Clinical Interventions: Overview & Methods

1
Clinical Interventions Overview Methods

• Dr. Kline
• FSU-PC

2
What is Psychotherapy?

• Psychotherapy essentially is treatment conducted
  within a professional relationship by trained
  therapists to help/facilitate clients in distress
  (Neitzel et al., 2003).
• This definition, allows us to identify
• The participants (i.e., the client and
  therapist)
• The basic framework of the situation
  (professional relationship)
• The basic goal of the therapy (reduction of
  emotional distress/help with the problem).

3
Who are the therapists?

• While, therapists are trained professionals at
  dealing with clients problems issues, the type
  of training, theoretical orientation, years of
  education, scope of ability vary.
• In general the following individuals are
  considered therapists
• Clinical Psychologists (PhD PsyD)
• Masters level psychologists
• Psychiatrists
• MSW
• Marriage and Family therapists (MFT)

4
Characteristics associated with good therapists?
Clients prefer therapists with advanced training.
Advanced Training
Includes communication, relationship-building,
self-monitoring skills.
Good Interpersonal Skills
Should be able to listen to clients effectively
communicate with them.
Good Listening Ability
Genuineness, empathy, Unconditional positive
regard.
These promote rapport with the client build
trust.
5
Who are the clients?

• Clients, like therapists, vary is several
  characteristics, but with one notable exception
• Most clients that seek help from a therapist
  have reached a point where their coping
  mechanisms no longer function.
• Occasionally, some clients seek therapy because
  someone else is distressed (e.g., a parent,
  judge, employer, spouse, or other family member).
  
• These clients tend to be less motivated than
  clients
• seeking help for themselves.

6
Which clients tend to fare better in their
treatment outcomes?

• 1. Clients who do their homework tend to do
  better. That is, clients who complete
  assignments given to them by their therapists
  (e.g., keep a diary of emotions, etc.) show
  better treatment outcomes.
• Burns Spangler (2000) reported that
  depressed patients who were homework compliant,
  reported decreases in depression.
• 2. Clients who are cooperative open tend to
  have better treatment outcomes than clients who
  are resistant defensive. (Orlinksy, Grawe,
  Parks, 1994).

7
The Therapeutic Relationship

• A. Professional Guidelines- therapists have
  commitments to honor in their relationship with a
  client. These commitments protect the client
  therapeutic relationship.
• These commitments are
• Confidentiality information about the client
  isnt revealed with anyone except for unique
  circumstances (e.g., client is danger to
  himself/herself, is a danger to others).
• Informed consent therapists must tell clients
• what the guidelines are for confidentiality.
• Ethics - Clients have a right to know what is
  appropriate conduct for therapists within a
  therapeutic relationship. The ethics code for
  these issues are published in the American
  Psychological Associations Ethical Principles
  of Psychologists and Code of Conduct.

8
Therapist Objectivity Self-Disclosure

• Although therapists need to be empathetic
  understanding, there will be situations in which
  therapists will have to push their clients to
  overcome resistance in dealing with a problem.
• This requires objectivity on the therapists
  part, because the therapist will have to
  determine when to detach themselves from their
  clients so they can insist their clients
  progress towards a solution to their problems.
• However, there will also be occasions in which
  therapists may want to use self-disclosure
  (divulging something about themselves to their
  client) as a means of building trust and rapport
  with their clients.
• E.g., a family counselor whose been divorced may
  carefully divulge something about his/her own
  experience so as to build common ground with a
  client going through a divorce. The client
  identifies with the therapist, thereby
  promoting trust in the therapeutic relationship.
  
• Caution therapists should only divulge a minor
  bit of information about themselves to their
  clients. Too much or too little information may
  impair the relationship between the therapist and
  client.

9
C. Therapeutic Alliance determined by two
factors
Factor 1 The emotional ties that develop
between the therapist client (trust, respect,
etc.).

• Factor 2 The common goal of the therapeutic
  relationship which is to help the client achieve
  his/her goals.

10
The Settings of Psychotherapy
Outpatient Settings
Inpatient Settings
Therapists office, rented spaces in community
centers, etc.
Public, private, VA hospitals, residential
rehab treatment centers, prisons, jails, etc.
Therapist office-most common setting for therapy.
Privacy is required.
Hospital-most common setting for treatment.
Psychopathology is usually fairly serious with
in-patient care.
11
Goals of Psychotherapy

• 1. Fostering insight Therapy should improve a
  clients insight into why he or she behaves the
  way they do.
• The rationale here is that by understanding
  your behavior problems (mistakes), you are
  empowered to make behavior changes that are
  adaptive healthy.
• According to Nietzel et al., 2003, therapists
  of all theoretical backgrounds need to encourage
  their patients to understand their actions.
• One method for facilitating insight in your
  patients, is for the therapist to interpret the
  clients behavior.
• This is done to motivate clients to examine
  their own behavior and draw inferences about the
  meaning of their actions. Note this is not to
  show clients the therapist is right!!!!!
• Caution Therapists will want to avoid
  divulging information that is too
• confrontational to clients who are
  disturbed or who have a fairly severe
• diagnosis that may not be able to handle
  such news at the time.

12
2. Reducing emotional discomfort

• Therapists often are faced with clients who are
  in severe emotional pain anguish. This makes
  therapy challenging as the patient is greatly
  distressed.
• Therapists dont want to completely reduce the
  clients distress as this may eliminate their
  desire to address their problems, but will want
  to reduce the clients distress to some extent to
  promote a positive treatment outcome.
• One way to achieve this goal is for therapists
  to use the therapeutic relationship to improve
  the clients emotional strength. For instance,
  if the client feels they can count on the
  therapist be understanding and non-judgmental,
  they are better equipped to deal with the
  onslaughts from the others.
• Therapists can convey the message to clients
  that although things seem hopeless and
  insurmountable now, you will be able to make
  changes in your life that improve your outlook
  considerably.

13
3. Encouraging Catharsis

• Catharsis, involves releasing pent-up emotions
  (frustration, anger, helplessness) that have been
  bothering the client for a long period of time.
• Therapists should encourage catharsis, by
  empowering clients to express their emotions,
  frustrations, and issues in therapy.
• Therapist to client
• Tell me how you feel about that?.
• How did that make you feel when he/she did that
  to you?...
• There is some evidence that such emotion-focused
  techniques may be helpful in easing tension for
  clients who are distressed or repressing their
  problems.

14
4. Providing New Information

• Among other things, therapists help their clients
  by educating them.
• That is, therapists provide information to
  clients about their
• maladaptive thought patterns (e.g., identifying
  irrational or inaccurate beliefs)
• Problem behaviors (e.g., self-destructive
  behaviors such as addictions, actions designed to
  hurt others).

15
Psychodynamic Therapies

• Psychodynamic therapies assume that an
  individuals behavior is determined by the
  interaction of powerful competing forces within
  the person.
• These forces are largely
• unconscious (outside the persons awareness)
• Develop in early childhood.
• Result in coping mechanisms designed to deal
  with anxiety.
• This is a push-pull theory!!!!

16
Origins of Psychoanalysis

• Shortly into Freuds career as a physician, he
  examined several patients who displayed
  neurological symptoms with no known organic cause
  (e.g., some patients complained of paralysis, yet
  could move their limbs in their sleep).
• Freud labeled these patients as, neurotics.
  Most of these patients exhibited hysterical
  paralyses, amnesia, blindness, speech loss.
• Treatment for these neuroses consisted of baths
  or electrically generated heat, which Freud
  believed resulted in symptom relief due to the
  power of suggestion (e.g., placebo effect).
• Freud decided to try hypnosis as a method of
  suggestion that might alleviate neurotics
  symptoms.

17
Hypnosis its history with psychoanalysis

• Joseph Breuer, a colleague of Freuds,
  recommended that hypnosis and the cathartic
  method be used to treat neurotics.
• Breuer had a patient (Anna O.) come to him
  complaining of (headaches, cough, neck arm
  paralyses) that originated shortly before her
  fathers death, but became worse afterwards.
• Breuer, noticed Anna when into trance-like
  states that resembled hypnosis. During one of
  these trances he encouraged his patient to
  describe the events that occurred during her day.
  This resulted in a short-term improvement in her
  symptoms immediately following the trance.
• On one session, Breuer noticed that one of her
  symptoms that was linked with a distressing
  event, disappeared following her account of the
  event in her trance.
• Breuer made the connection between the
  distressing event that Anna had either forgotten
  or was simply unaware of during the day and her
  neurological symptoms.
• Using hypnosis, Breuer encouraged Anna to recall
  everything about her symptoms and the events in
  her life. This seemed to work as symptoms
  continued to disappear with these therapeutic
  sessions.

18
Freuds use of hypnosis other treatments

• Freud took Breuers advice used hypnosis to
  treat neurotics.
• However, because not all patients could be easily
  hypnotized, he started simply requiring patients
  to close their eyes and recall emotions,
  thoughts, feelings, and events that came to mine.
• Later, he simply asked the to mention whatever
  they were thinking.
• He also started to ask patients to describe their
  dreams as he felt dreams may divulge hidden
  motives/events that were the route of their
  problems.

19
Goals of Psychoanalysis

• The goal of psychoanalysis is to make a clients
  unconscious motives, drives, and conflicts
  available to them so they can deal with it.
• Freud reasoned that if individuals were
  confronted with the reasons why they behaved in
  maladaptive ways, they would be forced to change
  their behaviors.
• However, the client must figure these things out
  for himself/herself, with the therapist as a
  guide.

20
Three main goals of Psychoanalytic treatment

• 1. Intellectual emotional insight into the
  underlying causes of the clients issues.
• 2. Working through the implications of these
  insights.
• 3. Strengthening the egos control over the id
  superego.
• This takes on average (3-5 sessions per week for
  2-15 years) with a psychoanalyst.

21
Psychoanalytic Treatment Methods

• 1. Free Association Evolved from a
  non-hypnotic way for Freuds patients to
  consciously recover emotional memories.
• The client needs to say everything that comes to
  mind without editing or censorship (Neitzel et
  al., 2003). This should allow bits pieces of
  unconscious material to appear.
• The therapist will have to look for patterns of
  association that indicate something important.
• Clients who only talk about trivial issues
  (small-talk) are seen as constructing barriers
  that impedes their progress. Thus, there should
  be something of substance mentioned in the
  session.

22
2. Dream Analysis

• Freud believed dreams represented repressed
  memories, wishes, and desires.
• Freud argued dreams contained two kinds of
  content
• Manifest content- the actual events or images
  that occur in the dream.
• Latent content the unconscious information in
  the dream that occurs in the forms of symbols.
• Freud had clients recall the manifest content of
  their dreams, to see if he could detect the
  unconscious material masked in the dreams images
  and actions.
• Psychoanalysts may examine several dreams produce
  by a given client to see if any common themes
  develop and how these may relate to their
  problems in daily life.

23
3. Transference

• The clients feelings toward the therapist and
  their relationship is known as transference.
• Freud argued the unconscious information
  regarding authority figures from childhood lie at
  the root of many clients current problems.
• Therapists will try to remain a bit detached
  divulge very little about themselves to their
  clients to encourage clients to project onto them
  unconscious attributes motives associated with
  parents, spouses, other people in their lives
  (e.g., client may see therapist as neglectful
  parent, loving spouse, jealous lover, etc.).
• When transference occurs it provides the
  therapist and client with an opportunity for the
  client to discover the issues that are bothering
  them with other people in their lives.
• Therapists need to be careful that they dont
  project their own unconscious desires, feelings,
  so forth onto their clients, something called
  countertransference.

24
Behavior Therapies

• A. Assumptions of behavior therapies
• 1. Behavior disorders are assumed to have
  developed through learning (conditioning,
  modeling, etc.).
• 2. Therapies should be based on results of
  research in learning based methods.
• 3. The goal of behavior therapies is to modify
  overt, maladaptive behaviors.
• 4. Therapies should focus on clients current
  problems in their natural environments.
• 5. Treatment should be based on carefully
  controlled empirical studies examining the
  efficacy of therapies on treatment outcomes.

25
B. Origins of Behavior Therapy

• The link between behavioral methods
  psychopathology actually began in the 1920s and
  30s when Pavlov examined experimental neuroses in
  dogs after exposing them to electric shock.
• The dogs symptoms included agitation, barking,
  biting the equipment, forgetting previously
  learned events (Nietzel et al. 2003).
• Watson Raynors work on Little Albert was a
  follow-up to Pavlovs work described above. They
  showed you could condition fear responses in an
  11-month old infant through classical
  conditioning.

26
Origins (contd.)

• By the 1950s 60s behavior treatment was used to
  treat a variety of problems (anxiety disorders,
  sexual disorders, schizophrenia, etc.).
• Today, behavior therapies rank high among
  treatments for a variety of psychopathology and
  is the gold standard for treating certain
  disorders (phobias, anxiety, autism).

27
Behavior therapy treatment methods

• 1. Systematic Desensitization first developed
  by Joseph Volpe in 1958, the goal of this
  treatment is to extinguish fear and/or anxiety in
  individuals (and organisms).
• This is accomplished by systematically exposing
  individuals to fear-eliciting stimuli that are
  gradually increased in intensity over trials.
• Therapy consists of three parts
• Relaxation training
• Creating a graduated hierarchy of fear-evoking
  events
• Imagined /virtual reality desensitization

28
Formula for Systematic Desensitization

• Part I Clients are trained to employ a
  relaxation method to reduce anxiety.
• Progressive relaxation training, a common
  relaxation method, requires that clients
  voluntarily tense specific muscle groups (hands,
  arms, etc.) for a period of time then focus on
  the sensations of relaxation that follow muscle
  release.
• E.g., require clients to clench the fist for
  several seconds followed by release.
• Part II The therapist creates a graduated
  hierarchy of events/situations the client finds
  as increasingly anxiety-provoking. Each event
  (or stimulus) should be perceived as more anxious
  than the preceding event.
• Part III The client may use either imagined
  desensitization or more realistic
  desensitization. On the first trial on imagined
  desensitization, the client mentally
  visualizes the first event on the graduated
  hierarchy and tries to remain relaxed until
  fear/anxiety is extinguished. If they can do
  this for 10 seconds, the therapist encourages
  them to visualize the next event on the
  hierarchy, and so forth.
• Clients may also use a more real-world
  approach, by being exposed to carefully monitored
  levels of the fear-eliciting stimulus. Again, if
  clients can go 10 seconds with little to no
  anxiety, they are then exposed to a slightly more
  intense version of the fear-eliciting stimulus,
  and so forth.

29
Desensitization Hierarchy

• Imagine writing the word, spider.
• Image while reading a book you notice a small
  spider on the cover.
• Imagine a spider the size of your hand across the
  room from you.
• Imagine the big spider has crawled closer to you
  its about 3 feet from you.
• Imaging the spider is now 1 foot away and
  crawling towards your hand.
• Imagine the spider is crawling onto your hand.

30
2. Exposure techniques

• The goal of exposure therapy is to fully expose
  the client to the fear-eliciting stimuli so that
  they experience anxiety and wait until it finally
  extinguishes. One common exposure method is
  flooding.
• Floodingrequires that client is exposed to a
  maximally intense level of the fear-eliciting
  stimulus. This should cause a severe anxiety
  response that with prolonged exposure (time)
  should diminish, thus extinguishing the
  association between anxiety the fear-eliciting
  stimulus.
• E.g., putting a tarantula in the hand of
• a client with arachnophobia!!!!

31
Important points for exposure methods

• Exposure methods will only work if enough time is
  allowed for the anxiety responses to extinguish.
• Removing the fear-eliciting stimulus too early
  will only reinforce avoidance behavior, thus
  strengthening the association between the anxiety
  fear-eliciting stimulus.
• Therefore, exposure therapies require a strong
  commitment on the part of both client
  therapist.

32
Efficacy of Exposure treatments

• Exposure treatments have been shown to be
  successful in treating obsessive-compulsive
  disorder (OCD), phobias, panic disorder.
• In treating OCD, clients are exposed to the
  stimulus linked with their obsessive thoughts
  (e.g., dirt) not allowed to engage in the
  ritualistic behaviors that usually reduce their
  anxiety (e.g., compulsive hand-washing).
• This is called exposure and response prevention
  (ERP).

33
3. Modeling

• Has been used to treat phobias, social
  withdrawal, OCD, antisocial conduction,
  aggressiveness, autism.
• A client with a clinical problem, can observe
  live or videotaped models performing behaviors
  that the client avoids with no negative
  consequences experienced.
• Treatment is most effective when are very similar
  to the client, have high status, are reinforced
  for their responses (Neitzel et al., 2003).

34
Contingency management

• Refers to operant conditioning methods where
  behaviors are strengthened or reduced based on
  consequences.
• Shaping - develops new behaviors by
  strengthening successive approximations of
  desired responses.
• Time out- reduces frequency of undesirable
  behaviors by removing client from setting where
  being has been reinforced.
• Contingency contracting-a formal contract is
  written out by a therapist client stating what
  consequences will be for undesirable behaviors.
• Token Economies- tokens are earned for
  desired behaviors, lost for unwanted behaviors.
  Tokens may be used to obtain something else
  (e.g., like money to buy things).

35
Cognitive-Behavioral Therapy

• All cognitive therapies attempt to modify
  individuals thoughts (cognitions), thereby
  resulting in changes in the clients responses.
• Cognitive approaches assume psychopathology
  results from faulty/inaccurate cognitions
  (beliefs, schemas, problem-solving strategies)
  that are linked with our affectivity (emotions).
• E.g., depression results from negative thoughts
  beliefs about the self (I am worthless, No one
  loves me, Im a failure, etc.). These
  negative beliefs result in negative affectivity,
  thereby leading to depressive symptoms.
• If you change the faulty perception, the
  maladaptive actions underlying affectivity
  resulting in depressed mood will dissipate.

36
The combination of behavior cognition in
cognitive-behavioral therapy

• Cognitive-Behavioral therapy represents the
  blending of cognitive behavioral techniques to
  treat psychopathology.
• Therapists with a behavioral orientation,
  recognized the importance of perception
  thoughts in treating disorders, while cognitive
  therapists recognized the significance of change
  maladaptive actions in improving self-esteem.

37
Cognitive-Behavioral treatment methods

• 1. Becks Cognitive Therapy Developed by Aaron
  Beck, this method attempts to improve mental
  problems by identifying correcting the
  distorted beliefs (thoughts) that result in the
  abnormal behaviors.
• Beck argues that logical errors distortions in
  thinking result in depression other forms of
  negative affectivity.
• E.g., A man concludes that hes worthless,
  because a woman he asked on a date turns him
  down. There may be multiple reasons for her
  response that has nothing to do with him, but he
  focuses on his unworthiness.

38
Applying Becks therapy

• Distorted inaccurate beliefs are identified
  corrected by therapists using these strategies
  (see Neitzel et al., 2003, p255).

• Recognizing the connections between cognitions,
  affect, behavior.
• 2. Monitoring occurrences of cognitive
  distortions.
• 3. Examining the evidence for against these
  distortions.
• 4. Substituting more realistic interpretations
  for dysfunctional thoughts.
• 5. Providing assignments that allow clients to
  practice new thinking strategies more effective
  problem-solving.

39
2. Rational Emotive Behavior Therapy

• REBT, developed by Albert Ellis, attempts to
  treat abnormal behavior that results from
  irrational thoughts beliefs.
• Individuals with irrational, self-defeating
  thoughts, develop unrealistic expectations of
  what is needed for them to be happy. When these
  expectations/beliefs are unmet, depression
  anxiety result.
• The goal of REBT is to replace the clients
  irrational self-destructive beliefs with
  rational, logical thinking patterns that do not
  result in negative affectivity.
• Therapists need to be strong, direct, and focused
  when
• working with clients.

40
Humanistic Therapies

• These therapies focus on helping clients deal
  with their anxieties, focus on clients
  positive/healthy thoughts behaviors, and strive
  to help clients recognize their full potential
  as individuals.
• Behavior problems result from anxieties, which
  impair an individuals ability to grow develop
  into health well adjusted adults.
• Clients are seen as in charge of their own
  therapeutic intervention basically good people.
  

41
Humanistic Therapy Methods

• 1. Client-Centered Therapy Carl Rogers
  developed this form of treatment which views the
  client as the one in charge of his or her
  therapeutic outcome.
• He argued that therapists need to enable clients
  to discover for themselves the cause of their
  problems as well as the mechanisms by which the
  client could resolve their problems.
• If the therapist provides a comfortable,
  empathetic environment for the client to focus on
  their problems, then client will improve (if-then
  statements).
• Therefore, the goal of client-centered therapy is
  to provide the client with an opportunity to
  further his/her personal growth. Therapists need
  to express unconditional positive regard,
  empathy, congruence to help their clients.

42
Unconditional Positive Regard

• According to Rogers, this conveys three important
  pieces of information to clients
• 1. The therapist cares about the client.
• 2. The therapist accepts the client (for who
  they are).
• 3. The therapist trusts the clients ability to
  change.
• In a nutshell, unconditional positive regard,
  means not placing conditions of worth on others.
  Rather, people are cared about and accepted as
  they are. You dont need to earn someones
  love, but are given it freely, regardless of your
  behavior.

43
Empathy

• Therapists can only help their clients if they
  possess the ability to place themselves in their
  clients positions.
• That is, the therapist must try to see the world
  as the client does to understand what the client
  is feeling.
• Empathy is conveyed via active listening. In
  particular, therapists, reflect what the client
  has said to the client.
• This serves two purposes
• Communicates the therapists knowledge of the
  clients problems.
• Indicates the therapists desire to understand
  the clients problem.

44
Congruence

• Therapists responses to clients should be
  consistent with their feelings.
• That is, therapists need to be honest open with
  their own feelings so as to be sensitive and
  genuine with their clients.
• Clients need to be able to trust their
  therapists. If the therapist makes a comment to
  the client, they should feel they can believe
  the therapist.
• Thus, actions should reflect real the therapists
  real feelings and thoughts.