临床与咨询心理学导论 15 - Psychotherapy Overview

L15 Introduction to Psychotherapy 

参考文献：Pomerantz, A. (2013). Clinical psychology: science, practice, and culture (3rd ed.). Thousand Oaks, CA: SAGE Publications.

15.1 Theoretical Orientations

• Theoretical orientation: Preference for a specific theory that provides a psychologist with a conceptual framework for understanding a client’s needs and for formulating specific interventions.

• A variety of perspectives:

- Psychoanalytic & Psychodynamic

- Humanistic / Client-Centered

- Behavioral

- Cognitive

- Cognitive-Behavioral

- Mindfulness & Acceptance Based

Psychodynamic Approaches - Sigmund Freud

• View: Problems are symptoms of unresolved traumas and conflicts.

• Focus of treatment:

- Inner, often unconscious motivations

- Resolving conflicts between personal needs and social requirements

• Approach:

- Clients work through problems by developing a better understanding the relationships between overt problems and unresolved, internal conflicts that cause them;

- Making the unconscious conscious.

Humanistic Approaches - Carl Rogers

• View: Problems result from difficulties in daily life, especially a lack of meaningful relationships and goals.

• Focus of treatment:

- The whole person ;

- Achieving potential for personal performance and greater richness of experience.

• Approach:

- Relationship with the therapist is key;

- Empathy, genuineness, and unconditional positive regard.

Behavioral Approaches - Joseph Wolpe & B. F. Skinner

• View:

Problems are the result of learned behaviors that are not helpful or adaptive.

• Focus of treatment:

Observable maladaptive behavior(s) and the environmental contingencies that sustain them.

• Approach: Clients learn healthy behaviors by applying the principles of conditioning (e.g., reinforcement, punishment).

Cognitive Approaches - Aaron T. Beck

• View: Problems result from what we think (cognitive content) and how we think (cognitive process)

• Focus of treatment:

- Identifying and changing cognitive distortions

• Approach: Clients learn adaptive ways of thinking about experiences through identifying and challenging problematic thought patterns

Mindfulness/Acceptance Approaches - Steve Hayes

• View: Problems result from an inability to accept what is out of one’s control

• Focus of treatment: Maximize potential for a full and meaningful life

• Approach:

- Learn skills to deal with painful thoughts/feelings so that they have less impact and influence over you

- Clarify your values

- Use skills/knowledge to guide, inspire and motivate changes for for a life worth living

15.2 Types of Psychotherapy Practiced by Psychologists

Most Common Types of Therapy Practiced

• Most popular theoretical orientations have changed over time

• Cognitive and cognitive-behavioral approaches have become very popular

Eclectic & Integrative Approaches

• Eclectic therapy: Selecting the best treatment for a given client based on empirical data - Usually based on client diagnosis

• Integrative therapy: Blending techniques in order to create an entirely new, hybrid form of therapy

• Assimilative approach

- Therapist is grounded in one primary theoretical orientation

- Other techniques are incorporated

• Distinguished from an eclectic approach because techniques are blended together; Distinguished from an integrative approach because one single theoretical orientation is dominant

15.3 Common Factors in Treatment Approaches

• Common factors: Features observed across all forms of therapy

• Therapeutic Alliance: A trusting relationship of two partners working toward a common goal

- Different from other relationships

• Unilateral: Focus is on the client’s needs

• Systematic: Agree on steps to reach an identified goal

• Formal: Specified boundaries

• Time-limited: Specific time limit

• Of common factors, therapeutic alliance is best predictor of outcome

• Hope: Positive expectations for treatment

- Optimism that treatment will produce desired changes

• Attention: Acknowledging a problem and focusing on it may lead to improvement

- Even before treatment techniques are used, some improvement may be observed

Three-Stage Model

• Sequence of common factors over the course of therapy

• Three-stage sequential model of common factors

1. Support factors

- Therapeutic alliance, trust, warmth

2. Learning factors

- Changing expectations, thought patterns, increasing insight

3. Action factors

- Facing fears, taking risks, practicing new behaviors, working through problems

How do do it: Genuineness; Respect; Empathy; Warmth

15.4 Differences across Approaches

• Insight versus action

- Psychodynamic

• Insight-oriented

• Focus on gaining insight into one’s unconscious motives

- Cognitive and Behavioral Therapies

• Action-oriented

• Focus on changing overt behaviors

• More specific behavioral goals

• Focus on therapeutic relationship

- Important in all schools of therapy

- Emphasized the most in humanistic therapy

• Thought to be the necessary & sufficient element in humanistic therapy

• Focus within versus outside therapy session

- Emphasis within sessions

- Psychodynamic

- Humanistic

- Emphasis outside sessions

• “Homework”: Tasks and activities assigned to be completed between treatment sessions

- Behavioral

- Cognitive

15.5 Which one is more important?

Are Common Factors More Important?

• Dodo-bird Verdict

- Argument that different types of therapy generally produce equivalent outcomes

- Must be due to common factors

• Evidence used to support this verdict comes from studies that compared different treatments (without considering the specific problems/disorders being treated)

Are Specific Techniques More Important?

• Evidence-based treatments movement

- Specific therapies for specific disorders

- Analysis leading to dodo-bird verdict collapses across:

• Many different kinds of therapy

• Many different kinds of problems

• Direct comparisons for specific disorders

- For some disorders and symptoms, certain therapies appear superior

- Strong support for cognitive-behavioral techniques

Multiple Factors are Important!

“The treatment method, the therapist, the client, and the principles of change are vital contributors, and all must be studied. Comprehensive evidence-based practices will consider all of these determinants and their optimal combinations. Common and specific effects and art and science appear properly complementary, not at either/or dichotomies.” (Paul, 2007, p. 141)

15.6 Does Psychotherapy Work?

• Efficacy studies: Does therapy work “in the lab”?

- Well-defined group of clients

- Meet diagnostic criteria only for the disorder being studied

- Manualized treatment

- Random assignment to treatment or control

• Landmark meta-analysis (Glass & Miller, 1980)

- 475 psychotherapy efficacy studies

- “The average person who receives therapy is better off than 80% of the persons who do not” (effect size = 0.85)

• Effectiveness studies: Does therapy work “in the real world”?

- Wider range of clients

- Complex diagnostic profiles

- Variability in therapist methods (i.e., no manuals)

- Typically does not include a control group

• “Mental Health” (Consumer Reports, 1995)

- ~90% of people who felt “very poor” or “fairly poor” before starting therapy felt “so-so, good or very good” after completing therapy