Clients' opinions may be biased,
CHAPTER 11
Page 2:
Does Psychotherapy Work?
 Questions about the outcome of
psychotherapy have been prominent
throughout the history of clinical
psychology
 Studies investigating these questions

have taken many forms
Most evidence offered in support of
psychotherapy came in the form of
anecdotes, testimonials, and case

studies
Controlled, empirical studies of
therapy outcome didn't appear
regularly until the 1950s
 Hans Eysenck published a study in
the 1950s claiming that
psychotherapy was of little benefit,
inspiring subsequent empirical
studies
 Meta-analyses began to appear in the
late 1970s and 1980s, consistently
showing positive results about how
well psychotherapy works
Whom, When, and How
Should Researchers Ask?
Designing and running an empirical

study to measure the outcome of
psychotherapy can be complex
 Different people involved in therapy
may have different vantage points on
the results
 Researchers may seek opinions from
clients, therapists, and society

therapists' views can be biased as
well, and society may have its own
perspective
 Researchers can solicit multiple
opinions
 Researchers must also consider when
to ask about therapy outcome,
immediately after therapy ends or at
various points in therapy
 Researchers have many options
regarding how to measure the
outcome of psychotherapy, including
questionnaires, interviews, or
behavioral measures
Page 4:
Efficacy Versus
Effectiveness of
Psychotherapy
 Empirical studies of psychotherapy
outcome generally fall into two
categories
 Efficacy studies measure how well
psychotherapy works in a controlled
research study
 Effectiveness studies measure how
well psychotherapy works in real-
world settings
 Meta-analyses have shown
consistently positive results about the
efficacy and effectiveness of
psychotherapy
Page 6:
Considering Culture
 Clients from diverse cultures often

hold widely varying expectations
about the psychotherapy process
 Culturally competent therapists can
attain a more successful
psychotherapy outcome by
appreciating the presumptions related
to each client's cultural background
Psychotherapy as traditionally

practiced in North America and the
Western world may clash with the
expectations of individuals from
diverse cultural backgrounds
Page 7: Cultural
Values and
Communication
Styles in
Psychotherapy
 Cultural values influence the
communication styles of clients in
psychotherapy
o Eastern cultures prefer to
avoid negative thoughts and
may be less comfortable self-
disclosing
o Western cultures emphasize
individualism, while Eastern
cultures prioritize
collectivism
 Training psychotherapists to be
culturally competent is important
o Four levels of training: self-
understanding, listening to
clients' cultural values,
accepting clients' cultural
values, understanding clients'
cultural values
Page 7: Importance
of Appreciating
Cultural
Background in
Psychotherapy
 It is important for psychotherapists to
appreciate clients' expectations about
psychotherapy related to their
cultural background
 Different cultural values may be
important to recognize
o Clients from non-Western
cultures may prefer to
"conceal" rather than "reveal"
o Clients from Eastern cultures
may feel a stronger sense of
shame about personal
problems or shortcomings
Page 7: Efficacy and
Effectiveness Studies
in Psychotherapy
 Efficacy studies focus on the cause-
effect relationship between therapy
and outcome
o Control as many aspects of
therapy as possible for
internal validity
o Well-defined groups of
patients, manualized
treatment guidelines, random
assignment
 Effectiveness studies focus on how
therapy works in real-world settings
o Include a wider range of
clients, allow for greater
 variability between therapists'
methods
o May or may not include a
control group for comparison
Page 8: Results of
Efficacy Studies
 Thousands of efficacy studies
confirm that psychotherapy works
 Meta-analyses show consistent
findings of psychotherapy's benefits
 Average effect size for
psychotherapy is .85, indicating
significant improvement compared to
those who do not receive therapy
 Psychotherapy benefits endure over
time, exceed placebo effects, and
represent clinically significant
change in well-being
Page 8: Exceptions
and Transdiagnostic
Approach in
Efficacy Studies
 Psychotherapy is not a panacea, and
some clients may worsen or
experience short-lived benefits
 Recent focus on transdiagnostic
approach in efficacy studies
 Targeting underlying pathology and
core emotional disorders rather than
superficial symptoms of specific
disorders
Page 9:
Symptoms of negative
affect or neuroticism
 Unified protocol focuses on reducing
negative thoughts, preventing
unhealthy avoidance, and
encouraging positive behaviors
 Efficacy of unified protocol for
emotional disorders is strong and
growing
Gap between research and
practice in therapy
 Gap between efficacy research and
therapy practice is problematic
 Efforts to bridge the gap have
increased in recent years
 Reluctance of therapists to practice
according to efficacy research is a
significant challenge
 Dissemination of evidence-based
treatments has become a major focus
 Strategies for dissemination include
case studies, brief and inexpensive
training, and direct-to-consumer
marketing
 Practice-oriented research and
practice-research networks aim to
increase collaboration between
researchers and therapists
Page 10:
Reasons for the gap
between research and
practice
 Therapists value their own intuition
and judgments over scientific data
 Therapists see research as irrelevant
to their day-to-day practice
  Reluctance to adopt treatments o 92% of people feeling fairly
supported by efficacy studies poses a poor at the beginning of
challenge in dissemination therapy were feeling very
good, good, or at least so-so
Dissemination strategies by the time of the survey.
 Findings converge with meta-
analyses of efficacy studies.
 Case studies are more persuasive to
psychologists in private practice than
research reviews Methodological questions
 Psychologists in private practice are and limitations
more willing to undergo brief and
inexpensive training
 Consumer Reports study is
 Forcing clinicians to use evidence-
constrained by methodological
based treatments without getting
questions.
them on board first can lead to
 Sampling bias: those with successful
resistance
therapy experiences were more likely
 Direct-to-consumer marketing could
to respond.
help dissemination efforts
 How many clients would have
 Practice-oriented research and
improved without psychotherapy?
practice-research networks aim to
 Reliability and validity of clients'
increase collaboration between
self-reports about psychotherapy
researchers and therapists
outcome.

Page 11: Complementing efficacy

studies
Results of Effectiveness
Studies  Effectiveness studies complement
efficacy studies.
 Together, they strongly support the
 Effectiveness studies have generated
benefits of psychotherapy.
positive results, similar to efficacy
studies.
 Psychotherapy works as it is Meta-analyses of
commonly applied in realistic
settings.
effectiveness studies for
 Example of an effectiveness study: cognitive-behavioral
Consumer Reports magazine survey
in 1995.
therapy
 Primary finding: psychotherapy had
 Two meta-analyses combining the
very positive, lasting effects.
results of effectiveness studies for
o 87% of people feeling very
anxiety disorders and depression.
poor at the beginning of
 Cognitive-behavioral therapy was
therapy were feeling very
highly effective in both cases.
good, good, or at least so-so
by the time of the survey.
  Fell slightly below the levels of
symptom relief found in efficacy
studies.
Page 12:
Alternate Ways to Measure
Psychotherapy Outcome
 Neurobiological effects of
psychotherapy.
 Psychotherapy changes the brain.
 Studies using fMRI and PET
neuroimaging technologies.
 Successful therapy for specific
disorders produces reliable changes
in brain activity and structure.
 Examples: decrease in metabolism in
the caudate nucleus for obsessive-
compulsive disorder, effects on
dorsal striatum for depression,
changes in frontal regions for
cognitive-behavioral therapy and
interpersonal psychotherapy.
Medical cost offset
 Indirect way to assess the outcome of
psychotherapy.
 Many people with mental or
emotional problems seek medical
assistance or delay treatment, leading
to worsened physical state and
increased medical costs.
 Data suggests that psychotherapy
reduces medical costs.
 Review of more than 90 studies
found that clients receiving therapy
spent fewer days in the hospital and
saw their medical costs reduced by
15.7%.
 Comparable clients in control groups
spent more days in the hospital and
saw their medical costs increased by
12.3%.
 Psychotherapy also reduces the need
for emergency room visits.
Which type of
psychotherapy is best?
 Infighting among different
orientations and approaches about
which had the strongest empirical
support.
 Behaviorists and nonbehaviorists
were the main combatants.
 Competition between different
brands of psychotherapy.
Page 13:
 Empirical outcome studies in the
latter half of the 1900s compared
different forms of therapy against
each other
 Surprising result: a virtual tie, with
competing therapies found to work
equally well
 Explanation: common factors across
all forms of psychotherapy
contribute to similar results
 Common factors are therapeutic and
function as "active ingredients" in all
forms of psychotherapy
Therapeutic
Relationship/Alliance
 Strong relationship between therapist
and client is the most supported
common factor for psychotherapy
outcome
 Quality of the therapeutic
relationship strongly contributes to
psychotherapy outcome
 The therapeutic relationship is the

best predictor of therapy outcome
and accounts for more variability
than specific therapy techniques
 Clients prefer a warm therapist they
can relate to over a treatment with
empirical support
 Quality of the therapeutic
relationship is vital regardless of the
therapist's emphasis on it
 Correlation between therapy alliance
rating and therapy outcome is strong
for both cognitive-behavioral therapy
and brief supportive therapy groups
 The therapeutic alliance may
facilitate client improvement and
vice versa
 Specific components of the
therapeutic relationship include the
therapist's ability to provide empathy
and acceptance to the client
Page 15:
 Therapists can establish healing
interpersonal relationships with
clients regardless of presenting
problems or techniques chosen
o Empirical research supports
specific components of the
therapeutic relationship
 The alliance between
therapist and client
 Collaboration
 Goal consensus
 Cohesion (for group
therapy)
 Empathy
 Positive regard and
affirmation
 Providing feedback to
clients
 Both techniques and therapeutic
relationships are important in therapy
Page 15-16:
 Controversy exists regarding whether
client change is due to techniques or
the therapeutic relationship
 Graduate programs recognize the
importance of the therapeutic
relationship but do not offer
systematic, evidence-based alliance
training
Page 16:
 Hope and positive expectations are
common factors in therapy
 Attention to the client's issues can
lead to improvement
 Other common factors include
reinforcement of novel behaviors,
desensitization to threatening stimuli,
confronting a problem, and skill
training
 A three-stage sequential model of
common factors: support factors,
learning factors, and action factors
Page 17:
 The therapeutic relationship/alliance
is the leading candidate for the
common ingredient in psychotherapy
 Other common factors include
hope/optimism, attention, and insight
 Different forms of psychotherapy
work about equally
 Personal values and preferences play
a role in selecting therapy
Page 18:
Reconsidering the
Dodo Bird Verdict: Page 19: In My
Specific Treatments Practice...
for Specific  Clients have different reactions to the
prescriptive approach to therapy.
Disorders  Some clients are thrilled to know
there is evidence-based treatment for
 Some researchers argue that certain their specific diagnosis.
psychotherapies are superior to  Other clients have concerns about
others in treating specific problems. therapy being chosen for them and
 Lists, books, and websites suggest receiving a cookie-cutter treatment.
that therapies are not equally  Assuring clients that their
effective. preferences will be considered and
 Dianne Chambless argues against the therapy can be personalized helps
idea that all psychotherapy alleviate concerns.
approaches are equally effective.  Clients often enter therapy with little
o Studies have not yet information or misinformation about
examined specific how therapy decisions are made.
comparisons of therapies for  Explaining the therapy process and
certain disorders. the influence of therapy outcome
o Chambless supports research on treatment choices is
manualized, evidence-based beneficial for clients.
treatments and has led task
forces to establish criteria for
efficacious treatments.
 Other researchers counter the idea
that common factors are more
important than specific therapy
techniques.
o Common factors such as
therapist-client alliance play a
significant role in
determining treatment
outcome.
o They argue for an approach
that emphasizes common
factors and the therapeutic
relationship.
 Client preferences should not be
overlooked in therapy decisions.

CHAPTER 12
Page 1:
 Introduction to the chapter on
psychodynamic orientation
 Psychodynamic therapy was the first
historically and dominated the field
in the first half of the 1900s
 Other therapies like humanistic,
behavioral, and cognitive therapies
emerged as reactions against
psychodynamic approach
 Psychodynamic therapy has lost
popularity and reputation in recent
times
 Despite the decline, it remains
widely used and relevant in certain
areas of the profession
Page 2:
 The decline of psychodynamic
therapy is reflected in popular press
statements
 Psychoanalysis and psychodynamic
therapies are considered to be in a
beleaguered state
 Psychodynamic therapy is still used
and influential in contemporary
culture
 The term "psychodynamic
psychotherapy" covers a range of
therapies including Freud's original
approach and subsequent revisions
and expansions
 The primary goal of psychodynamic
psychotherapy is to make the
unconscious conscious
Page 3:
 Psychodynamic psychotherapy helps
clients become aware of unconscious
thoughts and feelings
 Insight is a key concept in
psychodynamic therapy
 Making the unconscious conscious
allows for deliberate control of
unconscious processes
 Freud's idea of the unconscious is a
fundamental contribution to clinical
psychology
 Unconscious processes have a
powerful influence on our lives and
underlie psychopathology
 Psychodynamic psychotherapists
infer and hypothesize about clients'
unconscious activity
 Free association is a technique used
to access the unconscious in
psychodynamic therapy
Page 4:
 Spontaneous speech without editing
reveals inner thoughts and feelings
o Examples: very young
children, intoxicated adults
 Free association in psychotherapy
allows for unconscious processes to
become evident
 Distinguishing free association from
word association
o Word association: therapist
presents a list of words, client
responds with first word that
comes to mind
o Jungian therapists develop
hypotheses based on
associations or response time
o Free association involves no
stimulus from therapist
Page 4:
 Freudian slips as revealing
unconscious wishes
 Examples: verbal and behavioral
slips
o Ray's missed flight due to
losing keys and missing
airport exit reveals
unconscious dread of meeting
and conflicts with sister
o Amy misspelling baby's
name as "Benjamine" reveals
unconscious wish to have a
child with Liz's husband
Page 5:
 Dreams as communication of
unconscious material
 Freud's theory of dream work:
conversion of latent content to
manifest content
 Therapist analyzes dreams to
uncover unconscious meaning
 Client's help in interpreting symbols
in dreams
 Dream interpretations remain
inferential rather than factual
Page 5:
 Resistance as client behavior to
avoid certain issues in therapy
 Examples of resistance: changing the
subject, talking about unessential
topics, being late or missing
appointments
 Resistance motivated by anxiety
about exposing unconscious thoughts
and feelings
 Psychodynamic psychotherapists use
resistance to guide future efforts
Page 6
 Importance of uncovering and
interpreting unconscious material
during therapy
o Psychodynamic therapists
often analyze dreams
 Example of Talia and her avoidance
of discussing her mother in therapy
o Talia's unconscious feelings
of resentment towards her
mother
o Talia's discomfort in
acknowledging these feelings
 Psychodynamic psychotherapists
believe that identifying defense
mechanisms can improve clients'
lives
 Freud's structural model of the mind:
id, superego, and ego
o Id generates pleasure-seeking
impulses
o Superego establishes rules
and restrictions
o Ego mediates between id and
superego
Page 7
 Ego's role in managing conflicts

between id and superego
Defense mechanisms as techniques
developed by the ego
 Common defense mechanisms
o Repression: repressing
conscious awareness of
impulses and conflicts
o Projection: attributing
objectionable qualities to
others
o Reaction formation: doing the
opposite of the id's impulse
 o Displacement: redirecting the
id's impulse towards a safer
target
o Sublimation: redirecting the
id's impulse in a way that
benefits others
 Illustration of defense mechanisms
using the example of physical
aggression and the ego's
management of the conflict caused
by the superego's rejection
Page 8:
Metaphorically
Speaking If You’ve
Been to a Movie
Theater, You
Understand
Projection
 Projection as a defense mechanism
works similarly to projection in a
movie theater
 The ego acts as the movie projector
and the id impulse as the movie
 The ego projects the id impulse onto
others, not seeing it in oneself
 Example of Randy who frequently
has the id impulse "I want to steal"
 Randy sees this impulse on others
but not on himself
 Projection becomes a prominent
feature of an individual's personality
when heavily relied upon
 Defense mechanisms can define a
person or the problems they bring to
therapy
 Randy's case illustrates paranoia and
viewing others as crooks and oneself
as a potential victim
 Psychodynamic psychotherapists aim
to make individuals aware of their
own unconscious processes and
tendency to project onto others
Page 9: Defense
Mechanisms and
Alternate Definitions
of Freudian Terms
 Defense mechanisms can include
projecting the impulse onto others,
forming a reaction against the
impulse, displacing the impulse onto
a safer target, or sublimating the
impulse
 Psychodynamic psychotherapists
believe some defense mechanisms
are more mature or healthy than
others
 Denial and repression are considered
immature, while sublimation is
viewed as mature
 The goal of psychodynamic
psychotherapy is to help clients
become aware of their defense
mechanisms and move towards more
mature ways of managing internal
conflicts
 Alternate definitions of Freudian
terms: id as "it", superego as "over-
me", and ego as "me"
 Defense mechanisms characterize the
whole person and the problems they
bring to therapy
Transference
  Transference is essential to the
psychodynamic approach
 It is the tendency for clients to form
relationships with therapists where
they unconsciously expect the
therapist to behave like important
people from their pasts
 Clients transfer feelings,
expectations, and assumptions from
early relationships onto the therapist
 Transference distorts the client's
view of the therapist and influences
their interactions
Page 10:
 Transference is a concept in
psychodynamic therapy
o It is not exclusive to therapy,
but present in all kinds of
relationships
 Transference is illustrated through
the example of Asaan and his piano
teachers
o Asaan developed strong
feelings of fear and
resentment towards his harsh
piano teacher, Ms. Terrell
o When Asaan starts lessons
with a new teacher, Ms.
Wallace, he transfers his
feelings from Ms. Terrell
onto her
o Asaan's perception of Ms.
Wallace is distorted by his
unconscious transference
Page 10-11:
 Psychodynamic theory suggests that
we all experience powerful early
relationships that shape our
expectations for future relationships
 When forming new relationships, we
may unconsciously transfer feelings
and expectations from past
relationships onto new people
 Psychodynamic therapists help
clients become aware of their
transference tendencies and how they
affect their relationships and lives
 Therapists seek to experience
transference firsthand in the client-
therapist relationship
 Therapists offer interpretations of the
transference to the client, calling
attention to their unconscious
tendencies
 Interpretations may take time for
clients to fully understand and accept
 The "blank screen" role of the
therapist is essential to the
transference process
o Therapists reveal very little
about themselves to their
clients
o This allows clients to
attribute their feelings solely
to transference from past
relationships
 In the Internet age, maintaining the
blank screen role is increasingly
difficult due to clients googling their
therapists and finding personal
information
Page 11:
 Clinical example of transference
with Marcus and Dr. Wallace
o Marcus dominates the
conversation and interrupts
Dr. Wallace, as if not
allowing her to speak
o Marcus repeatedly uses the
phrase "Before you tell me
I'm wrong," defending his
 statements as if responding to
an imagined challenge
o Dr. Wallace does not
challenge Marcus, but
remains attentive and
affirming
Note: This is a summary of the main ideas
and supporting details from the given
transcript.
Page 12: Claudia's
Transference
 Claudia, a 27-year-old client,
exhibited clear signs of transference
during therapy
 She expressed feelings of being a
burden and wasting the therapist's
time
 Claudia interrupted herself multiple
times and attempted to leave the
session
 The therapist reassured Claudia and
encouraged her to continue sharing
 Claudia's childhood experiences with
her father influenced her
expectations of being ignored or
dismissed
 The therapist helped Claudia become
aware of her unconscious
expectations and worked through
them in therapy
 Claudia's awareness of her
transference tendencies improved her
relationships and reduced anxiety
and depression
Page 13: Marcus's
Transference
 Marcus had a similar experience of
transference in therapy
 He perceived the therapist as
doubting and confronting him,
despite the therapist being a blank
screen
 Marcus explained that his parents
consistently challenged and doubted
him during his childhood
 Marcus transferred these
expectations onto his relationships
with the therapist, girlfriend, and
supervisor
 The therapist identified Marcus's
transference and pointed it out to him
 Through therapy, Marcus became
more aware of his unconscious
transference tendencies and replaced
them with a more realistic
perspective
 His relationships improved, and his
anxiety and depression decreased
Countertransference
 Therapists can also experience
transference towards their clients,
known as countertransference
 Countertransference involves the
therapist's unconscious distortion of
their reactions to the client based on
their own personal experiences
 Psychodynamic therapists strive to
minimize countertransference
 Training programs often require
therapists to undergo therapy
themselves to become aware of their
own unconscious issues and prevent
countertransference towards clients.
Page 14:
Considering Culture

Culture-Specific
Responses to the
“Blank Screen”
Therapist
 Psychodynamic psychotherapists
strive to remain "blank screens" to
their clients
o They don't self-disclose much
about their personal
background
o This facilitates transference,
which is essential to the
psychodynamic process
 Clients of different cultures may
respond differently to a "blank
screen" therapist
 Atkinson, Thompson, and Grant
(1993) identified eight distinct
therapist roles that clients may seek
o Adviser, Advocate,
Facilitator of indigenous
support systems, Facilitator
of indigenous healing
systems, Consultant, Change
agent, Counselor,
Psychotherapist
 People less acculturated to
mainstream U.S. culture tend to
favor the first four roles, while those
with higher levels of acculturation
tend to favor the last four
 Psychodynamic psychotherapists
may need to adapt the blank screen
role to accommodate diverse clients
Page 15:
Psychosexual Stages:
Clinical Implications
Freud's psychosexual stages of

development: oral, anal, phallic,
latency, and genital
 Fixation can occur when children
become emotionally "stuck" at a
certain stage
The first three stages receive the

most attention from psychodynamic
psychotherapists
 Oral stage:
o Focuses on dependency and
the child's need for others
o Overindulgence can lead to
overly trusting and naive
personalities
o Lack of responsiveness can
lead to mistrust and
pessimism
 Anal stage:
o Focuses on control and toilet
training
o Too much demand for control
can lead to obsessive and
compulsive behaviors
o Too little demand for control
can lead to disorganization
and laxity
 Phallic stage:
o Controversial stage related to
children's desire for a special
relationship with parents
o Parental response shapes the
child's self-worth
o Overly positive response can
lead to arrogance or egotism
o Rejection of the child's
wishes can lead to low self-
worth and insecurity
Page 17:
 Psychodynamic psychotherapy has
been reinvented in various forms
since its origins with Freud.
 o Revisions have deemphasized
the biological and sexual
elements of the theory.
o Ego psychology revised
Freud's psychosexual stages
to highlight social
relationships and adaptive
tendencies of the ego.
o The object relations school
emphasized relationships
between internalized
"objects" rather than internal
conflict.
o The self-psychology school
emphasized parental roles in
the child's development of
self.
o Karen Horney criticized
Freud's theories regarding
females and their
development.
 Psychodynamic psychotherapy has
always been among the longest and
most expensive forms of
psychotherapy.
 Recent variations of psychodynamic
psychotherapy have emphasized
efficiency.
 Brief psychodynamic psychotherapy
has become more common than the
classic version of Freudian
psychoanalysis.
 Brief psychodynamic psychotherapy
refers to therapy lasting fewer than
24 sessions.
 Brief psychodynamic psychotherapy
tends to be more successful for mild
and narrowly defined problems, with
an active therapist and a focus on the
present.
Page 19:
Page 18:
 Table 12.1 compares brief and long-
term psychodynamic psychotherapy.
o Brief therapy forms a
therapeutic alliance rapidly,
focuses on specific problems,
and has a relatively high level
of therapist activity.
o Long-term therapy forms a
therapeutic alliance
gradually, focuses on a broad
range of problems, and has a
relatively low level of
therapist activity.
 Interpersonal therapy (IPT) is a
contemporary variation of
psychodynamic psychotherapy.
o IPT was developed in the
1980s to treat depression but
has been used for other
disorders as well.
o It lasts about 14 to 20
sessions and focuses on
improving interpersonal
relationships to alleviate
depressive symptoms.
o IPT emphasizes current
interpersonal relationships
and role expectations.
o It tends to deemphasize
aspects of traditional
psychodynamic
psychotherapy related to
intrapsychic structure and
childhood fixations.
o IPT identifies specific
interpersonal problem areas
that contribute to clients'
problems, such as role
transitions, role disputes,
interpersonal deficits, and
grief.
 IPT (Interpersonal Psychotherapy)
proceeds in three stages
 o First stage involves
categorizing client's problems
into four categories: role
transitions, role disputes,
interpersonal deficits, and
grief
o Intermediate sessions focus
on improving client's
problems identified in the
first stage
 Common
psychodynamic
methods used,
including focus on
current emotions,
exploration of
transference and
resistance
 Educational
component where
therapist teaches
client about
depression and its
symptoms
o Final stage involves review
of client's accomplishments,
recognition of their capacity
to succeed over depression
without therapist's help, and
efforts to prevent relapse
 IPSRT (Interpersonal and Social
Rhythm Therapy) is a variation of
IPT designed for clients with bipolar
disorder
o Augments IPT with efforts to
control and stabilize daily
rhythms, sleep/wake cycles,
and social interactions
o Regularity in daily activities
and interpersonal
relationships can be
protective for individuals
prone to extreme mood
variations
o Encourages clients to make
and follow detailed daily
schedules and track their
behavior and mood
o Evidence supports IPSRT as
a beneficial treatment for
bipolar disorder
Page 20:
 TLDP (Time-Limited Dynamic
Psychotherapy) is a modern
application of the concept of
"corrective emotional experience"
 TLDP is experiential in nature and
typically briefer than classic
psychoanalysis
 Therapist's primary task is to identify
the client's unconscious "script" that
they unknowingly follow in
relationships
 TLDP therapists use a visual diagram
called the cyclical maladaptive
pattern to help clients become aware
of specific thoughts and behaviors
that contribute to their faulty script
 Difficulty in gauging the effects of
psychodynamic psychotherapy due
to challenges in defining and
measuring outcomes and concepts
such as the unconscious,
transference, insight, and defense
mechanisms
 Methodology of outcome studies for
psychodynamic therapy is widely
disparaged and few psychodynamic
therapies have been manualized or
subjected to empirical trials
Page 21:
Metaphorically
Speaking If You’ve
Watched the
Olympics, You
Understand
Allegiance Effects
 Judges' nationalities are displayed
alongside their scores in Olympic
events.
o This suggests that judges'
allegiance to their home
countries may limit their
objectivity.
 Allegiance effects may also be
present in psychotherapy outcome
research.
o Researchers conducting the
research may have
preferences for certain
therapies, which can
influence the results.
 Luborsky et al. (1999) found that
allegiance effects can account for
about two-thirds of the variance in
treatment comparisons.
 Recent studies have corroborated the
severity of allegiance effects in
psychotherapy outcome studies.
o A review of 30 separate
meta-analyses concluded that
the connection between
researcher allegiance and
study outcomes is substantial
and robust.
o Some argue that Luborsky et
al. may have underestimated
allegiance effects, while
others believe they
overestimated their
conclusions.
Page 22: In spite of
these methodological
challenges, there
have been many
attempts to measure
the outcome of
psychodynamic
psychotherapy.
 A large-scale review of
psychoanalytic and psychodynamic
outcome studies found that the
majority of clients improve
substantially.
 Meta-analyses of psychodynamic
treatment have concluded that it is
beneficial for a wide range of clinical
problems.
 Empirical data supports the use of
psychodynamic psychotherapy for
specific problems such as personality
disorders, depression, bulimia,
anorexia, panic disorder, and
complex clinical conditions.
 However, the number of well-
defined, single disorder studies is
small, suggesting caution in
interpreting the existing evidence.
 Psychodynamic psychotherapy lags
behind behavioral and cognitive
therapy in terms of empirical data
supporting its use.
 Some empirical evidence exists for
the benefits of transference
interpretations in psychodynamic
psychotherapy.
o Clients who received
transference interpretations
showed greater benefits and
insight.
o Insight gained through
transference was associated
 with better outcomes,
especially for borderline and
other personality disorders.
Page 23:
 Transference-focused psychotherapy
has been developed for clients with
specific issues
o References: Goodman, 2013;
Kernberg, 2016; Normandin,
Ensink, & Kernberg, 2015;
Yeomans, Clarkin, Kernberg,
& American Psychiatric
Association, 2015; Yeomans,
Levy, & Caligor, 2013
 Countertransference reactions by
therapists negatively correlate with
outcome for the client
o Meta-analyses conducted by
J. A. Hayes, Gelso, and
Hummel(2011)
 Therapist efforts to manage
countertransference positively
correlate with therapy outcome
 Allegiance effects influence the
outcome of empirical studies
o Researchers' biases and
preferences can affect the
results
o Researchers conducting
studies are often not
psychodynamic in their
orientation
o Psychodynamic therapies
may be slightly inferior in
some meta-analyses due to
allegiance effects
o Reference: Luborsky et al.
(1999)
Page 24:
 Initial conceptualization of Denise's
issues
o Emotional issues from the
phallic stage of development
o Lack of self-esteem and
seeking validation from
outside sources
o Feedback from diners in her
restaurant being cut off
contributing to her depression
 Denise using defense mechanisms,
particularly projection, to deal with
unacceptable impulses of anger
towards the new restaurant owner
 Denise's unconscious anger towards
the new owner manifesting in her
lateness and slow work
 Examples of resistance and
transference in Denise's relationship
with the therapist
 Interventions aimed at making
Denise more conscious of her
unconscious processes
o Offering interpretations of
her actions to bring
awareness
Page 25:
Psychodynamic
psychotherapy
 Founded on the theories of Sigmund
Freud
 Presumes the presence of a powerful
unconscious component of the mind
 Primary goal is insight or making
unconscious processes conscious
 Highly inferential approach to
psychotherapy
 Difficult to assess problems and
therapy's impact objectively or
empirically
Accessing the unconscious
 Free association
 Freudian slips
 Dreams
 Resistance displayed by clients
during therapy
Unconscious conflict and
defense mechanisms
 Conflict between the id and the
superego
 Ego mediates using defense
mechanisms
 Defense mechanisms include
repression, projection, reaction
formation, displacement, and
sublimation
 Reliance on defense mechanisms can
characterize an individual's
personality and clinical issues
Transference
 Clients often experience transference
toward their psychodynamic
therapists
 Unknowingly and unrealistically
expect the therapist to relate to them
as important people from their pasts
have related to them
 Psychodynamic therapists assume a
"blank screen" role to facilitate the
transference process
 Clients may have transferred
similarly onto other people with
whom they have formed
relationships
Clinical issues and
psychosexual stages of
development
 Significant attention to clinical issues
that may stem from fixation at an
early psychosexual stage of
development (e.g., oral, anal, or
phallic)
Long-term and shorter
versions of psychodynamic
psychotherapy
 Traditionally long-term, but shorter
versions have emerged (ITP and
TLDP)
 Evidence suggests efficacy,
especially with depressed clients
 Nature of psychodynamic
psychotherapy hinders the collection
of empirical outcome data
 Data collected suggest it is roughly
as effective as other forms of
psychotherapy

CHAPTER 13
Page 1:
 Carl Rogers disagreed with Freud's
assumptions about therapy and
people
o Rogers pioneered the
humanistic movement in
psychology and humanistic
therapy
o Humanistic approach stood in
opposition to the Freudian
view
 Inner nature of people is good or
neutral, not evil
o It is best to bring out and
encourage this inner nature
o Denying or suppressing it can
lead to sickness
Page 2:
 Rogers' approach to therapy remains
influential today
 Rogers and his followers created a
family of therapies known as
humanistic therapy
 Humanistic therapy aims to foster
self-actualization
 Psychological problems are seen as a
result of a stifled growth process
 The therapist's role is to create a
climate for clients to resume their
natural growth
Page 3:
 The need for positive regard can
override the natural tendency to self-
actualize
Conditional positive regard can lead

to a discrepancy between the real self
and the ideal self
 This discrepancy is called
incongruence and is viewed as the
root of psychopathology
 Congruence is achieved when self-
actualization is allowed to guide a
person's life without interference
from conditions of worth
 Congruence leads to mental health
optimization
 Conditions of worth can eventually
become incorporated into a person's
own views of themselves
Page 4:
 Humanists believe that people have
an inborn tendency to grow and
certain conditions foster their
growth.
o Unconditional positive regard
from others brings forth
unconditional positive self-
regard.
 Mark, a first-year college student,
decided to become a lawyer due to
strong encouragement from his
parents.
o His parents frequently
commented on Mark's
potential as a lawyer and
showed little interest in his
other activities.
 Mark took an art history course and
found himself fascinated by the
subject, but hid his interest from his
parents.
o He sensed that his parents
would reject him if they knew
he was passionate about art.
 Mark eventually became a lawyer
but felt unhappy that his artistic side
was never allowed to grow.

Page 5:
 The therapist in humanistic
psychotherapy fosters the client's
self-healing tendencies toward
growth.
 The therapist creates a therapeutic
relationship characterized by three
essential conditions.
o Empathy: The therapist
experiences empathy for the
client, understanding their
experiences without
judgment.
 Empathy can have a
positive impact on the
client, helping them
clarify their feelings
and feel valued and
supported.
o Unconditional Positive
Regard (UPR): The therapist
fully accepts the client "no
matter what."
 UPR is like
unobstructed sunlight
for plants, providing
the necessary
conditions for growth.
Page 6: Considering
Culture Empathy
Across Cultures
 Empathy is fundamental to
successful psychotherapy according
to the humanistic approach.
 Culture may place limits on the
extent to which a therapist can
empathize with clients who differ
from themselves in terms of
ethnicity, gender, age, or other
variables.
 Examples of cultural differences
impacting empathy:
o Stephanie, a woman seeking
therapy for depressive
symptoms after a
miscarriage. Would a female
therapist be more capable of
empathizing with her?
o Namrata and Amit, a married
couple arguing about the
language they will speak at
home after their baby is born.
Would an Indian, bilingual
therapist have a greater
capacity for empathy?
o Faye, a 75-year-old woman
struggling with loss and
health issues. Can a therapist
half her age genuinely
empathize with her?
 Little empirical research has been
conducted on this topic, and the
results have been inconsistent.
Page 7: Genuineness
Empathy and UPR
Unconditional Positive Regard

(UPR) allows clients to grow in a
self-directed way without fear of
losing respect or acceptance.
Therapists unconditionally prizing

clients can lead to clients prizing
themselves unconditionally,
facilitating higher levels of
congruence and self-actualization.
 An empirical study showed a strong
correlation between increases in
congruence and overall therapy
benefits.
 Humanistic therapists prioritize
accepting clients entirely and
 unconditionally to promote natural
growth.
 Genuineness is essential in therapist-
client relationships, where therapists
truly empathize and unconditionally
prize clients.
 Being genuine helps establish
therapeutic relationships that feel
"real" and encourages clients to open
up and engage more fully.
 Humanistic therapists encourage
transparency and self-disclosure,
guided by the goal of benefiting the
client.
Note: The transcript continues beyond page
7, but the given instructions only cover the
content up to page 7.
Page 8:
 Relationship characterized by
genuineness and transparency
o Therapist expresses real
feelings
 Warm acceptance and prizing of the
other person as an individual
 Sensitive ability to see the other
person's world and themselves
 Benefits for the other individual in
the relationship
o Experience and understand
repressed aspects of
themselves
o Better integration and ability
to function effectively
o Becoming more similar to the
person they want to be
o Increased self-direction and
self-confidence
o Becoming more unique and
self-expressive
o Increased understanding and
acceptance of others
o Improved ability to cope with
life's problems
Necessary and
Sufficient? (Page 8)
 Rogers claimed that empathy,
unconditional positive regard (UPR),
and genuineness are necessary and
sufficient for successful
psychotherapy
 Research initially supported this
claim, but more recent research
suggests they are necessary but not
always sufficient
 Empathy, UPR, and genuineness are
common factors in successful
psychotherapy
Page 9:
 The author has wrestled with
Rogers's claim that the three core
elements of humanistic therapy are
necessary and sufficient
 The author had a client, Anthony,
who needed more than empathy,
UPR, and genuineness
o Cognitive therapy and
behavioral activation were
used to help Anthony
challenge his negative
thoughts and engage in
positive behaviors
 Not every client needs additional
techniques, some are self-propelled
and only need the core elements
 The author had a client, Tiana, who
was motivated to change and had
insights into her issues
o The therapeutic relationship,
founded on the core elements,
 allowed her to work out her
own issues
Page 10: Therapist
Attitudes, Not
Behaviors
 Humanists view empathy, UPR, and
genuineness as attitudes, not
behaviors
 Humanists emphasize how therapists
should be with clients rather than
specific actions
 Therapists' attitudes are
communicated to and perceived by
the client, affecting success in
therapy
Reflection: An Important
Therapist Response
 Humanists believe that reflection is a
therapist behavior that contributes to
the success of therapy
 Reflection is a mechanism to
communicate empathy, UPR, and
genuineness
 Reflection involves rephrasing or
restating the client's statements to
highlight their feelings or emotions
 Humanistic therapists mirror their
clients' affect, even if it is not
explicitly stated
Reflection should not be a

mechanical technique, but an attitude
of questioning and checking
perceptions
Page 11:
 Rogers expressed regret about the
way "reflection of feeling" had been
used as a technique
 Reflection should be an attitude
rather than a technical skill
 Therapists should ask clients if their
understanding of their feelings is
correct, rather than telling them how
they feel
 Rogers suggested using terms like
"Testing Understandings" or
"Checking Perceptions" instead of
"Reflections of Feeling"
Metaphorically Speaking If
You've Looked in a
Magnifying Mirror, You
Understand Reflection
 Reflection in therapy is similar to
looking in a mirror for feedback on
appearance
 Humanistic therapists provide clients
with feedback about their emotions
through reflection
 Reflection helps clients better
appreciate their emotional selves
 Magnifying mirrors amplify features
and show parts of ourselves we may
not have been fully aware of
 Emotional mirroring by humanistic
therapists can highlight emotions that
clients may not have been fully
aware of
Page 12:
Alternatives to Humanism
 Existential therapy and Gestalt
therapy have been influenced by
humanism
 Existential therapy focuses on the

premise that each person is
essentially alone in the world,
leading to anxiety and
meaninglessness
 Existential therapists emphasize
clients' abilities to create their own
meaning through their decisions
 Gestalt therapy focuses on the here
and now, emphasizing awareness and
integration of thoughts, feelings, and
actions
 Both approaches continue to
influence many therapists today
Page 13: Existential
Therapy and Gestalt
Therapy
 Existential therapy focuses on
individuals taking control of their
lives and finding meaning
o Not easily studied empirically
o Meta-analysis found it works
well for some clients,
especially those who are
physically ill or concerned
with the meaning of life
 Gestalt therapy emphasizes a holistic
approach to enhancing the client's
experience
o Focuses on both mental and
physical perceptions
o Encourages clients to reach
their full potential through
role-play techniques
o Emphasizes the present
moment and integration and
awareness of all parts of the
self
Page 13-14:
Motivational
Interviewing
 Motivational interviewing (MI) is a
briefer approach to therapy
 Developed by William Miller
 Originally used to treat addictive
behaviors, but now used for a wide
range of client problems
 MI addresses clients' ambivalence or
uncertainty about making major
changes to their way of life
 MI therapists help clients see the
discrepancy between their behavior
and their own values
MI elicits motivation from within the

clients, rather than imposing it from
without
 MI can be used as a full-fledged
treatment or as an augmentation to
other therapies
 MI principles include expressing
empathy, developing discrepancy,
avoiding argumentation, rolling with
resistance, identifying "sustain talk"
and "change talk," and supporting
self-efficacy
 Research shows that MI produces
beneficial outcomes for a wide range
of problems, including psychological
and physical symptoms
Page 15:
Main Ideas:
 Motivational Interviewing (MI) is an
effective approach in addressing
various behavioral and psychological
issues.
 MI can be integrated into other forms

of treatment. Page 16:
 Positive psychology movement
overlaps with humanistic principles. Main Ideas:
 Positive interventions and strength-
based counseling focus on enhancing
 Therapists should consider both
well-being and strengths of
strengths and weaknesses of clients.
individuals.
 The "four-front approach"
encourages therapists to consider
Supporting Details: four areas of a client's life.
 Positive psychology techniques can
 MI can help with smoking, exercise, be categorized into seven basic
weight-loss efforts, anxiety categories.
disorders, depression, violence  Positive interventions and strength-
toward intimate partners, HIV risk, based counseling can be blended into
cholesterol levels, diabetes other forms of therapy.
management, and blood pressure.  Positive interventions and strength-
o MI sparks change in based counseling have empirical data
behaviors that worsen or supporting their benefits.
enhance these issues.
 MI is a bright spot for humanistic Supporting Details:
therapies in evidence-based
treatments.
 The "four-front approach" considers
 Positive psychology emphasizes
weaknesses, strengths, destructive
human strengths and happiness in
factors, and resources in a client's
addition to symptom reduction.
life.
 Positive psychology acknowledges
 Positive psychology techniques
the potential of individuals to
include savoring, gratitude, kindness,
develop positive attributes and
empathy, optimism, strength-based
prevent psychological problems.
activities, and meaning.
 Positive interventions and strength-
 Positive interventions and strength-
based counseling focus on enhancing
based counseling can be integrated
positive emotions, engagement,
into other forms of therapy.
relationships, meaning, and
 Positive interventions and strength-
achievement.
based counseling have empirical data
 Happiness is a protective factor
supporting their benefits in
against mental disorders.
increasing happiness levels.
 Therapies derived from positive
psychology nurture what is strong in


clients.
Therapies in positive psychology go
Page 17:
by various names, such as positive
 Positive psychology interventions
interventions or strength-based
have been found to be effective in
counseling.
reducing depressive symptoms and
 promoting posttraumatic growth and
resilience.
o Examples include
interventions with individuals
who have experienced
traumatic events such as
active military combat.
o Positive psychology
interventions may be more
acceptable to clients and
result in greater adherence
and lower dropout rates
compared to other types of
therapy.
 Emotionally Focused Therapy (EFT)
is a short-term humanistic therapy
that emphasizes the expression and
healing power of emotions.
o EFT is frequently practiced
with couples and aims to
enhance closeness and
replace patterns of blaming
and withdrawing with
empathy and self-disclosure.
o EFT has been found to be
beneficial to couples and
individuals with depression,
PTSD, and other clinical
issues.
 Arthur Bohart and Karen Tallman
have developed a modern adaptation
of humanism that emphasizes the
client's active role in generating their
own solutions to personal problems.
o Therapy is seen as creating a
better problem-solving
climate rather than trying to
fix the person.
Page 18:
 Bohart and Tallman argue against
symptom-focused, technique-
dominated approaches to therapy and
believe in mobilizing clients to help
themselves.
 Carl Rogers was a pioneer of
psychotherapy outcome research and
attempted to present his ideas as
testable hypotheses.
 Recent meta-analyses of humanistic
therapy outcome studies indicate that
humanistic therapies are generally as
effective as other major approaches
to psychotherapy.
 Humanistic therapies have been
found to be effective for depression,
relationship problems, coping with
long-term illness, substance abuse,
eating disorders, and psychotic
disorders.
 Empirical studies have shown that
empathy, positive regard, and
genuineness play important roles in
the success of therapy, regardless of
the therapeutic approach.
Note: This note provides an overview of
positive psychology interventions,
Emotionally Focused Therapy (EFT), a
modern adaptation of humanism, and the
effectiveness of humanistic therapies. It
highlights the benefits of positive
psychology interventions and EFT, as well
as the importance of empathy, positive
regard, and genuineness in therapy. The note
also mentions the research efforts of Carl
Rogers and the overall effectiveness of
humanistic therapies compared to other
approaches.
Page 19:
 Empathy, positive regard, and
genuineness are essential
components of therapy
o Supported by empirical
research (R. Elliott, Bohart,
Watson, & Greenberg, 2011;
 Farber & Doolin, 2011;
Kolden, Klein, Wang, &
Austin, 2011; Zuroff et al.,
2010)
 Motivational interviewing (MI) is an
evidence-based psychotherapy
o MI is effective for a wide
range of psychological and
physical problems
o Supported by research
(Arkowitz & Westra, 2009;
Hettema et al., 2005; Jensen
et al., 2011; Lundahl &
Burke, 2009; W. R. Miller &
Rose, 2009; Musser &
Murphy, 2009; Rubak et al.,
2005)
Denise in
Humanistic
Psychotherapy
 Denise's dissatisfaction with her job
and personal family history are
discussed
 Denise felt valued by her family for
her cooking abilities
 Her job as a chef provided similar
opportunities for appreciation, but
new policies limited her interaction
with customers
 Denise's self-worth became tied to
cooking and meeting others'
expectations
 Therapist communicates empathy
and acceptance of Denise's
experiences
 Therapist recognizes Denise's
potential beyond cooking and
encourages exploration of other
interests
 Denise expresses anger towards her
family and boss, which is accepted
and validated by the therapist
 Over time, Denise accepts herself
more fully and explores professional
opportunities outside of cooking
 Denise no longer depends on positive
feedback from others and is able to
give herself unconditional positive
regard
Page 21:
 Humanistic approach to
psychotherapy is based on the belief
that people strive to grow in a
positive, healthy way
 Incongruence between real and ideal
selves leads to psychological
problems
 Humanistic therapists foster self-
actualization by providing empathy,
unconditional positive regard, and
genuineness
 Reflection of feeling is a key
component of humanistic therapy
 Humanistic principles influence
other contemporary approaches such
as motivational interviewing,
positive interventions/strength-based
counseling, and emotionally focused
therapy
 Motivational interviewing has
extensive empirical research
supporting its benefits
 Limited empirical research on the
benefits of humanistic therapy in
general, but it is typically as
beneficial as other approaches.
CHAPTER 14
 Clinical psychologists use numerous
forms of behavior therapy

Page 2:
Page 3:
Origins of Behavior
Therapy Techniques Based on
Operant Conditioning
 Behavior therapy is the clinical
application of behavioral principles  Contingency management
 Theoretical and experimental roots  Token economies
extending back hundreds of years  Shaping
 Ivan Pavlov's work on classical  Behavioral activation
conditioning in the late 1800s and


early 1900s
Pavlov's dogs learned to associate
Techniques Based on
food with specific stimuli through Classical Conditioning
repeated pairing
 John Watson brought Pavlov's work  Exposure therapy
to the United States and argued for  Systematic desensitization
the study of observable behavior  Assertiveness training

Goal of Behavior Therapy Alternatives to Behavior

 Primary goal is observable behavior
Therapy
change
 Behavioral consultation
 Contrasts with the emphasis on
 Parent training
internal, mental processes in
 Teacher training
psychodynamic and humanistic
approaches
 Behavior therapy emerged as a
reaction against perceived
Page 4:
weaknesses of psychodynamic
approach How Well Does It Work?
Emphasis on Empiricism  Effectiveness of behavior therapy
 Research on the outcomes of
behavior therapy
 Behavior therapists believe that the
study of human behavior should be
scientific Origins of Behavior
 Behavior therapy is grounded in Therapy
empiricism
  Ivan Pavlov's work on classical
conditioning
 John Watson's introduction of
Pavlov's work to the United States
 Edward Lee Thorndike and B.F.
Skinner's contributions to operant
conditioning
Goal of Behavior Therapy
 Primary goal is observable behavior
change
 Contrasts with the emphasis on
internal, mental processes in
psychodynamic and humanistic
approaches
Emphasis on Empiricism
 Behavior therapists believe that the
study of human behavior should be
scientific
 Behavior therapy is grounded in
empiricism
 Clinical psychologists use numerous
forms of behavior therapy
Page 5: Scientific
Evaluation in
Behavior Therapy
 Behavior therapy should employ
methods that can be scientifically
evaluated
 Theories of treatment should be
stated as testable hypotheses
 Data collection is an essential part of
behavior therapy
 Behavior therapy follows the five
steps of the scientific method
Table 14.1: Application of
the Steps of the Scientific
Method by Behavioral
Therapists
1. Observing a phenomenon
o Assessing client behavior
through observation,
interview, or testing
o Defining a target behavior
o Establishing a baseline level
of target behavior
2. Developing hypotheses to explain
the phenomenon
o Functionally analyzing target
behavior to determine
influencing factors
o Establishing specific
behavioral goals for treatment
o Planning interventions to
alter behavior
3. Testing the hypotheses through
experimentation
o Implementing planned
interventions
4. Observing the outcome of the tests
o Collecting data on changes in
the target behavior
o Comparing data collected
during or after treatment to
baseline data
o Comparing data to goals
5. Revising the hypotheses
o Modifying treatment plan
based on observed outcomes
o Restarting the scientific
process with revised
hypotheses
Page 6: Defining
Problems
Behaviorally
 Behavioral therapists view client
behaviors as the problem itself, not
symptoms of an underlying problem
 Defining problems behaviorally
allows for easy identification of
target behaviors and measurement of
changes in therapy
 Clients may have different
definitions of their own problems,
focusing on feelings and thoughts
 Behavioral therapists redefine
problems by focusing on observable
and measurable behaviors
 Problem behaviors are ideal targets
for behavioral interventions
 Behavioral therapists do not adopt a
medical-model view of
psychological problems
Page 7: Measuring
Change Observably
 Behavioral therapists measure
therapy outcome through observable
changes
 Other therapists may measure change
in more inferential ways
 Behavioral therapists reject
introspection and focus on outward
demonstrations of change in clients
 External, environmental factors are
emphasized over internal personality
traits
 Behavioral therapists look for the
causes of problems in the world
around the client, not within the
client themselves
Page 8:
Two Types of Conditioning
 Behavioral therapists believe that
behavior is the result of conditioning
 Conditioning explains the acquisition
and modification of disordered
behavior
 Conditioning can be separated into
two types: classical and operant
Classical Conditioning
 Pavlov's dog studies exemplify
classical conditioning
 Dogs learned that certain stimuli
predicted the arrival of food, causing
them to salivate
 Four components of classical
conditioning: unconditioned
stimulus, unconditioned response,
conditioned stimulus, conditioned
response
Classical conditioning is a passive

type of learning
Variables such as generalization and

discrimination can influence
behavior in classical conditioning
Operant Conditioning
 Operant conditioning occurs when
the organism operates on the
environment and incorporates the
consequences of behavior into future
decisions
 Behavior is a function of its
consequences
 Operant conditioning is a more
active style of learning than classical
conditioning
 Consequences shape all behavior,
including abnormal behavior
  Clinical psychologists can induce
behavioral changes by changing
contingencies or revising "if...then..."
statements
Page 9:
Techniques Based on
Classical Conditioning
 Exposure therapy is the clinical
psychologist's version of "facing
your fears"
 Phobias are the result of classical
conditioning
 Exposure therapy weakens and
eliminates the pairing of a feared
object with an aversive outcome
 Repeated exposure to the feared
object without the expected aversive
outcome reduces the fear response
Page 10:
 Exposure therapy is an effective
treatment for fear and anxiety
disorders.
o Wayne, who has a fear of
dogs due to a vicious attack,
is used as a clinical example.
o Exposure therapy aims to
expose Wayne to dog-related
stimuli to "unlearn" the
association between dogs and
fear.
 The therapist has choices to make
when conducting exposure therapy.
o One important choice is
between imaginal and in vivo
exposure.
 Imaginal exposure
involves visualizing
dogs and dog-related
items.
 In vivo exposure
means directly seeing,
hearing, and touching
dogs.
 Written exposure can
also be used, where
clients write about
anxiety-provoking
things.
o In vivo exposures can also be
interoceptive, focusing on
sensations within the client's
own body.
 Another important choice is the
extent of exposure to fear-inducing
stimuli.
o Gradual exposure, known as
graded exposure, involves
creating an anxiety hierarchy
and gradually exposing the
client to stimuli from the
lowest level to the highest
level.
o Exposure all at once, known
as flooding or implosion, can
produce rapid change but
may be intolerable or
traumatizing for clients.
Page 11:
 An example of an anxiety hierarchy
for graded in vivo exposure for fear
of dogs is provided.
 Exposure therapies are commonly
used for phobias, anxiety disorders,
and PTSD.
 Exposure and response prevention is
a specific application of exposure
therapy used for obsessive-
compulsive disorder.
o It involves graded exposure
to obsessive thoughts or
 situations that elicit such
thoughts while
simultaneously preventing
the client's typical response.
 Systematic desensitization is similar
to exposure therapy but involves
pairing the feared object with a new
response that is incompatible with
anxiety.
o The goal is to replace and
block the fear response with a
new response.
Page 12: Systematic
Desensitization
 The new response that replaces and
blocks the fear response is
relaxation.
 The first step of systematic
desensitization is relaxation training.
o Behavior therapist teaches the
client progressive relaxation
techniques.
o Various muscles are
systematically tensed and
relaxed.
 Scripted instructions are used during
relaxation training.
 Clients move through an anxiety
hierarchy and achieve a relaxed state
before each exposure.
 Fear is gradually overcome by
pairing the feared object with
relaxation.
Page 12:
Assertiveness
Training
 Assertiveness training targets clients'
social anxieties.
 It helps clients insist on appropriate
service, ask someone out on a date,
request a raise, etc.
 It includes elements of exposure
therapy and systematic
desensitization.
 Exposure comes in the form of
facing interpersonal fears.
 Assertiveness replaces relaxation as
the new response that inhibits
anxiety.
 Training begins with direct
instructions and modeling of
assertive behaviors.
 Clients rehearse assertive behavior in
role-play situations and receive
feedback.
 Homework assignments are given to
practice assertiveness skills in real-
world situations.
Page 13:
Considering Culture
 Assertiveness training assumes that
assertiveness is a good thing.
 Not all cultures hold the value of
assertiveness equally.
 Individualistic cultures value
autonomy and becoming one's own
person.
 Collectivistic cultures prioritize
group orientation and identity.
 Therapists should be aware of
cultural differences to avoid
overpathologizing.
 Native American culture values
collectivism.
 Case studies highlight the need for
sensitivity in assertiveness training.
  Cultural appropriateness and
adjustments should be considered in
treatment.
Page 13: Clinical
Example
 Deborah, a 26-year-old woman, is
frustrated with others making
decisions for her wedding.
 She has difficulty asserting herself
and telling her mother and sister to
"butt out."
 Example of a situation at the
wedding dress shop where she was
pressured to buy a different dress.
 Dr. Paxton, her behaviorally oriented
clinical psychologist, is working with
her.
Page 14: Deborah's
assertiveness
training
 Deborah felt unable to take charge of
the situation at the wedding dress
shop
 Her fiancé told her she needed to
stand up to her mother and sister
 Dr. Paxton conducted assertiveness
training with Deborah
o Taught her specific assertive
phrases to say
o Coached her on specific
behaviors involved in
assertive responses
o Modeled the responses for
her
o Deborah rehearsed the
assertive responses with Dr.
Paxton
o Homework assignments were
given to help Deborah
practice asserting herself
Page 15: Techniques
based on operant
conditioning
 Contingency management is the
process of changing the
contingencies controlling behavior
 Behavior occurs because of its
consequences
 Reinforcement and punishment are
the consequences of behavior
 Reinforcement makes a behavior
more likely to recur, punishment
makes it less likely
 Individual differences exist in what
is reinforcing or punishing
 Client input is sought on prospective
contingencies
 Example of reinforcement and
punishment in practice
o Jodi tried to use a puppy as
reinforcement for her
daughter Jade's homework
completion, but Jade did not
want a puppy
o Zachary and Julia used
sending their son Dominic to
his room as punishment, but
he enjoyed the activities in
his room
Page 16:
 Reinforcement and punishment can
be divided into positive and negative
types.
o Positive reinforcement means
"getting something good" and
 increases the likelihood of
behavior recurring.
o Negative reinforcement
means "losing something
bad" and also increases the
likelihood of behavior
recurring.
o Positive punishment means
"getting something bad" and
decreases the likelihood of
behavior recurring.
o Negative punishment means
"losing something good" and
also decreases the likelihood
of behavior recurring.
 Behavior therapists use both
reinforcement and punishment, but
reinforcement is generally preferred.
 Punishment must be used ethically
and is most effective when used
immediately and consistently.
 Aversion therapy is an example of
the clinical use of punishment.
 Dr. Howard, a clinical psychologist,
used the four varieties of
reinforcement with Patty, a juvenile
detention center inmate.
o Positive reinforcement: Patty
received a new magazine if
she attended classes without
outbursts.
o Negative reinforcement:
Patty's ankle restraints would
be removed if she attended
classes without outbursts.
o Positive punishment: Patty
would receive a 2-hour
detention without magazines
if she had an outburst.
o Negative punishment: Patty's
magazines would be
confiscated if she had an
outburst.
Page 17:
 Extinction refers to the removal of
expected reinforcement, resulting in
a decrease in behavior frequency.
 The extinction burst is the temporary
intensification of behavior when
expected reinforcement is not
received.
 The example of a malfunctioning
soda machine is used to explain
extinction and the extinction burst.
 In the short run, behavior intensifies
when expected reinforcement is not
received.
 The time it takes for behavior to be
extinguished depends on the
consistency of the denial of expected
reinforcement.
 Inconsistent denial of expected
reinforcement may take longer for
behavior to become extinct.
 The example of a slot machine is
given as an example of an
inconsistent and unpredictable
machine.
 The consistency of a contingency
management technique can influence
its success in changing behavior.
Example of Wendy:
 Wendy, an 8-year-old second grader,
became difficult at meal times.
 She cried and screamed about the
food, claiming she didn't like it and it
made her stomach hurt.
 Her parents were confused because it
was the same food she had eaten
before and her pediatrician found no
stomach ailments.
 Dr. Evans, a clinical psychologist,
asked Wendy's parents about what
happened after meal times.
Page 18
  Wendy cried and screamed at meal
times
o Parents allowed her to eat
something else
o Wendy usually selected her
favorite junk food
 Dr. Evans developed a contingency
management plan based on
extinction
o Wendy's behavior was being
positively reinforced by the
junk food
o Recommended removing
positive reinforcements and
not letting her replace family
meal with junk food
 Wendy's behavior initially got worse,
but within a few days, she stopped
crying and screaming and resumed
eating with her family
 Wendy's case exemplifies the
extinction burst
o Crying and screaming
behavior increased after the
reinforcement was removed
o Only after her parents
continued to withhold the
reinforcement did her
behavior dwindle
Page 19
 Token economies
o Clients earn tokens for
participating in
predetermined target
behaviors
o Tokens can be exchanged for
reinforcements
o Can be used in inpatient
units, correctional facilities,
and other supervised settings
 Token economies are versatile across
clients
o Different target behaviors for
each client
o Success depends on the
perceived value of the
reinforcements
 Potential limitation of token
economies is generalization
o Goal is to modify behavior
across all settings
o Strategies to maximize
generalization include
tapering off tokens gradually,
using naturally occurring
reinforcements, increasing
delay between behavior and
reinforcement, and providing
reinforcement in a variety of
settings
Shaping
 Used when target behavior is
complex, challenging, or novel
 Involves reinforcing successive
approximations of the target
behavior
 Example of Dina, a client with
depressive symptoms
o Goal is to increase social
interactions
o Shaping strategy used to
gradually increase social
activities
o Jointly determine personally
meaningful reinforcement
(renting a DVD)
o Raise the bar each week until
Dina is completing the full
set of target behaviors for
several consecutive weeks

Page 20: Shaping
and Behavioral
Activation
 Shaping program involves increment
between each successive
approximation
o Steps should not be too
difficult or too small
o Adjustments should be made
based on client's experience
 Behavioral activation is a form of
behavior therapy
o Designed to treat depression
o Increases frequency of
positively reinforcing
behaviors
o Reduces avoidance of

unpleasant experiences
Important to understand the function
of a behavior from the client's point
of view
o Positive reinforcement or
avoidance of something
unpleasant
 Operant conditioning forms the basis
of behavioral activation
o Classical conditioning may
also play a role
Page 21: Behavioral
Activation and
Observational
Learning
 Behavioral activation can be
successful in treating other problems
o Anxiety disorders, psychotic
disorders, personality
disorders, schizophrenia,
chronic pain
Increasing frequency of pleasant,

rewarding activities may be a central
part of therapeutic change
 Observational learning is a technique
where the client observes a
demonstration of desired behavior
o Given chances to imitate it
and receive feedback
 Models are most effective when they
are similar to the client
 Observational learning allows for
imitation and vicarious learning
o Client can learn to expect
reinforcement or punishment
by observing the model's
consequences
Page 22:
Alternatives to
Behavior Therapy
 Behavioral consultation is an indirect
way for a behavior therapist to
modify a client's behavior
o Involves three parties: the
client, the consultee, and the
consultant (therapist)
o Consultee is someone who
spends significant time with
the client and has control
over their behavior
o Examples include parents,
teachers, caretakers, or
corporate managers
 Behavioral consultation involves five
stages:
o Initiation of the consulting
relationship
o Problem identification
o Problem analysis
o Plan implementation
 Plan evaluation

o
Example of behavioral consultation:
Kathleen seeks help with
productivity problems related to an
administrative assistant, Pam
Page 23: Parent
Training
 Parent training is a specific form of
behavioral consultation where
parents seek help with their
children's problematic behaviors
 Range of problem behaviors includes
sleep-related problems, bedwetting,
hyperactivity, oppositional and
defiant behaviors, etc.
 Parent training involves
reinforcement and punishment
techniques
 Goal is for the child's behavior to
improve in various settings
 Example of parent training: Heather
seeks help with her 7-year-old son's
problematic bedtime behavior
Page 24: Teacher
Training
 Teacher training is similar to parent
training, but focuses on behaviors
that occur at school
Problem behaviors can be

interpersonal, disruptive, or
academic in nature
 Behavioral consultants help teachers
analyze the consequences of a child's
behavior
 Example of teacher training: Ms.
Palmer seeks help with a disruptive
student, Brian
Page 25: Denise in
Behavior Therapy
 Denise experiencing depression-
related difficulties due to new
policies at work
o Denise provided background
information about her
childhood, which the
therapist found irrelevant
o Therapist focused on
observable behaviors rather
than thoughts and feelings
 Three specific behaviors identified
for intervention: getting to work on
time, preparing dishes accurately,
and exercising
 Baseline established for each
behavior to compare with after
treatment
 Specific goals set for each target
behavior
 Behavioral activation and
contingency management approach
used
 Initial contingencies set for each
behavior, gradually increased as
Denise met goals
Behavioral activation plan

implemented, scheduling positive
reinforcing activities
 Denise met final behavioral goals in
all three areas within 8 weeks
Page 26: How well
does it work?
 Behavior therapies are highly
supported by empirical evidence
 Behavior therapies have been found
efficacious for a wide range of
disorders, including anxiety
 disorders, depression, and children's
behavior disorders
 Behavior therapy has produced
efficacy data for specific
interventions for specific problems
 Lists of empirically supported
treatments often include behavior
therapies
 Behavior therapies lend themselves
to manualization and quantitative
outcome measurement
 Behavior therapists emphasize an
empirical, scientific approach to
therapy

Page 27: Chapter

Summary
 Behavior therapy focuses on
observable, measurable behavior
 Problematic behavior is viewed as
the clinical problem, not a symptom
of an underlying disorder
 Primary goal is overt behavioral
change
 Methods rely on empirical, testable
hypotheses
 Conditioning is seen as the primary
cause of behavior
 Clinical efforts focus on altering
learned contingencies or breaking
learned associations
 Behavior therapy principles can be
used in a consulting capacity
 Behavior therapy has demonstrated
empirical efficacy for anxiety
disorders, depression, children

CHAPTER 15
Page 2:
 Cognitive therapy is the prevailing
approach in clinical psychology
o Surveys show a significant
increase in the popularity of
cognitive therapy since the
1980s
o More clinical psychologists
endorse cognitive therapy as
their primary orientation
compared to other approaches
 Cognitive therapy strikes a balance
between behavioral therapy and
psychodynamic therapy
o It is brief, structured, and
targeted like behavioral
therapy
o It focuses on important
mental processes like
psychodynamic therapy
 Cognitive therapy developed as a
reaction against behavioral and
psychodynamic approaches
o Behavioral therapy
techniques based on
conditioning were not always
effective
o Therapists recognized the
unique and important role of
cognition in human behavior
Page 3:
 Cognitive therapy began as a
revision of behavioral therapy
 Aaron Beck and Albert Ellis broke
from psychoanalytic tradition and
developed their own styles of therapy
Cognitive therapy overlaps with

behavioral therapy, but it has
evolved into its own approach
 The goal of cognitive therapy is
logical thinking
 Cognitions, such as thoughts, beliefs,
interpretations, and assumptions,
play a crucial role in cognitive
therapy
 Psychological problems arise from
illogical cognitions, while
psychological wellness stems from
logical cognitions
Page 4:
 The role of the cognitive therapist is
to fix faulty thinking
 Cognitive therapists emphasize the
importance of cognitions in our day-
to-day lives
 Cognitive therapists endorse a three-
step model: things happen, we
interpret those things, and those
interpretations directly influence our
feelings
 Events themselves do not determine
our feelings, but rather the way we
think about those events
Page 5:
 An example of the power of
cognitions is how we interpret an
unexpected overnight snowfall
 Three-step model: events happen, we
interpret those events, and our
interpretations influence our mood
Page 6:
  Different people have different
reactions to the same event based on
their thoughts about it
 The mail carrier feels dread about the
snow because she thinks it will make
her day miserable
o She thinks about being cold,
wet, slipping and falling, and
her route taking longer
 The neighbor who owns a snowplow
business feels elated about the snow
because he thinks it will make him
money and allow him to help people
 The high school student feels relief
about the snow because he thinks it
means school will be cancelled and
he'll have extra time to study
Page 6-7:
The meaning we assign to events

shapes our feelings
Cognitive therapy focuses on

revising cognitions to ensure they
correspond to the event
 Illogical thoughts can lead to
unnecessary and unpleasant feelings
 The goal is to revise thoughts to
make realistic sense
 Different methods of revising
cognitions exist
 The three-stage sequence:
identification of illogical thoughts,
challenging them, and replacing
them with logical thoughts
 Cognitive therapists help clients
identify automatic illogical thoughts
 Challenging illogical thoughts can
involve verbal persuasion or testing
the accuracy of beliefs through real-
world behaviors
 Revising thoughts can be difficult at
first, but the goal is for clients to be
able to do it on their own
 Cultural sensitivity is important in
the process of revising cognitions
Page 7:
 Cognitive therapists also function as
teachers, educating clients about the
cognitive approach
 They explain the difference between
the two-step and three-step models of
understanding the sources of feelings
 They train clients to recognize
illogical thoughts and track them in a
written format
 The goal is for clients to become
independent learners
 Homework assignments are given,
similar to teachers assigning
homework
Page 8: Cognitive
Therapy Between
Sessions
 Cognitive therapists believe that
therapy work happens between
sessions
 Homework can be written or
behavioral
o Written homework involves
keeping a record of events,
cognitions, feelings, and
attempts to revise cognitions
o Behavioral homework
involves performing certain
behaviors to examine
illogical thoughts
 Discussion of homework is a
significant part of subsequent
sessions
Considering Culture
Cognitive Therapy
With LGBTQ
Clients
 Negative attitudes towards LGBTQ
individuals still persist in society
 LGBTQ individuals may hold beliefs
that disapprove of their own sexual
orientation or lifestyle
 These beliefs can hinder self-respect,
self-worth, and contribute to
depression or other problems
 Cultural competence and self-
awareness are essential for clinical
psychologists
 Clinical psychologists should
understand clients' beliefs and avoid
equating their own views as the
"logical" way to think
Page 9: A Brief,
Structured, Focused
Approach
 Cognitive therapy aims for a positive
outcome in fewer than 15 sessions
 Sessions typically take place once
per week and taper off as the client
improves
 Factors contributing to the efficiency
of cognitive therapy include focusing
on current problems, goal-oriented
approach, and structured therapy
sessions
 Cognitive therapy sessions have a
predetermined agenda and are
sequentially organized into segments
Two Approaches to
Cognitive Therapy
 Albert Ellis and Aaron Beck are
pioneers of cognitive therapy
 Each developed their own version of
cognitive therapy independently
 Both approaches focus on improving
clients' symptoms by correcting
illogical thinking
 Terminology and techniques
distinguish Ellis's and Beck's
approaches
Albert Ellis
 Ellis's approach is called rational
emotive behavior therapy (REBT)
 Emphasizes the connection between
rationality and emotion
 Believes that emotional disturbances
are a result of irrational thinking
ABCDE model is used to understand

and record the impact of cognitions
on emotions
Note: The note includes the main ideas from
the transcript, with supporting details
provided in sub-bullets. The note is
organized into sections based on the page
numbers and important information. The
note is within the token limit.
Page 11: Ellis's
ABCDE Model
 Activating event (A), Belief (B), and
emotional Consequence (C)
o Irrational beliefs function as
rigid, dogmatic demands we
apply to ourselves
 Examples of irrational
o
beliefs: "I must get an A in
every class," "I need to be
dating someone," "I can't let
my family down"
o These beliefs are not absolute
rules, but strong preferences
o Coupled with overestimations
of the consequences of failure
 Ellis's model adds two more steps:
Dispute (D) and Effective new belief
(E)
o Dispute targets the irrational
belief (B)
o Disputing irrational beliefs
can lead to therapeutic
benefit
o Disputing can take the form
of pointed questions or
statements attacking the
irrational nature of beliefs
o Effective dispute affords the
opportunity to replace the
irrational belief with a more
rational one
 Example of Keyon seeking therapy
for excessive anxiety about the CPA
exam
o Identified activating event
(A) as studying for or
thinking about the exam
o Emotional consequence (C)
was anxiety
o Identified two irrational
beliefs (B): "I absolutely have
to pass the CPA exam on my
first attempt" and "If I don't
pass, my career is doomed
and that would destroy me"
o Dispute (D) involved
questioning the logic of
Keyon's beliefs
o Effective new beliefs (E)
were developed, reducing
Keyon's anxiety
Page 12: Applying
the ABCDE Model
 Keyon was persuaded by Dr. Liu's
arguments and began to disbelieve
his irrational thoughts
 Replaced original irrational beliefs
with effective new beliefs
 The ABCDE model can be used in
written format, often in the form of a
five-column thought journal
 Clients can sort their experiences
into the five-column structure to
identify irrational beliefs, construct
disputes, and generate effective new
beliefs
 The goal is for clients to eventually
internalize the ABCDE process
without relying on external aids
 Table 15.2 summarizes the full
ABCDE acronym and provides an
example of its application in Keyon's
therapy with Dr. Liu
Page 13:
Considering Culture
Are Some Beliefs
Too Sacred to
Dispute?
 Cody, a 22-year-old college student,
grew up in a family with strict
religious beliefs
o Premarital sex is sinful, and
anyone who engages in it is
an immoral person who will
spend the afterlife in hell
 Cody had sex with his girlfriend for
the first time and is anxious about it
  Cody seeks help from clinical
psychologist Dr. Talia Brown
 Dr. Brown holds different religious
beliefs than Cody and does not share
his beliefs about premarital sex
 Dr. Brown sees Cody's beliefs as
irrational and distorted
 Dr. Brown plans to help Cody reduce
his anxiety by replacing his belief
that "Premarital sex is sinful" with
"Premarital sex is OK in some
circumstances"
 The question arises: who decides
what beliefs are irrational?
 Some psychologists argue that
cultural confrontation is preferable in
certain cases
 Cultural confrontation can be
essential in multicultural counseling
competence
 Cognitive therapists recognize the
importance of cultural competence
when working with diverse clients
 The idea of cultural confrontation
goes against the traditional wisdom
of respecting clients' values without
challenging them
 Should Dr. Brown proceed with
challenging Cody's religious beliefs
about premarital sex?
 Will Cody be receptive to Dr.
Brown's strategy?
 If you were the client, how would
you respond?
 Which beliefs of yours would you
see as too sacred for your
psychologist to dispute?
Page 14: Web Link
15.3 Judith Beck
Aaron Beck
 Aaron Beck developed cognitive
therapy as a way to conceptualize
and treat depression
 Beck's theory of depression includes
the cognitive triad: thoughts about
the self, the external world, and the
future contribute to mental health
 When all three of these beliefs are
negative, they produce depression
 Beck's approach aims to increase
logical thinking in clients
 Beck's approach uses a dysfunctional
thought record to organize clients'
experiences
 The dysfunctional thought record
includes columns for description of
the event/situation, automatic
thoughts, emotions, adaptive
response, and outcome
 Beck created a vocabulary to identify
common ways clients' thoughts can
be distorted
 Common thought distortions are
taught to clients in cognitive therapy
Page 15:
Common Thought
Distortions
 All-or-nothing thinking
o Evaluating everything as
either wonderful or terrible
o No middle ground or "gray
area"
 Catastrophizing
o Expecting the worst in the
future

o Unlikely to occur realistically
Magnification/minimization
o Making a mountain out of a
molehill for negative events
o Playing down the importance
of positive events
  Personalization
o Assuming excessive personal
responsibility for negative
events
 Overgeneralization
o Applying lessons learned
from negative experiences
more broadly than warranted
 Mental filtering
o Ignoring positive events and
focusing excessively on
negative events
 Mind reading
o Presuming to know what
others are thinking critically
or disapprovingly
o Impossible to know what
others think
Beck's Cognitive Therapy
 Labeling illogical thoughts as
thought distortions weakens them
 Enables clients to dismiss illogical
thoughts and replace them with more
adaptive and logical thoughts
 Decreases psychological distress
Clinical Example: Olivia
 30-year-old woman recently
divorced after a 3-year marriage
 Feels depressed about being without
a partner
 Beliefs: "I'm no good at
relationships," "Living alone is
intolerable," "Something wrong with
me"
 Dr. Zimmerman educates Olivia
about Beck's cognitive approach and
common thought distortions
 They work together to attack the
flawed logic in Olivia's beliefs by
labeling them as distortions
 Olivia develops the ability to identify
and oppose her illogical thoughts and
replace them with logical alternatives
 Moves from a state of despair to
contentment and mild hopefulness
Page 16:
Beliefs as Hypotheses
 Beck argued that beliefs are
hypotheses, not proven facts
 Exposing a belief as illogical is a
potent way to challenge it
Example: Ayana
 Ayana has a negative self-image
centered on the belief "I'm stupid"
 Belief causes sadness and inhibits
her from applying to college
 Exploration reveals belief is not
entirely based on truth
 Ayana has evidence of intelligence
(B+ GPA, honors courses, helping
friends with homework)
 Ayana focuses only on the negative
aspects (D in math, friends with
better GPAs, recent physics test)
 Ayana is taught about common
thought distortions that explain her
irrational belief
 She is magnifying weaknesses,
minimizing strengths,
overgeneralizing, and using all-or-
nothing thinking
 Ayana seems more motivated to keep
her self-image than to change it
 Reveals reluctance to see herself as
smart due to fear of parents'
resentment if she goes to college
 Encouraged to test the belief by
discussing college with her parents
 Parents are supportive and proud,

contradicting Ayana's belief
 Ayana replaces inaccurate belief
about her parents' view with a more
accurate one
 Able to replace illogical belief of
being stupid with the logical belief of
being bright and capable
 Starts working on college
applications
Page 17:
 Beck's approach to cognitive therapy
includes personal "experiments" to
test beliefs
o Homework assignments
designed to bolster or
undermine client's beliefs
 Clinical example of Frank, a chain-
restaurant manager seeking therapy
for depression
o Frank believes he is not
employable elsewhere
o Dr. Morris challenges the
logic of Frank's belief and
uses words to persuade him
that it is illogical
o Dr. Morris assigns homework
to test Frank's belief
 Frank creates a
resume highlighting
his skills and
experiences
 Frank responds to
want ads to see the
response from
employers
o If the homework assignments
result in feedback
inconsistent with Frank's
belief, he will abandon the
belief and feel more hopeful
Page 17:
 Cognitive therapists are careful to
effectively refute illogical thoughts
when assigning homework
 Ellis and Beck's approaches overlap
and therapists often incorporate
elements of both styles
 Therapeutic goals of both approaches
are the same: identify and evaluate
illogical thinking and replace it with
rational alternatives to alleviate
psychological symptoms
Page 18:
 Cognitive therapy is now applied
universally across a range of
psychological problems
 It is increasingly used for problems
outside the range of traditional
mental disorders
Page 18:
 Cognitive therapists teach clients to
be their own defense attorneys in the
"cognitive courtroom" of the mind
 Clients are trained to spot illogical
thoughts, object to them, and insist
on logical thoughts
 Two opposing voices in the mind
represented by the two columns in
the cognitive model: Belief (B) and
Effective new belief (E)
 Column D (Dispute) serves as an
objection to the illogical voice (B)
and an opportunity for the logical
voice (E) to make a more logical
statement
 Example of Shannon, a college
student with the belief "If I fail an
exam, I'm stupid"
 o Shannon can dispute this
belief effectively by
providing objections such as
an unfair test or previous
good grades
o By objecting and correcting
illogical thoughts, individuals
can defend themselves and
avoid negative consequences
like depression
Page 19:
The Third Wave:
Mindfulness- and
Acceptance-Based
Therapies
 New therapies based on mindfulness
and acceptance have become popular
and empirically supported.
 These therapies are often called
"third-wave" therapies.
 They are not strictly cognitive
therapies, but also include behavioral
and other elements.
 Three particular forms of these
therapies will be examined:
acceptance and commitment therapy,
dialectical behavior therapy, and
metacognitive therapy.
Commonalities among
Third-Wave Therapies
 Mindfulness is at the core of these
therapies.
 Mindfulness can be difficult to
define, but it involves paying
attention to the present moment
without judgment or attachment.
 Mindfulness is an innate human
capacity to deliberately pay full
attention to our actual experience.
 Mindfulness is the awareness that
arises from intentionally attending to
the present moment.
Mindfulness and its Origins
 Mindfulness derives from Buddhist
traditions but is used without explicit

religious ties.
Mindfulness promotes full
engagement with one's own internal
mental processes in a
nonconfrontational way.
 Mindfulness-based therapists focus
on changing people's relationships to
their thoughts rather than changing
the thoughts themselves.
Page 20:
Acceptance and Change
 Mindfulness-based therapies
encourage acceptance of internal
experiences rather than avoidance.
 This acceptance can facilitate
positive change for clients with
various psychological problems.
 Urge surfing is an example of a
clinical intervention that relies on
mindfulness.
 Urge surfing encourages clients to
relate differently to their urges and
realize that they are temporary and
not all-powerful.
 The critical element of this treatment
is not the urge itself but the way the
client responds to the urge.
 Mindfulness and acceptance can be
valuable components of therapeutic
 practice and can complement other
approaches.
Therapists can enhance other forms

of therapy by blending in elements of
mindfulness and acceptance.
 Adding a mindfulness component to
exposure and response prevention
significantly increased improvement
for clients with OCD.
Page 21: Acceptance
and Commitment
Therapy (ACT)
 ACT is a therapy developed by
Steven C. Hayes
 ACT focuses on accepting internal
psychological experiences
o Internal experiences include
emotions, thoughts, and
sensations
 Experiential avoidance can lead to
psychological problems
 Acceptance means facing one's
internal fears
 Metaphors used to explain
acceptance in ACT
o Thoughts as a parade:
acknowledging thoughts
without reacting to them
o Jumping off a step: trusting
and not battling for control

with internal experiences
The C in ACT refers to a

commitment to personal values
The T in ACT refers to taking action

consistent with personal values
FEAR is replaced by ACT in ACT
therapy
o FEAR stands for fusion,
evaluation, avoidance, and
reason-giving
Page 22: Dialectical
Behavior Therapy
(DBT)
 DBT was developed by Marsha
Linehan for the treatment of
borderline personality disorder
(BPD)
 DBT is now considered a treatment
of choice for BPD
 DBT is based on the
conceptualization of BPD as a
problem of emotional regulation
 Emotional dysregulation in BPD is
influenced by biological
predisposition and an invalidating
interpersonal environment
 Core practices in DBT include
problem solving, validation, and
dialectics
 Problem solving helps clients
strategize for the best possible
outcome and overcome factors that
inhibit effective problem solving
 Validation in DBT is stronger than
empathy and communicates that the
client's feelings are important and
sensible
 Dialectics in DBT involve resolving
contradictory feelings or experiences
of the client
Page 23: Dialectics
in DBT and Skills
Training
 Therapist in DBT balances respect
and confrontation
o Therapist points out client's
wish to live and wish to die
 o Discusses ways to strengthen
healthier wishes
 Dialectic of simultaneous acceptance
and change in DBT
o Therapist accepts clients
while pushing them to change
o Clients should adopt the same
attitude toward themselves
o Striking a balance is essential
 Four specific modules of skills
training in DBT
o Emotion regulation:
identifying, describing, and
accepting negative emotions
o Distress tolerance: self-
soothing techniques and
impulse control
o Interpersonal effectiveness:
assertive social skills to
preserve relationships
o Mindfulness skills: engaging
fully in present experiences
without avoidance or
evaluation
Page 24:
Metacognitive
Therapy and
Cognitive Therapy
for Medical
Problems
 Metacognitive Therapy
o Activating event can be a
cognition itself, not just
external occurrence
o Reactions to own thoughts
can cause psychological
problems
o Cognitive attentional
syndrome (CAS) describes
problematic thinking style
o Positive and negative beliefs
about worry can cause
trouble
 Metacognitive therapy applied to
anxiety disorders and schizophrenia
 Cognitive Therapy for Medical
Problems
o Beliefs about illness, injury,
or condition can influence
recovery
o Irrational beliefs can hinder
recovery and cause excessive
worry
o Cognitive therapy has
beneficial effects on healing
process and prognosis
o Applied to various medical
problems such as tinnitus,
chronic pain, sexual disorders
 Example of cognitive therapy for
medical problems with breast cancer
patient
o Correcting illogical beliefs to
reduce distress and improve
coping
Page 25: Cognitive
Therapy and
Schema Therapy
Cognitive Therapy
 Cognitive therapy challenges
irrational thoughts and replaces them
with rational thoughts.
 Jackie's therapy with Dr. Richards
helps her identify and replace
irrational thoughts about her breast
cancer.
  Jackie's new beliefs are realistic and
free of distortions.
 These new beliefs improve Jackie's
psychological state and medical
prognosis.
Schema Therapy
 Schema therapy is for clients with
borderline personality disorder or
other complex clinical issues.
 It focuses on deep-seated cognitions
called schemas that develop in
childhood due to poor parenting.
 The therapist helps the client see the
falsehood of these schemas and uses
the therapeutic relationship to
demonstrate their falsehood.
 Schema therapy has evidence in the
treatment of borderline personality
disorder, long-term depression, and
complex eating disorders.
Page 26: Efficacy of
Cognitive Therapy
and Mindfulness-
Based Therapies
Efficacy of Cognitive
Therapy
 Cognitive therapy has strong
empirical evidence supporting its
efficacy.
 It is effective for a wide range of
psychological disorders, including
depression, anxiety disorders,
bulimia, posttraumatic stress
disorder, and personality disorders.
 Cognitive therapy improves overall
quality of life, including physical and
psychological variables.
 Specific components of cognitive
therapy, such as homework, have
been found to enhance therapy
outcomes.
Efficacy of Mindfulness-
Based Therapies
 Mindfulness-based therapies have
robust effects across a wide range of
clinical problems, especially anxiety
disorders, depression, and stress.
 They have positive effects in specific
problems like eating disorders,
psychosis, and weight loss.
 Dialectical Behavior Therapy (DBT)
is well-established for borderline
personality disorder and other
disorders.
 Acceptance and Commitment
Therapy (ACT) has empirical
evidence in the treatment of anxiety

and mood disorders.
Schema therapy has growing
evidence for borderline personality
disorder, chronic depression, and
complex eating disorders.
Empirical Evaluation in
Cognitive Therapy
 Cognitive therapists emphasize
aspects of therapy that can be overtly
measured and observed.
 Problems are defined in terms that
can be measured, such as numerical
ratings of symptom severity.
 Empirical evaluation is facilitated to
assess the effectiveness of therapy.

Page 27:
Cognitive interventions in
therapy
 Objective measurement of anxiety
levels before and after therapy
 Facilitates empirical outcome
research on the effectiveness of
cognitive therapy
Case study: Denise in
Cognitive Psychotherapy
 Denise's primary symptoms were
depressive
 Trigger for depressive symptoms
was the change in ownership of the
restaurant where she works as a chef
 New owner's policies, such as menu
control and restrictions on customer
interaction, contributed to Denise's
depressive symptoms
Cognitive therapy approach
 Combination of Ellis's and Beck's
techniques
 Educating Denise about the cognitive
model
 Explaining the role of automatic
thoughts or beliefs in influencing
emotions
 Using Ellis's ABCDE model to help
Denise understand her experience
 Providing a list of Beck's cognitive
distortions to help Denise dispute
irrational thoughts
Identifying beliefs and
thoughts
Filling in Columns A (activating

event) and C (emotional
consequence)
 Struggle to identify beliefs (B), but
eventually identified the thought "I'm
incompetent"
 Denise believed the new policies
were motivated by the boss's desire
to prevent her incompetence from
affecting the restaurant's business
Disputing irrational
thoughts
 Focusing on Stage D (dispute)
 Encouraging Denise to think
critically about her belief of
incompetence
 Asking questions to challenge the
belief and explore alternative
interpretations
 Initially foreign to Denise, but
became more familiar and
comfortable over time
Homework assignments
and thought journal
 Using a five-column thought journal
to track activating events, beliefs,
emotional consequences, disputes,
and effective new beliefs
 Uncharted territory for Denise, but
she gradually became more
comfortable with completing the
journal