Explore the meanings of automatic thoughts by questioning the patient about them
- Tested by direct evidence or logical analysis

1. Decatastrophizing (helps patients prepare for feared consequences, decreases

avoidance)
2. Reattribution (tests automatic thoughts and assumptions by considering alternative
causes of events)
 3. Redefining (making a problem more concrete or specific and stating it in terms of the
patient’s own behavior)
4. Decentering (primarily used when treating anxious patients who worngly believe that
they are the focus of everyone’s attention)

Behavioral techniques:

1. Hypothesis testing (evidence for and against beliefs)

2. Exposure therapy (provide data on the thoughts, images and physiological symptoms
and self-reported level of tension experienced by the anxious patient)
3. Behavioral rehearsal/role-playing (practice skills or techniques that are later applied
in real life, modeling)
4. Diversion techniques (reduce strong emotions and decrease negative thinking e.g.
physical activity, social contact, work, play and visual imagery)
5. Activity scheduling (provides structure and encourages involvement)
6. Graded-task assignment (the patient initiates an activity at a nonthreatening level
while the therapist gradually increases the difficulty of assigned tasks)
Week 6: Outcomes of Research and Techniques

Outcomes of Counselling and Psychotherapy

- We cannot be sure that counselling or psychotherapy was actually responsible for

the changes that came about
- Psychological symptoms tend to go away over time and then come back
- This is why it is important to compare changes in clients who have undergone
therapy with changes in a similar group of individuals who have not
undergone therapy (control group)
- Efficacy = the potential to bring about a desired effect

- Findings: clients who do receive therapy tend to improve more over time (not due to
chance)
- Use placebo groups AND control groups to determine whether active
ingredients of the therapy are responsible for bringing about positve change
- Placebo interventions do actually bring about some positive results compared
to no-treatment control
- Active therapeutic intervention still does better

- Effect size around 0.75 to 0.85 (large effect)

- Larger effect than any medical or surgical procedures (overall effect size of
0.5, medium effect)
- Cohen’s d of 0.85 means that around 85% of clients who have had therapy do
better than the average person who has not had therapy

- Desired outcome = to be free from severe psychological distress

- “Clinically significant improvement” (levels of abnormally high psychological
distress have been reduced to measures within a normal range)
- 60% of clients in psychotherapy improved to an extent that was clinically
significant
- Effectiveness = the extent to which an intervention, when used under ordinary
circumstances brings about a desired effect

- 5-10% of patients get worse in therapy (around 10-15% in substance abuse work)
- Less than 5% in control conditions
- Around 20% of patients indicated that there was something in their therapy
that was harmful or problematic
- Half of clients ultimately drop out of therapy (withdraw before the therapist
thinks is advisable or fail to attend last schedule session)

- ED50 = the amount of something that is required to produce the desired effect in
50% of the population
- Between ten and twenty sessions
- ED75 is 58 sessions
 - Conclusion: the more therapy clients have, the better they tend to get (shown
in both the efficacy and the effectiveness)
- Law of diminishing returns = negatively accelerating curve; as clients have
more and more sessions, the added benefit of each session becomes less
and less

- After therapy: follow-up

- Relapse = a return to ill-health following a period of improvement
- Depending on the issue, it may worsen again after therapy is over

- There is no evidence to support the practice of encouraging or requiring clients to

discontinue pharmacological treatments while participating in psychological therapies

Technique and Practice Factors

- Therapeutic technique = a well-defined procedure implemented to accomplish a

particular task or goal
- Technical interventions were cited by clients as the most common type of
events that led to the formation and strengthening of the therapeutic alliance
- Technique and orientation factors may contribute only 15% towards the
overall outcomes of therapy
- Other studies have compared technique-oriented therapies with
non-technique-oriented therapies and have found that they are equally helpful
- Component study = a study which looks at the efficacy of particular aspects of
therapeutic practice
- Additive designs look at the effect of adding a particular practice, while
dismantling designs look at the effect of taking away a particular practice
- Some techniques may be more effective with some clients than with others
- Clients do better with therapies that are aligned with their pre-existing ways of
functioning (capitalization hypothesis)

1. Cognitive-Behavioral Techniques

- Exposure = purposefully invoking anxiety by direct confrontation with the

situations that produce fear in the client (most successful when carried out
during a long interrupted period of time, as opposed to several shorter periods
spaced over time)
- In vivo exposure (clear evidence of efficacy with specific and social phobias)
- Imaginal exposure (less effective than in vivo exposure, but useful when it is
not possible to actually encounter the feared stimulus e.g. traumatized by
war)
- Virtual reality exposure (as effective as in vivo exposure for individuals with
flying and height phobias)
- Interoceptive exposure (greater efficacy with panic disorder than other CBT
techniques, some evidence that it is effective in the treatment of
claustrophobia)
 - Exposure and response prevention (useful for OCD symptoms
- Cue exposure (shown to be effective in treatment of alcohol abuse)
- Systematic desensitization = gradated imaginal exposure techniques,
combined with muscular relaxation, have tended to receive more mixed
empirical support than other exposure procedures, with evidence that they
can improve subjective levels of anxiety, but do not necessarily reduce levels
of fear-avoidant behaviors

Implication for practice: clients who go to therapy for specific or social phobias should be
referred to a practitioner who does specific techniques mentioned above

- Paradoxical interventions = a therapeutic technique in which a client is

directed by the therapist to continue undesired symptomatic behavior, and
even increase it, to show that the client has voluntary control over it (highly
effective, especially with reactive clients)

Implications for practice: if the client is finding it difficult to do the behavior they are trying to
learn, then maybe it would be helpful to do the opposite (keep in mind ethical implications)

- Activity scheduling = clients plan and monitor their daily activities e.g. by
making a schedule (.87 effect size)
- Cognitive techniques (lead to more positive change than an absence of
intervention, little evidence to suggest that they work in the way they are
hypothesized)

2. Psychodynamic techniques

- Interpretation (seem to be efficacious, contribute to the consolidation of the

therapeutic alliance)

Implications for practice: interpretations are most effective when they are worded in a
tentative, rather than absolute manner, just beyond the limits of the client’s awareness,
mixed with other response modes (such as questions and direct guidance), repeated several
times, later on in the therapeutic process, tailored to the individual client. Transference
interpretations are more helpful when they are accurate and embedded with a strong
therapeutic alliance

3. Humanistic and Experiential Techniques and Practices

- Non-directivity = when the therapist tries to refrain from directing their client in
any particular way (clients with high levels of resistance tend to benefit more
from non-directive practices, whereas those who aren’t benefit more from
directive practices)
- Experiencing = the extent to which inner felt senses and processes are the
foci of attention (related to the outcomes of therapy; predictor of the
involvement in the therapeutic process)
 - Deepening of emotional processing (catharsis in itself appears to be
inadequate for producing positive change, it needs to be combined with
cognitive processing of the emotion in order to be effective)
- Therapy is most effective when there are both high levels of emotion
and high levels of cognitive abstraction in a session
- Acceptance of emotions is more effective in reducing psychological
distress than its suppression
- Emotion-intensifying therapies have a negative effect on wellbeing

- Two-chair and empty-chair dialogues (effective for adult survivors of childhood

sexual abuse, reduction in traumatic symptoms)
- Can be very distressing
- No evidence that individuals with more trauma-related factors had
more difficulties with the imaginal confrontation intervention

- Focusing = method in which individuals are invited to attend to and carry

forward their bodily felt experiencing
- Help clients deepen their levels of experiencing
- Better outcomes than the regular therapy by itself \

4. Generic Techniques and Practices

- Contracting and Boundaries (contractual arrangements not related to the

outcomes of therapy. Crossing boundaries of therapeutic relationship,
however, is related with decrease efficacy of treatment. Boundary extensions
increased effects of therapy e.g. therapist calls client if they are in the hospital
or attends a special event for the client)
- Response modes: listening
- One of the most facilitative aspects of therapy
- Deepens therapeutic relationship, especially active listening

- Paraphrasing = restating the meaning of another person’s verbal disclosures

in one’s own words (most frequent technique other than listening, well
evaluated; higher client collaboration
- Restatements
- Reflections of feelings
- Non-verbal referents
- Summaries

- Encouragement (related to satisfaction with the therapist)

- Asking questions (may be helpful to some extent, and may enable clients to
express greater levels of affect)
- Guidance and advice (unhelpful)
- Touch (be careful when using this, with intention, being attentive to contextual
cues in order for it to be appropriate)
- Homework assignments (as long as it is relevant to the therapy process)
- Feedback on the client progress
 - Routine monitoring of client progress through inviting clients to
regularly complete outcome evaluation forms and through addressing
difficulties that might become evident is one of the most useful things
that therapists can do to enhance the effectiveness of their work

- Manualization (associated with worse outcomes)

- Telephone and internet-based interventions (limited in their effectiveness
Week 7: Client, Therapist and Relationship Factors

Client Factors
- The client is the one who is primarily responsible for change during therapy
- Clients’ experiences, characteristics and qualities have high correlation with
outcomes of therapy

Inferred Characteristics

1. Attitudes Towards Therapy

- Motivation and involvement
- Resistance = client behaviors that exhibits a reluctance to participate
in the tasks of therapy (inversely related to therapy outcomes)
- Related to the client’s level of intrinsic or autonomous motivation for
therapy
- Outcome expectation
- Self-fulfilling prophecies
- Hope
- Usually clients with substance abuse and anxiety problems would
seem to do best when they have high expectations there is less
evidence that this is also the case for clients with depression

Implications for practice:

- It is essential for therapists to use words of encouragement and hope and conveying
to clients that they can recover so that clients see therapy as valueable
- Clients with really high expectations of therapy should have their expectations
reduced so that they don’t get disappointed

- Process Expectations (what clients expect to happen in therapy)

- Clients who do not anticipate pain or embarrassment in therapy tend
to respond less positively to therapeutic interventions
- Clients who have a clear understanding of the process and goals of
therapy and their role within it tend to get the most out of their
therapeutic work
- Those who have a more ambiguous understanding of the role are less
satisfied, less productive and more defensive
- Induction procedures where expectations are evaluated reduce
drop-out rates

Implications for practice:

- Helping clients develop realistic and clear expectations of what will happen in therapy
may be an important element of initial and assessment sessions

- Predilection (clients’ beliefs about the origins of their distress and what they
expect will be helpful to them)
 - The more clients understood their depression in relatively abstract
terms, the better they did in cognitive therapy (which gave them an
opportunity to examine their personal meanings) but the worse they
did in behavioral therapy (which focused on behavioral changes)
- Conclusion: clients do better in therapies that match their predicitons

Implications for practice:

- Ask clients about how issues could best be helped in initial assessment sessions as
well as what they think the origins of the problems are

- Preferences
- Doesn’t make a difference to the therapeutic outcome

- Psychosocial functioning
- Clients with higher levels of manifest (overt) distress have better
clinical outcomes; due to more motivation for change or more room for
improvement
- Clients with more latent (underlying) levels of psychological, social
and interpersonal functioning, the reverse tends to be true; individuals
with higher levels of psychological dysfunction tend to get the least out
of therapy

- Personality disorders (constellations of relatively enduring, maladaptive traits

that can result in significant subjective distress and functional impairment)
- What influences outcomes most is how many personality disorders
one is diagnosed with
- Some personality disorders are more predictive of poor outcomes than
others (e.g. borderline and schizotypal)
- Clients diagnosed with dependent personalities seem to experience
some of the worst outcomes in treatment for depression

- Attachment style (individuals’ particular patterns of behaving, thinking and

feeling in close relationships)
- 93.3% of securely attached individuals showed clinically significant
and reliable change in cognitive therapy for depression
- 52.5% of avoidant clients showed reliable/significant change
- 38.5% of ambivalent clients showed reliable/significant change (also
less likely to complete therapy)
- Clients with higher levels of interpersonal difficulties (high levels of
hostility, social avoidance and non-assertiveness) tend to have poorer
therapeutic outcomes
- Securely attached clients and those with better interpersonal
relationships form better alliances with their therapists (quality of the
therapeutic alliance is one of the best predictors of therapeutic
outcomes)
- Clients with dismissive attachment styles tend to do well in therapy
(form strong therapeutic alliances)
 - Perfectionism
- High levels of perfectionism show less improvement in therapy (the
difference arises specifically in the second half of therapy)

Implications for practice:

- When working with perfectionist clients, it may be particularly important to convey an
accepting and non-judgmental attitude, and to encourage them to appreciate any
therapeutic gains they make

- Psychological Mindedness (a person’s ability to understand people and their

problems in psychological terms)
- The more the clients are psychologically minded, the better their
outcomes will be

- State of Change (the different stages in a process of behavior change)

- E.g. precontemplation, contemplation, preparation, action,
maintenance, termination
- People in the precontemplation stage are most likely to drop out of
therapy
- People in the action phase are least likely to drop out
- Behavior change programs are most successful when they are
tailored at clients’ particular stages

Implications for practice:

- Set realistic goals in therapy of advancing one or two stages

- Level of social support

- Counselling and psychotherapy may play a critical role in triggering
clients to establish new friendships, re-establish ties with old friends or
develop more satisfying relationships with family members and
through that process play a key role in helping to improve the quality
of their lives

- Clients of different gender, age, sexuality, race and class seem to do about equally
well in therapy
- There is some evidence that clients from black and minority ethnic
backgrounds, as well as those of lower socio-economic status, are more likely
to drop out of therapy and may use therapeutic services less

Therapist Factors

= enduring and relatively stable traits of the therapists

- How do these relate to client improvement?

- Pseudoshrink vs. supershrink
 - supportive -expressive and cognitive-behavioral psychotherapists had somewhat
better results than the drugs counsellors
- There was a large variation of outcomes among patients of therapists within
the same orientation
- Clients of the most effective therapist had an average rate of change ten
times greater than the mean of the sample
- Clients of the least effective therapist actually had a worsening of symptoms
- The differences in effectiveness from one therapist to another, would seem to
be considerably greater than the differences in effectiveness between all
therapists of any orientation
- Other analyses have concluded that there is actually still little conclusive
evidence of statistically significant therapist effects
- Therapist effects tend to be reduced among more experienced therapists and
therapists practicing according to a manual

Inferred Characteristics

1. Psychological functioning
- Positive relationship between therapists’ wellbeing and client outcomes

2. Personality
- Therapist’s personality is one of the most important factors; little evidence
linking specific personality traits to outcomes
- Therapists who have more dogmatic attitudes or ideas tend to have
poorer client outcomes

3. Beliefs and Values

- Therapist’s views on what conduct should look like is directly related to
clients’ outcomes
- The more the clients’ values converge on those of their therapists, the more
therapists (but not clients) rate their clients as improved
- Prejudiced views reduce the ability to have a positive alliance

Observed Characteristics

1. Gender
- Clients with female therapists were more satisfied with their therapy than
clients of male therapists (experiencing less negative affect, appear more
trusting and secure, and less worried) about the impressions they were
making on their therapists
- It doesn’t matter if therapist’s gender matches their client’s gender

2. Sexual Orientation
- It benefits the therapeutic process if the therapist’s sexual orientation matches
their client’s (not in every case); the underlying reason is probably because it
fulfills the need of being accepted and understood by the therapist
 - Once behaviors and attitudes are accounted for in analyses, the sexual
orientation actually makes little difference (just contributes to making the client
feel safe and secure in therapy)

3. Age and Experience

- Age does not necessarily matter, but life experience does

4. Ethnicity
- Does not make a difference

Implications for practice:

- When working with clients from marginalized social groups, it is important for
therapists to relate to them in non-pathologizing, affirming ways to help their clients
feel good about who they are in both their personal and social identities

Professional Characteristics

1. Training
- Clients of therapists with more training experience did achieve better overall
outcomes and lower drop-out rates, stayed in therapy for longer and were
more satisfied with their therapy
- Specific, manualized concepts and tasks lead to therapist training that is more
effective
- Skilfulness and credibility is most rated to positive outcomes

2. Professional Status
- Paraprofessional = a mental health care worker, paid or voluntary, who is not
formally qualified in the psychological treatment of mental distress
- Trained mental health professionals get better results than trained medical
professionals

3. Supervision
- Can enhance therapists’ self-awareness, help them apply skills and
knowledge in a more consistent way and help them experience greater
self-efficacy
- Safety and acceptance = a feeling of not being threatened and judged; feeling
affirmed in one’s work and orientation, trust, empathy; a sense of being able
to disclose all aspects of one’s practice
- Equality = a sense of collaboration, collegiality and mutuality, which may be
enhanced through the supervisor’s self-disclosure
- Challenge = the development of new insights

4. Professional Experience
- No relationship between this and client outcomes
- Training does
Relational Factors

1. Therapeutic Alliance
= the quality and strength of the collaborative relationship between therapist and client
- The therapist’s and client’s agreement on the goals of therapy
- Therapist and client consensus on the tasks of therapy
- The existence of a positive affective bond between therapist and client
- The more positive the therapeutic alliance, the less likely clients drop out of therapy
- Independent from the type of therapy

Implications for practice: one of the first main priorities in the first sessions should be to
establish a strong therapeutic alliance with the client: a positive affective bond, a sense of
working together towards the same goals and some agreement about how therapy should
proceed

2. Goal Consensus and Collaboration

= therapist-client agreement on therapy goals
= mutual involvement of patient and therapist in a helping relationship
- One of the four demonstrably effective elements of the therapeutic
relationship

3. Therapist Interpersonal Skills

- Empathy = entering the private perceptual world of another and having an
accurate, felt understanding of their experiencing
- Demonstrably effective element of the therapeutic relationship
- Empathy is related to outcomes in the less relationally-oriented
therapies as well
- Positive regard = a warm acceptance of the other and their experiences
without conditions
- One of the most valued aspects of therapy
- Friendliness, warmth and affirmation are important and lead to best
outcomes, therefore more neutral therapists were classified as less
effective

4. Congruence
= being freely and deeply oneself in a relationship, with one’s experiences accurately
represented in awareness
- Promising and probably effective element of the therapeutic relationship

Therapist’s Clinical Skills

1. Management of Countertransference
= therapist’s reaction to clients that are based on therapist’s unresolved conflicts
- Transference = the process of transferring to and repeating early patterns of
behavior with present-day partners
- Promising and probably effective element of the therapeutic relationship

2. Self-disclosure
= therapist statements that reveal something personal about the therapist (one of the most
controversial techniques)
- Self-involving statements = a form of self-disclosure in which the therapist
expresses a personal response to the client in the present
- Promising and probably effective element of the therapeutic relationship

Implications for practice:

- Disclose infrequently
- It is more appropriate to disclose less intimate material
- Use disclosure to validate the client’s reality, normalize, strengthen the alliance or
offer alternative ways to think or act
- Avoid disclosures that are for your own needs, remove the focus from the client,
interfere with the flow of the session, burden or confuse the client, are intrusive or
blur the boundaries
- May be helpful to reassure clients
- Carefully observe how clients respond to disclosures and ask about their reactions,
using this information to judge the appropriateness of further disclosures (be
responsive to the needs of individual clients)

3. Feedback
= information provided to a person, from an external source, about the person’s behavior or
the effects of that behavior
- observation/description
- Emotional reaction
- Inferences
- Mirroring
- Promising and effective element of the therapeutic relationship

Implications for practice:

- Give positive feedback first
- Ensure that a safe and trusting therapeutic relationship has been established
- Make the aims and function of giving the feedback clear to the client
- Share the feedback in a collaborative, rather than didactic manner, and to be open to
the possibility that the feedback may be wrong or unhelpful
- To bear in mind that clients with low self-esteem or who are in a depressed mood
may hear feedback more negatively than it is intended

4. Repairing alliance ruptures

= a tension or breakdown in the collaborative relationship between client and therapist
- Promising and probably effective element of the therapeutic relationship

Implications for Practice:

- Attend to the rupture
- Develop an awareness of how you feel in relation to the rupture
- Take responsibility for your part in it and talk about that with your client
- Try to empathically understand the client’s experience
- Maintain the stance of a participant/observer rather than getting hooked into a
dysfunctional cycle
 5. Transference Interpretations
= interpretations that try to help the client understand the link between their interactions with
the therapist and the interactions they experience with others
- Promising and probably effective

Multicultural Theories of Psychotherapy

Basic Concepts

- Cultural constructionism = a process whereby individuals construct their world

through social processes that contain cultural symbols and metaphors
- ethnocentrism = cultural or ethnic bias—whether conscious or unconscious—in
which an individual views the world from the perspective of his or her own group,
establishing the in-group as archetypal and rating all other groups with reference to
this ideal.

1. Collectivistic
2. Individualistic

Cultural Competence

= a set of congruent behaviors, attitudes and policies that reflect an understanding of how
cultural and sociopolitical influences shape individuals’ worldviews and related health
behaviors

Six specific multicultural guidelines:

Commitment to Cultural Awareness and Knowledge of Self and Others

1. Psychologists are encouraged to recognize that, as cultural beings, they may hold
attitudes and beliefs that can detrimentally influence their perceptions of and
interactions with individuals who are ethnically and racially difference from
themselves
2. Psychologists are encouraged to recognize the importance of multicultural sensitivity
and responsiveness, knowledge and understanding about ethnically and racially
different individuals

Education

3. As educators, psychologists are encouraged to employ the constructs of

multiculturalism and diversity in psychological education

Research
 4. Culturally sensitive psychological researchers are encouraged to recognize the
importance of conducting culture-centered and ethical psychological researcg among
people from ethnic, linguistic and racial minority backgrounds

Practice

5. Psychologists strive to apply culturally appropriate skills in clinical and other applied
psychological practices

Organizational change and policy development

6. Psychologists are encouraged to use organizational change processes to support

culturally informed organizationally policy development and practices

Empowerment

- Racial microaggressions = assaults that individuals receive on a regular basis solely

because of their race, color or ethnicity
- Therapeutic empowerment helps clients increase their access to resources, develop
options to exercise choice, improve self and collective esteem, implement culturally
relevant assertiveness, affirm cultural strengths, etc.

Assumptions:
1. Reality is constructed in a context
2. Experience is valuable knowledge
3. Learning and healing result from sharing multiple perspectives
4. Learning and healing are anchored in meaningful and relevant contexts

- Cultural trauma = a legacy of adversity, pain and suffering among many minority
group members
- Aversive racism = negative evaluations of racial/ethnic minorities are realized by a
persistent avoidance of interaction with other racial and ethnic groups.
- Both liberal and conservative whites discriminate against Black people in
situations that do not implicate reacial prejudice as a basis for their actions
- Multicultural psychotherapies explore their beliefs, values and attitudes toward their
in-group members as well as their attitudes towards out-group members
- Cultural humility = a dynamic and lifelong process focusing on self-reflection
and personal critique, acknowledging one's own biases/privilege
- White privilege = unacknowledged systems that give power to white
americans and male individuals

History

- Psychoanalysts theorized that culture shapes behavior because individuals are

contextualized and embedded in social interactions that varied across social contexts
and historical periods
- Transcultural psychiatry
- Identity politics
 - Psychology of colonization (economic and emotional dependence of the colonized on
the colonizer)
- Education for the oppressed model (instruments of oppression that reinforce and
maintain the status quo and sicauk inequities)
- conscientization/critical consciousness
- Reevaluation counseling
- Two or more individuals take turns listening to each other without interruption
to recover from the effects of racism, classism, sexism and other types of
oppression
- Ethnic Family Therapy
- Know their own culture
- Avoid ethnocentric attitudes and behaviors
- Achieve an insider status
- Use intermediaries
- Have selected disclosure

Current Status

- Multiculturalism promotes empowerment, change and a transformative dialogue on

oppression
- The creation of the American Psychological Association of Ethnic Minority Affairs
advanced the role of multiculturalism in psychological theory and practice

Multicultural psychotherapies follow three models:

1. A cultural adaptation of dominant psychotherapy

2. Ethnic psychotherapies
3. Holistic approaches

- Use appropriate language; persons = therapeutic relationship, metaphors =

concepts shared by members of the cultural group, content = therapist’s
cultural knowledge, concepts = whether the treatment concepts are culturally
consonant with the client’s context, goals = whether clinical objectives are
congruent with clients’ adaptive cultural values, methods = cultural adaptation
and validation of methods and instruments, context = clients’ environment

Culturally adapting CBT:

1. Involving culturally diverse people in the development of interventions

2. Including collectivistic values
3. attending to religion or spirituality
4. Paying attention to the relevance of acculturation
5. Acknowledging the effects of oppression on mental health

- Folk healers = a type of indigenous psychotherapist use mechanisms similar

to those used by mainstream psychotherapists to reestablishe clients’ sense
of cultural belonging and historical continuity, promote self-healing and
 nurtures a balance between the sufferer, family, community and cosmos

- Psychology of liberation = based on Latin American Ideology, based on black

liberation theologists; indigenous traditions and practices (similar to critical
consciousness)
- Therapists collaborate with the oppressed in developing critical
analysis and engaging in transformativ actions
- Testimonio (a narrative used in therapy that chronicles traumatic
experiences and how these have affected the individual, family and
community)
- Cuento
- Dichos (a form of flash psychotherapy that consists of spanish
proverbs or idiomatic expressions that capture folk wisdom)

Theory of Personality

Minority identity development stages:

1. Conformity (individuals internalize racism and choose values, lifestyles and role
models from the dominant group)
2. Dissonance (individuals begin to question and suspect the dominant group’s cultural
values)
3. Resistance immersion (individuals endorse minority-held views and reject the
dominant culture’s values)
4. Introspection (individuals establish their racial ethnic identity without following all
cultural norms, beginning to question how certain values fit with their personal
identity)
5. Synergistic (individuals experience a sense of fulfillment toward their racial identity
without having to categorically accept their minority group’s values)

- Cultural consciousness = a process that helps clients increase their

psychocultural awareness
- Multicultural consciousness = therapists’ internalization and incorporation of
cultural competence into their everyday activities and into every aspect of
their behavior
- Cultural intelligence = the understanding of the impact of culture on
individuals’ behavior

Theory of Psychotherapy

Ethnocentric stages:

1. Denial (individuals deny the existence of cultural differences and avoid personal
contact with other culturally diverse people)
2. Defense (individuals recognize other cultures but denigrate them)
3. Minimization (individuals view their own culture as being universal and believe other
cultures are just like theirs)
Multicultural sensitivity development:

1. Acceptance (individuals recognize and value cultural differences without judging

them)
2. Adaptation (individuals develop multicultural skills)
3. Integration (individuals’ sense of self expands to include diverse worldviews)

Process of Psychotherapy

1. The Therapeutic Relationship

a. Low accultured clients expect therapist to act as adviser, advocate or
facilitator of indigenous support systems (e.g. use modeling, selective
self-disclosure and didactic strategies)

2. Cultural Empathy
a. Clients of color expect their therapists to demonstrate cultural credibility
b. = the learned ability to obtain an understanding of the experience of culturally
diverse individuals informed by cultural knowledge and interpretation

3. Ethnocultural Transference and Countertransference

a. Suspend preconceptions about clients’ race and ethnicity contexts
b. Recognize the client may be quite different from other members of their racial
or ethnic group
c. Consider how racial or ethnic differences between therapist and client may
affect psychotherapy
d. Acknowledge that power, privilege, oppression and racism might affect their
intentions with clients
Extra Chapter: Positive Psychotherapy
Basic Concepts

- Flourishing = a state characterized by positive emotions, a strong sense of personal

meaning, good work and positive relationships
- Requires more than relieving the symptoms of psychological distress

- Goal:
- Alleviating symptoms
- Building positive resources
- Knowing personal strengths, learning skills to cultivate positive emotions,
strengthening positive relationships, finding meaning and purpose in life
- Explore potential for growth

Other Systems

- Negative impressions are more quick to form and more resistant to change than
positive ones, negative memories stay with us longer than positive ones
- Evolutionarily adaptive because pessimism made organisms more likely to
take care of their family. However, nowadays we live in much more stable and
safe environments with steady resources but this tendency prevails
- 65% Barrier:
- Both cognitive therapy and SSRIs only have a 65% response rate (including
placebo, that can explain up to 55%)
- Due to lack of motivation, comorbid issues, live in unhealthy environments
(creates negative beliefs about the possibility of change)
- 10-15% adults deteriorate after psychotherapy and 25-35% show no
improvements, 40% terminate therapy prematurely; probably because
psychotherapy focuses on symptom relief and not sustainable changes
- Cure = deep transformative change across multiple domains of personality,
character and behavior that persist over time

- Alternative to deficit-oriented psychotherapy (learn to function well in the face of

psychological distress; recover-oriented care)
- The absence of positive characteristics e.g. hope, optimism and gratitude,
predicts the onset of depression far better than the presence of negative
factors e.g. history of depression, neuroticism, physical illness
- Presence of character strength e.g. hope, appreciation of beauty and
excellence and spirituality hugely contributes to recovery

History

- Socrates, Plato, Aristotle: living a virtuous life is necessary for happiness

- Before WW2: psychology’s mission was to cure psychopathology, make the lives of
all people more productive and fulfilling and nurture talents
 - After WW2: psychology’s mission became treating psychopathology. Some
humanistic psychologists still focused on growth and describing a good life
- In the past 18 years, positive psychology has been gaining recognition
- Effectiveness has been demonstrated for depression, PTSD, BPD and
psychosis

Theory of Personality

- Don’t believe that childhood trauma play a significant role in the development of
psychopathology
- 40-50% of happiness is accounted for by genetics
- Only 10-15% of happiness is explained by life circumstances
- Optimism, spirituality and positive coping styles are associated with posttraumatic
growth independent of posttraumatic stress
- Having a high sense of purpose in life is associated with a reduced risk for
life-threatening conditions

Other Concepts

Assumptions of positive psychotherapy:

1. Psychopathology results when clients’ inherent capacities for growth, fulfillment and
happiness are thwarted by sociocultural factors
2. Positive emotions and strengths are authentic and as real as symptoms and
disorders
3. Effective therapeutic relationships can be built on exploration and analysis of positive
personal characteristics and experiences

Theory of Psychotherapy

Based on two major theories:

1. Seligman’s PERMA conceptualization of wellbeing
a. Five scientifically measurable and manageable components
b. Fulfillment in these five components is associated with lower rates of
depression and higher life satisfaction

Positive emotions (about past, present and future; undo the effects of negative emotions,
build resilience. Associated with positive life outcomes.)

Engagement (flow e.g. task challenge matches skill level of the person; involvement,
absorption in work, intimate relations and leisure. Eliminates boredom, anhedonia
and rumination by engaging attentional resources and leaving a person feeling
accomplished.)

Relationships (need to belong. Enhance longevity and wellbeing)

Meaning (need to use strengths to serve something bigger than oneself. People with higher
purpose in life show higher persistence in a difficult situation and recover faster from
injury or adversity. Therapy can help clients define goals, identify overarching
 meaning in their lives, which buffers against feelings of hopelessness and \
uncontrollability.)

Accomplishment (concrete achievements or accomplishments that give the individual deep

sense of satisfaction and fulfilment. Actively using strength, monitoring the situation to make
flexible changes, consistency and pursuing intrinsically motivating and meaningful goals.)

2. Character strengths as active therapeutic ingredients

a. = traits that are valued in their own right and are not tied to specific outcomes
b. Help understand the ways in which clients can be good, sane and high
functioning
c. People who experience gratitude, love, kindness, etc. are more likely to be
happy and satisfied
d. Important to assess strengths not just weaknesses
e. Nurturing strengths produces growth, not just remediation
f. Repairing weakness doesn’t necessarily make clients stronger/happier
g. Using strengths increases clients’ self-efficacy and confidence
h. Strengths offer ways for clients to be the individuals they want to be 9e.g.
Kind, creative, grateful)
i. Strengths are built through specific and realistic actions
j. Dimensional approach (under-use of strengths can lead to psychopathology)
k. Golden mean = the right combination of strengths applied to the right degree
in the right situation

The Full Life: PERMA + character strengths

- Happiness and satisfaction

Process of Psychotherapy

- Gratitude journal throughout the process (three good things that happened each day)

1. Phase 1
a. Three sessions (reflect on positive experiences and instances where they
could overcome challenges)
b. Identify resilience and strengths that enabled this resilience (clients learn how
to use strengths to deal with challenging situations)

Exercises:
- Positive Introduction = starting activity in the first session (client describes an event in
which they overcame a challenge)
- Strengths assessment
- Better version of me (clients set specific goals that utilize their strengths to address
their concerns. Writing down the goal increases success by 42%)

2. Phase 2
a. 4-8 sessions (teach clients how to use their strengths in a calibrated and
flexible way to adaptively meet situational challenges)
 b. Final session is a review session of therapeutic progress and real-world
assignments

Exercises:
- Creating psychological space = clients write a bitter memory from a third-person
perspective. This makes the narrative less personal and emotional and leaves more
attentional resources to analyse the meaning of the memory and their emotions
- Reconsolidation = clients recall subtle details of the memory in a relaxed state (helps
them recollect and reconsolidate positive or adaptive aspects of the memory that
might have been overlooked because of the mind’s bias towards negativity)
- Mindful self-focus = encouraged to observe negative memories, rather than reacting
to them (helps loosen emotional attachment to memory)
- Diversion = clients learn to recognize external cues that activate the recall of a bitter
memory and are helped to immediately engage in an alternative physical or cognitive
activity to stop the full rehearsing of the bitter memory

Other exercises:
- Gratitude letter = clients recall a person who did something kind for them and writes a
letter for them
- Gratitude visit = clients read the content of the letter to the person they wrote it to
- Sacrificing versus maximizing = helps clients understand how to be aware of energy
and time expenditures on tasks and to manage this expenditure toward appropriate
and beneficial ends; raises awareness to activities that distract us from encountering
negatives or simply do not contribute to well-being

3. Phase 3
a. 8-14 (restoring or fostering positive relationships, learn tp pursue meaning
and purpose which helps them control psychological distress and buffers
against hopelessness and lack of control)

Mechanisms of Psychotherapy

- Cultivation of positive emotions (directing attentional resources to them e.g. gratitude

journal, gratitude letter and savoring)
- Positive appraisal (skills that use strengths, learn negative consequences of holding
on to such memories, learn a more nuanced emotional vocabulary, learn skills that
use their strengths)
- Therapeutic writing (writing both positive and negative events allows one to make
sense of the events and explore deeper dimensions of the experiences; use
resilience of the past and present to visualize a meaningful future)
- Resource activation (applies clients’ resources like strengths, abilities, etc. to action)
- Experiential skill building (allows clients to develop their signature strengths)

Evidence

- Significantly lower symptoms of distress and enhance wellbeing with medium to large
effect sizes