Handout #1- Becoming an Effective Therapist Four Traditional Perspectives in Psychotherapy Therapeutic Focus what the therapist emphasizes

s (defenses, maladaptive behaviour, schemas, etc.) emphasis on schemas Therapeutic Relationship refers to the nature of therapist-client relationship or bond (expert-novice, superiorinferior, or mutual collaborators) tending to being collaborative Therapeutic Change refers to the mechanisms of change that underlie the psychotherapeutic process the common mechanism is desensitization (a process of extinguishing an emotional response to a stimuli that formerly induced it) I. Psychodynamic Perspective- encompasses a wide range of therapeutic approaches that emphasize the concept that thoughts, feelings, and behaviours are manifestations of inner drives such as the unconscious A. Therapeutic Focus Modern analysts are more likely to focus on relational themes, emphasizing the self, love objects and their interactions Slap & Slap-Shelton claim Freuds structural model is a theoretical and clinical cul de sac. They contend that the schema model is a more parsimonious way of conceptualizing mental functioning and psychopathology that better fits the clinical data of psychoanalysis than the structural model Schema Model of Slap & Slap-Shelton: ego and sequestered schema. Schemas are based on past experience but modified by new experience and form the basis of adaptive behaviour Weiss approach in ego psychology: psychotherapy is a process in which the client is helped by the therapist to change the pathogenic beliefs (self view, world view, and the moral and ethical assumptions of others). The individuals personality reflects his attempt at mastery and adaptation. These beliefs warn the individual about the dangerous consequences of pursuing certain goals or experiencing certain wishes, affects, or ideas. Horowitz: proposes that everyone has a repertoire of multiple schemas of self and other. Self-schemas include ways to gain pleasure or avoid displeasure (innovational schemas); relating to other people and the world (role schemas); and ways of helping an individual decide which of two motives to choose (value schemas); superordinate schemas which articulate the self to the other schemas. Self-schema develop from the interaction of genetic and environmental factors Therapeutic relationship allows the client to develop an insight into these schemas. During the process of working through, the client is assisted in gradually replacing or modifying these schemas.
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B. Therapeutic Relationship Strupp & Binder: the therapeutic stance should be that of a reasonable, mature and trustworthy adult who fosters a symmetrical relationship between equals Luborsky: helping alliance Alderian approach: emphasizes a cooperative and collaborative relationship Weiss: the therapist and client have the same purposethe disconfirmation of pathogenic beliefs. Self-psychology: therapist role is not neutral; rather, he becomes a participant observer. Empathy is essentially strengthening the selfstructure. Kohut: considered empathy to be a form of vicarious introspection and saw it as having two functions: understanding and interpretation (understanding-immediate apprehension of the clients subjective world; interpretation- utilized to assist clients to see that their current reactions are based on empathic failure of significant others in childhood) C. Therapeutic Change Process Confrontation- the issue or concern is made evident and explicit Clarification- the concern is brought into sharper focus pointing to several instances that exemplify it Interpretation- the unconscious meaning or cause is made conscious Working through- refers to the repetitive and incremental process of exploring resistances that prevent insight from leading to change Psychoanalytic therapy attempts to minimize and desensitize anxiety by moving in small increments toward the feared object. Alderian therapy uncovers and removes the neurotic safeguard in an incremental fashion Slap & Slap-Shelton: treatment consists of helping the clients describe, clarify, and work through these sequestered, pathological schema. These schemas are exposed to the clients mature, adaptive ego in order to achiever integration. Repeated demonstration and working through of the traumatic events give rise to the pathological schemas and engenders a greater degree of self-observation, understanding, and emotional growth. Weiss: a process in which the therapist helps the client to change these beliefs through interpretation, but interpretation is not the only mechanism of change. He believes that clients may be helped to disconfirm these pathogenic beliefs and pursue healthier goals by their experiences with therapists. After this, clients may feel safe enough to develop insight on their own without the benefit of interpretation. Cognitive- Behavioral Perspective- includes various approaches that emphasize the primacy of maladaptive behaviours or faulty cognitions, or a combination of both maladaptive behaviours and cognitions as the basis for psychopathology.

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A. Therapeutic Focus Beck: introduced the schema concept with reference to depression and to the treatment of personality disorders. He proposed other schemas and subschemas in a manner very similar to lifestyle convictions. Various types of schemas: cognitive (self-evaluation and world view, or evaluation of others), affective, motivational, instrumental, and control schemas. Bandura: self systems Kelly: described personality constructs in a manner reminiscent of lifestyle convictions B. Therapeutic Relationship Aaron Beck: collaborative empiricism to refer to a therapeutic relationship that is collaborative and requires jointly determining the goals for treatment and where the therapist and patient become coinvestigators. He also believes that the therapists role is that of a guide and catalyst who promotes corrective experiences in addition to utilizing warmth, accurate empathy, and genuineness to appreciate the patients personal worldview Meichenbaum- accentuates the clinical value of a collaborative relationship when he advocates the importance of entering the patients perspective. In so doing, the patient and therapist can work together to establish a similar understanding and common expectations of treatment. C. Therapeutic Change Process Wolpe & Marks: describe systematic desensitization as a step-by-step procedure for replacing anxiety with relaxation while gradually increasing the clients exposure to an anxiety-producing situation or object. Thus, exposure, in varying degrees, leads to or produces desensitization. In the process, desensitization and extinction clients must redeploy their attention away from negative self-evaluations and toward either the feared object itself or helpful environmental aspects. As a result, they learn a greater degree of self-control or mastery. Cognitively oriented therapy approaches such as cognitive therapy and rational-emotive therapy target cognition to be desensitized through cognitive restructuring or disputation. Systems/Family Perspective A. Therapeutic Focus- psychoanalytically oriented family therapists, particularly the object relations approaches, and cognitive behaviourally oriented family therapy systems that reflect the schema-based perspective with individual patients also utilize schema formulations with couples and families. B. Therapeutic Relationship Satir: communications, strategic, structural and the MRI Interactional approaches all place premium on collaboration between therapist and the client, couple, or family, particularly with regard to cooperation and realigning roles and relationships
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Bowens Family Systems approach: endorses a collaborative relationship, wherein the therapists role is largely that of a coach Foley: concludes that in the object relations family system, structural and strategic perspectives conclude that the therapists role is that of teacher and a role model of positive healthy behaviour rather than that of expert C. Therapeutic Change Process Reframing- a classic curative mechanism in systemic and family therapeutic approaches which changes the conceptual or emotional context of the problems so that its meaning can be reconstrued in a more manageable and acceptable way. It is often utilized early in the course of strategic therapy and structured family therapy to enable the client to take some initial steps toward the therapeutic perspectives; the mechanism of exposure and desensitization occurs in an incremental fashion Humanistic Perspective- includes a variety of approaches that emphasize experience and meaning rather than drives, behaviour, or cognitions. A. Therapeutic Focus Carl Rogers: described the self concept, the self ideal and the selfstructure as the perception of the relationship of the I or me to others and to various aspects of life Kohut: his idea in self-psychology articulates the self and its development from the selfobject, with reference to the object that represents Gestalt Schools but also emphasizes I-Thou relations B. Therapeutic Relationship Carl Rogers: emphasized the importance of the therapists utilization of warmth, accurate empathy, and genuineness to appreciate the clients inner world, as well as to effect change (person/client centered therapy) Existentialist psychotherapists believe that a collaborative relationship of equals is fundamental to good therapeutic work. Kohuts Self Psychology: emphasizes the importance of collaboration, with its emphasis on the therapists empathic mirroring to connect with the patients inner world from the vantage point of the experiencing insider C. Therapeutic Change Process Yalom: contends that existential psychodynamics are similar to the psychoanalytic view of neurosis and desensitization. The existential formula has awareness of ultimate concerns (death, meaninglessness, isolation, freedom) arousing anxiety which is contained by defense mechanisms. The therapeutic strategy utilized in the experiential and existential approaches involves helping the client face the feared awareness of each ultimate concerns; helping the client gradually face their fears and stay with them. Havens: proposes that direct human-emotional contact by the therapist desensitizes isolation. He describes that in the process of facing their fears the phenomena of phenomenological reduction occurs. This means
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that attitudes are reframed or reconfigured based more totally on experiencing the other people. In staying with the other the therapist remains in the phenomenological world of the other to expose the client to an ultimate human connection. Beitman & Mooney: suggest that other experiential approaches, such as the gestalt therapies, and by extension client-centered therapies that target affects, effect change through the same mechanism of desensitization. The Integrative- Multicultural- Accountability Perspective Paradigm Shift- involves every facet of behavioural health practice including the role of clinician and client, the cultural context of therapy, the nature of the relationship between clinician and client, as well as clinical practice patterns Three Aspects of the Paradigm Shift: 1. a focus on accountability outcomes revolution- has immediate economic consequences; refers to the increasing emphasis, and even demand, that clinicians selectively provide only the kind of cost-effective therapeutic interventions that result in positive outcomes medical necessity (treatment necessity)- basis for the authorization of behavioural health care, such as psychotherapy In terms of psychotherapy, medical necessity refers to the determination that psychotherapeutic treatment is appropriate (and) necessary to meet a persons health needs, and consistent with the diagnosis and clinical standards of care Treatment efficiency- refers to the clinical utility of a course of treatment provided by a given provider in a given clinical setting (Is the treatment working for this particular client?) Treatment efficacy- refers to a research protocol that psychotherapy researchers use to study how well a treatment performs when provided under optimal research conditions (Does a new treatment intervention produce better outcomes than commonly used interventions or a placebo treatment?) Treatment effectiveness- refers to a research protocol that health services researchers use to study how well a treatment intervention performs with clients in a clinical setting (Generally speaking, does a given treatment intervention produce beneficial results in actual clinical practice?) Concepts of treatment efficacy or effectiveness are not clinically useful; only treatment efficiency is clinically useful. 2. a greater sensitivity to cultural factors multiculturalism- refers to more than ethnicityincludes language, customs, social beliefs, and values, norms, religious practices, gender role expectations, etc. cultural factors are important in therapy since these factors impact an individuals basic personality and identity structure multiculturalism is generic to all counselling relationships and impacts countless aspects of the psychotherapy process
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counsellors and psychotherapists must foster cultural sensitivity and competence in attitudes and beliefs, knowledge, and skills 3. the trend toward integration two ways of achieving integration: integrating theory and techniques from several approaches into clinical practice; integrating the findings of relevant clinical research into clinical practice Curative Factors & Dynamics in Psychotherapy Michael Lamberts Four Common Curative Elements: 1. Client Resources (spontaneous remission- the clients contribution to outcome) 40% of improvement occurs in any treatment inner resources: clients readiness for change, coping, and personal/social skills, motivation, ego-strength, intelligence, achievements, psychologicalmindedness, courage, and past history of success in change efforts outer resources: specific environmental resources that impact clients such as social support system, financial resources, and fortuitous events 2. Therapeutic Relationship Context in which the process of therapy is experienced and enacted 30% of improvement Strupp: the sine qua non in all forms of psychotherapy Orlinsky, Grawe, & Parks: the quality of the clients participation in the therapeutic relationship is the essential determinant of outcome (if clients are motivated, engaged, and collaborated in the work with the therapist, they benefit the most from the experience) Carl Rogers: empathy, respect, and genuineness If clients feel understood, safe, and hopeful, they are more likely to risk disclosing painful affects and intimate details of their lives, as well as risk thinking, feeling, and acting in more adaptive and healthier ways Duncan, Solovey, & Rusk: the most helpful alliances are likely to develop when the therapist establishes a therapeutic relationship that matches the clients definition of empathy, respect, and genuineness 3. Intervention Strategies and Tactics Include clinical interpretation, free-association, confrontation, cognitive restructuring, medication, empty chair technique, biofeedback, systematic desensitization, reframing, family sculpting, miracle questions, or other solution-focused techniques 15% of improvement Miller, Duncan, & Hubble: clients are much less impressed with their therapists interventions than are their therapists. They contend that an immediate implication of Lamberts research finding is that therapists spend less time trying to figure out the right intervention or practicing the right brand of therapy and spend more time doing what they do best understanding, listening, building relationships, and encouraging clients to find ways to help themselves 4. Faith, Hope, & Expectancy 15% of improvement

placebo effect- proportion of treatment outcomes related to clients belief in their therapist or provider of care, as well as their belief in and hopefulness about the efficacy of the specific treatment to make a difference in their lives nocebo effect (negative placebo) Benson, Matthews, & Clark: described the placebo effect as the faith factor suggesting that an individuals belief in the cure or in the clinician who provides the cure has healing or curative power Research indicates that simply expecting therapy to be helpful somehow reverses demoralization and mobilizes hope, and facilitates improvement When the clinician instills hope and the belief that the treatment will likely work, verbally and nonverbally, improvement and positive treatment outcomes tend to occur Fostering a positive expectation for change appears to be a prerequisite for successful treatment. Sperrys Four Phases of the Psychotherapy Process: 1. Engagement The first and most important stage of treatment Effective treatment outcomes require that the client be sufficiently engaged, committed to, and actively involved in the treatment process. High level of client readiness for change predicts collaboration, compliance, positive changes; while a low readiness predicts resistance, non-compliance, and no change. Goal is to develop a working therapeutic strategies to facilitate optimal engagement. Include: manifest empathic listening, trigger the placebo effect, reverse the clients demoralization, and provide effective suggestions and socialization to therapy Optimal degree of engagement should be achieved for treatment to continue: - The clients active involvement in negotiating treatment goals, and realistic expectations for their role, and the therapists role in the change process - The clients willingness to follow the ground rules of therapy - The negotiation of a formal or informal treatment contract - High level of client readiness for change (action level) 2. Assessment Assessment of the clients maladaptive patterns Pattern: refers to the predictable and consistent style or manner in which a person thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances and reflects the individuals baseline functioning. It also has physical, psychological, and social features and includes the individuals functional strengths which counterbalance dysfunction

Goal is to specify the clients maladaptive pattern, including behavioural, effective, and cognitive components which, if changed, lead to more adaptive functioning Commonly used methods: diagnostic questioning protocols or strategies, interventive questioning strategies, assessment by means of psychological inventories or other questionnaires, role playing or other forms of in-session enactment to elicit and/or clarify client patterns 3. Intervention Goal is to modify or transform the clients maladaptive pattern into a more adaptive pattern Potentially include all therapeutic intervention strategies and tactics such as focused pattern interruption strategies, cognitive restructuring, interpretation, and/or reframing methods, and eliciting and supporting internal and external client resources Decreasing symptomatology and/or increasing life functioning are typical treatment goals. Symptom reduction or removal is one of the first goals of treatment. This is usually achieved with medication and/or behavioural interventions As symptoms increase, one or more areas of life functioning decrease; and therapeutic efforts to increase functional capacity tend to be thwarted until symptomatology is decreased. 4. Maintenance & Termination Goal is to maintain the newly acquired adaptive pattern, to prevent relapse, and to reduce/eliminate the clients reliance on the treatment relationship Relapse: refers to a continuation of the original episode Recurrence: the instigation of a new episode In order to prevent relapse, therapists must assess the clients risk factors and potential for relapse, and incorporate relapse prevention strategies into the treatment process Therapeutic methods to accomplish these goals: to employ relapse prevention strategies, to set or negotiate a termination date, to schedule weaning sessions, and to increase space medication maintenance sessions when continued use is warranted