SYSTEMS OF PSYCHOTHERAPY--INTRODUCTION

Definitions of therapy. Can we distinguish psychotherapy from other interpersonal relationships? Many have tried!!!

Perhaps the longest definition in Psychology, from Meltzoff and Kornreich (1970).

“Psychotherapy is the informed and planful application of techniques, derived from established psychological principles, by persons qualified through training and experience to understand these principles and apply these techniques, with the intention of assisting individuals to modify such personal characteristics as feelings, values, attitudes, and behaviors, which are judged by the therapist to be maladaptive or maladjusted.”

There are 4 common aspects to most definitions of therapy:

1. A restricted relationship

2. The systematic application of techniques

3. By trained helpers

4. Directed at alleviating problems

Examples of the applications of techniques and their theoretical effects:

TECHNIQUE------------------------------------------>EFFECT

Unconditional positive regard------------------>Decreased conditions of worth

Dispute irrational ideas-------------------------->Cognitive restructuring

Counter-conditioning---------------------------->Decreased anxiety

Interpretations------------------------------------>Insight

Re-live the primal scene-------------------------->Catharsis

The techniques employed in psychotherapy have been distinguished from what are known as non-specific (common) factors. These are events in a relationship that can be found both inside and outside of psychotherapy.

1. Admit a problem

2. Ask for help

3. Meet someone new

4. Tell your story

5. Get an explanation for your problems (empathy and understanding)

6. Get a treatment rationale

7. Expect benefits

8. Increased attention

9. Increased self-reflection

10. An additional event in life

11. Pay money to change

Thus traditionally, psychotherapy has been conceptualized as consisting of a relationship involving both common factors and specific techniques. The techniques are thought to make psychotherapy unique. This traditional conceptualization has difficulties, however. Some or many events that occur in therapy may be construed as a either a common factor or a specific technique depending upon theoretical perspective. For example, empathy and understanding in the therapeutic relationship are often regarded as common factory, but they have the theoretical status of specific factors in Client-Centered Therapy. Also, “exposure” is usually regarded as a specific technique from a behavioral perspective, but “exposure” can also be construed as occurring whenever a client self-discloses (usually regarded as a common factor). Thus it is difficult to define psychotherapy as a unique endeavor.

Weinberger (1995) described 5 classes of COMMON FACTORS

1. The therapeutic relationship

A. The working alliance

B. Transference

2. Expectations of success

3. Confronting the problem

4. Providing an experience of mastery or cognitive control

5. Attributions of therapeutic success or failure.

Each of Weinberger’s classes are differentially emphasized by the 4 “super-schools” of therapy: Analytic, Behavioral, Cognitive, and Humanistic/Experiential.

Quotes of research summaries of previous editions of the Handbook: Generally from Garfield, Bergin, and others:

1986- “No one group of therapists, professional or otherwise, has a monopoly on securing positive results. We are still not sure as the active therapeutic variables responsible for pos. change.”

1986 and 1994- “The long-term dominance of major theories is over in favor of eclecticism and integration.”

1994- “A renewed emphasis on common factors as sources of therapeutic benefit.....A consensus that therapy does have some pos. effects above and beyond common factors.....Less agreement on the extent of change.....No agreement of which of the 250+forms of treatment secures the best results....Note a growing interest in ethics, values, and spiritual approaches to therapy.”

2004-“Lists of empirically supported treatments are static and seem to offer only a false guarantee of effectiveness. Although many practitioners and the public may be comforted by the notion that they are offering or receiving an empirically supported psychotherapy, the fact is the success of treatment appears to be largely dependent on the client and the therapist, not on the use of ‘proven’ empirically based treatments…..In contrast to other research strategies, outcome management makes empiricism a viable part of routine practice rather than a distant abstraction that practitioners find difficult to incorporate into practice….

CLASSES OF VARIABLES INVESTIGATED IN PSYCHOTHERAPY RESEARCH--from Orlinski, Howard, and others:

INPUT VARIABLES

1. Personal and professional characteristics of patients and their life situation. (E.g., gender, diagnosis, SES).

2. Personal and professional characteristics of therapists and their life situation. (E.g., gender, years of experience).

3. The organization and community within which therapy occurs. (E.g., hospital, outpatient clinic).

4. Beliefs and value orientations. (E.g., the goals of the patient [P] and the therapist [T].

OUTPUT VARIABLES--The consequences of therapy.

1. In the life of the P.

2. In the life of the T.

3. In the group and community of which P and T are a part.

4. With regard to the beliefs and value systems of P and T.

OUTCOME IS A SUBSET OF OUTPUT and refers to a value judgment of the life and the person of the P made by P, T, the community, or all 3. Evidence of outcome ought to be obtained from outside the P-T relationship.

PROCESS VARIABLES refer to all actions and experiences of P and T with respect to each other in therapy sessions, and with respect to each other outside of sessions; most process variables are theoretically related to outcome.

ASPECTS OF PROCESS

1. Formal--The therapeutic contract; the purpose, format, terms and limits of therapy.

2. Technical--The techniques and operations of therapy.

3. Interpersonal--The therapeutic bond; A) Role investment, B) Empathic resonance, & C) Mutual affirmation.

4. Intra personal--Patient self-relatedness, and patients’ ability to absorb the impact of the operations and the bond

5. Clinical--The in-session impacts or therapeutic realizations. The effects of the operations and the bond. These are also known as mini-outcomes.

6. Temporal--The sequential flow of events.

Examples of OUTCOME variables (all measured at the end of therapy)

Global ratings of improvement

MMPI scores

Back depression scale

Intensity of target symptoms

Examples of PROCESS variables

Patient openness to experience

Therapist’s level of empathy

Total number of patient self-statements

Patient involvement in the therapeutic process

Frequency of therapist’s interpretations