Clinical Interventions: Clinical Interventions: Overview & MethodsOverview & Methods

Clinical Interventions: Clinical Interventions: Overview & MethodsOverview & Methods

Dr. KlineDr. Kline

FSU-PCFSU-PC

What is Psychotherapy?What is Psychotherapy?Psychotherapy essentially is treatment conducted Psychotherapy essentially is treatment conducted

within a professional relationship by trained within a professional relationship by trained therapists to help/facilitate clients in distresstherapists to help/facilitate clients in distress (Neitzel (Neitzel et al., 2003). et al., 2003).

This definition, allows us to identify: This definition, allows us to identify: **The participantsThe participants (i.e., the client and therapist) (i.e., the client and therapist)**The basic framework of the situationThe basic framework of the situation (professional (professional

relationship)relationship)**The basic goal of the therapyThe basic goal of the therapy (reduction of emotional (reduction of emotional

distress/help with the problem).distress/help with the problem).

Who are the therapists?Who are the therapists? While, therapists are trained professionals at dealing While, therapists are trained professionals at dealing

with client’s problems & issues, the type of training, with client’s problems & issues, the type of training, theoretical orientation, years of education, & scope of theoretical orientation, years of education, & scope of ability vary. ability vary.

In general the following individuals are considered In general the following individuals are considered therapists:therapists:

Clinical Psychologists (PhD & PsyD)Clinical Psychologists (PhD & PsyD) Master’s level psychologistsMaster’s level psychologists PsychiatristsPsychiatrists MSWMSW Marriage and Family therapists (MFT)Marriage and Family therapists (MFT)

Characteristics associated with good therapists?Characteristics associated with good therapists?

Advanced Training

Includes communication, relationship-building, & self-monitoring skills.

Good Interpersonal Skills

Good Listening Ability

Should be able to listen to clients & effectively communicate with them.

Genuineness, empathy, &

Unconditional positive regard.These promote rapport with the client & build trust.

Clients prefer therapists with advanced training.

Who are the clients?Who are the clients?

Clients, like therapists, vary is several characteristics, but with Clients, like therapists, vary is several characteristics, but with one notable exception:one notable exception:

***Most clients that seek help from a therapist have ***Most clients that seek help from a therapist have reached a point where reached a point where their coping mechanisms no their coping mechanisms no longer functionlonger function.***.***

Occasionally, some clients seek therapy because someone else is Occasionally, some clients seek therapy because someone else is distressed (e.g., a parent, judge, employer, spouse, or other distressed (e.g., a parent, judge, employer, spouse, or other family member). family member).

These clients tend to be less motivated than clients These clients tend to be less motivated than clients seeking help for themselves. seeking help for themselves.

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

1. 1. Clients who “Clients who “do their homeworkdo their homework” tend to do better.” tend to do better. That is, That is, clients who “complete” assignments given to them by their clients who “complete” assignments given to them by their therapists (e.g., keep a diary of emotions, etc.) show better therapists (e.g., keep a diary of emotions, etc.) show better treatment outcomes. treatment outcomes.

Burns & Spangler (2000) reported that depressed patients Burns & Spangler (2000) reported that depressed patients who were homework compliant, reported decreases in who were homework compliant, reported decreases in depressiondepression. .

2. 2. Clients who are Clients who are cooperativecooperative & & openopen tend to have better tend to have better treatment outcomes treatment outcomes than clients who are resistant & defensive. than clients who are resistant & defensive. (Orlinksy, Grawe, & Parks, 1994). (Orlinksy, Grawe, & Parks, 1994).

The Therapeutic RelationshipThe Therapeutic Relationship A. A. Professional Guidelines-Professional Guidelines- therapists have therapists have commitments to honorcommitments to honor in their in their

relationship with a client. These commitments protect the client & therapeutic relationship with a client. These commitments protect the client & therapeutic relationship. relationship.

These These commitmentscommitments are: are: ConfidentialityConfidentiality – information about the client isn’t revealed with anyone – information about the client isn’t revealed with anyone

except for unique circumstances (e.g., client is danger to himself/herself, is a except for unique circumstances (e.g., client is danger to himself/herself, is a danger to others). danger to others).

Informed consentInformed consent – therapists must tell clients – therapists must tell clients what the guidelines are for confidentiality. what the guidelines are for confidentiality.

EthicsEthics - Clients have a right to know what is appropriate conduct for - Clients have a right to know what is appropriate conduct for therapists within a therapeutic relationship. The therapists within a therapeutic relationship. The ethics codeethics code for these issues for these issues are published in the American Psychological Association’s “are published in the American Psychological Association’s “Ethical Ethical Principles of Psychologists and Code of ConductPrinciples of Psychologists and Code of Conduct”. ”.

B.B. Therapist Objectivity & Self-DisclosureTherapist Objectivity & Self-Disclosure Although therapists need to be empathetic & understanding, there will be Although therapists need to be empathetic & understanding, there will be

situations in which therapists will have to situations in which therapists will have to “push” their clients to overcome “push” their clients to overcome resistance in dealing with a problemresistance in dealing with a problem . .

This requires This requires objectivityobjectivity on the therapist’s part, because the therapist will have on the therapist’s part, because the therapist will have to determine when to to determine when to detachdetach themselves from their clients so they can “insist” themselves from their clients so they can “insist” their clients progress towards a solution to their problems.their clients progress towards a solution to their problems.

However, there will also be occasions in which therapists may want to use However, there will also be occasions in which therapists may want to use self-self-disclosuredisclosure (divulging something about themselves to their client) as a means of (divulging something about themselves to their client) as a means of building trust and rapport with their clients. building trust and rapport with their clients.

E.g., a family counselor whose been divorced may carefully divulge something E.g., a family counselor whose been divorced may carefully divulge something about his/her own experience so as to build about his/her own experience so as to build common groundcommon ground with a client going with a client going through a divorce. The client through a divorce. The client ““identifiesidentifies”” with the therapist, thereby promoting with the therapist, thereby promoting trust in the therapeutic relationship. trust in the therapeutic relationship.

– Caution: therapists should only divulge a minor bit of information about Caution: therapists should only divulge a minor bit of information about themselves to their clients. themselves to their clients. Too much or too little information may impair the Too much or too little information may impair the relationship between the therapist and clientrelationship between the therapist and client . .

C. Therapeutic Alliance – determined by two factorsC. Therapeutic Alliance – determined by two factors

Factor 1Factor 1: The : The emotional tiesemotional ties that develop between the that develop between the therapist & client (trust, respect, etc.).therapist & client (trust, respect, etc.).

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

Outpatient Settings Inpatient Settings

Therapist’s office, rented spaces in community centers, etc.

Therapist office-most common setting for therapy. Privacy is required.

Public, private, & VA hospitals, residential rehab & treatment centers, prisons, jails, etc.

Hospital-most common setting for treatment. Psychopathology is usually fairly serious with in-patient care.

Goals of PsychotherapyGoals of PsychotherapyGoals of PsychotherapyGoals of Psychotherapy 1. 1. Fostering insight:Fostering insight: Therapy should improve a client’s insight Therapy should improve a client’s insight

into why he or she behaves the way they do.into why he or she behaves the way they do.

******The rationale here is that by understanding your behavior problems (mistakes), The rationale here is that by understanding your behavior problems (mistakes), you are empowered to make behavior changes that are adaptive & healthyyou are empowered to make behavior changes that are adaptive & healthy .***.***

According to Nietzel et al., 2003, therapists of all theoretical backgrounds need to According to Nietzel et al., 2003, therapists of all theoretical backgrounds need to encourage their patients to understand “their” actions. encourage their patients to understand “their” actions.

One method for facilitating insight in your patients, is for the therapist to One method for facilitating insight in your patients, is for the therapist to interpret the client’s behaviorinterpret the client’s behavior. .

****This is done to motivate clients to examine their own behavior and draw ****This is done to motivate clients to examine their own behavior and draw inferences about the meaning of their actions. inferences about the meaning of their actions. Note: this is not to show client’s Note: this is not to show client’s the therapist is right!!!!!***the therapist is right!!!!!***

Caution: Therapists will want to avoid divulging information that is too confrontational to client’s who are disturbed or who have a fairly severe

diagnosis that may not be able to handle such news at the time.

2. 2. Reducing emotional discomfort:Reducing emotional discomfort: Therapists often are faced with client’s who are in severe emotional pain & Therapists often are faced with client’s who are in severe emotional pain &

anguish. This makes therapy challenging as the patient is greatly distressed.anguish. This makes therapy challenging as the patient is greatly distressed.

Therapists don’t want to completely reduce the client’s distress as this may Therapists don’t want to completely reduce the client’s distress as this may eliminate their desire to address their problemseliminate their desire to address their problems, but will want to , but will want to reduce the reduce the client’s distress to some extent to promote a positive treatment outcome.client’s distress to some extent to promote a positive treatment outcome.

One way to achieve this goal is for therapists to use the therapeutic relationship One way to achieve this goal is for therapists to use the therapeutic relationship to improve the client’s emotional strength. For instance, if the client feels to improve the client’s emotional strength. For instance, if the client feels they can count on the therapist be understanding and non-judgmental, they are they can count on the therapist be understanding and non-judgmental, they are better equipped to deal with the onslaughts from the others. better equipped to deal with the onslaughts from the others.

Therapists can convey the message to client’s that although things seem Therapists can convey the message to client’s that although things seem hopeless and insurmountable now, you will be able to make changes in your hopeless and insurmountable now, you will be able to make changes in your life that improve your outlook considerably.life that improve your outlook considerably.

3. 3. Encouraging Catharsis:Encouraging Catharsis: Catharsis, involves releasing pent-up emotions (frustration, Catharsis, involves releasing pent-up emotions (frustration,

anger, helplessness) that have been bothering the client for a long anger, helplessness) that have been bothering the client for a long period of time.period of time.

Therapists should encourage catharsis, by empowering client’s Therapists should encourage catharsis, by empowering client’s to express their emotions, frustrations, and issues in therapyto express their emotions, frustrations, and issues in therapy. .

Therapist to client: Therapist to client: ““Tell me how you feel about that?….”Tell me how you feel about that?….” ““How did that make you feel when he/she did that to you?...”How did that make you feel when he/she did that to you?...”

There is some evidence that such emotion-focused techniques There is some evidence that such emotion-focused techniques may be helpful in easing tension for client’s who are distressed may be helpful in easing tension for client’s who are distressed or repressing their problems. or repressing their problems.

4. 4. Providing New InformationProviding New Information::

Among other things, therapists help their clients by Among other things, therapists help their clients by educating themeducating them..

That is, therapists provide information to client’s about That is, therapists provide information to client’s about their:their:

****maladaptive thought patternsmaladaptive thought patterns (e.g., identifying (e.g., identifying irrational or inaccurate beliefs) irrational or inaccurate beliefs)

**Problem behaviors**Problem behaviors (e.g., self-destructive behaviors (e.g., self-destructive behaviors such as addictions, actions designed to hurt others). such as addictions, actions designed to hurt others).

Psychodynamic TherapiesPsychodynamic TherapiesPsychodynamic TherapiesPsychodynamic Therapies Psychodynamic therapies assume that Psychodynamic therapies assume that an individual’s an individual’s

behavior is determined by the interaction of behavior is determined by the interaction of powerful competing forces within the person. powerful competing forces within the person.

These forces are largely:These forces are largely: ****unconscious (unconscious (outside the person’s awareness)outside the person’s awareness) ****Develop in early childhoodDevelop in early childhood. . ****Result in coping mechanisms designed to deal Result in coping mechanisms designed to deal

with anxiety.with anxiety.

This is a This is a push-pullpush-pull theory!!!! theory!!!!

Origins of PsychoanalysisOrigins of Psychoanalysis Shortly into Freud’s career as a physician, he examined several Shortly into Freud’s career as a physician, he examined several

patients who displayed neurological symptoms with no known patients who displayed neurological symptoms with no known organic cause (e.g., some patients complained of paralysis, yet organic cause (e.g., some patients complained of paralysis, yet could move their limbs in their sleep). could move their limbs in their sleep).

Freud labeled these patients as, “Freud labeled these patients as, “neuroticsneurotics.” .” Most of these Most of these patients exhibited hysterical paralyses, amnesia, blindness, & patients exhibited hysterical paralyses, amnesia, blindness, & speech loss. speech loss.

Treatment for these neuroses consisted of Treatment for these neuroses consisted of baths or electrically baths or electrically generated heat, which Freud believed resulted in symptom relief generated heat, which Freud believed resulted in symptom relief due to the power of suggestiondue to the power of suggestion (e.g., placebo effect). (e.g., placebo effect).

Freud decided to try Freud decided to try hypnosishypnosis as a method of suggestion that as a method of suggestion that might alleviate neurotics’ symptoms. might alleviate neurotics’ symptoms.

Hypnosis: its history with psychoanalysisHypnosis: its history with psychoanalysis Joseph Breuer, a colleague of Freud’s, recommended that hypnosis and the cathartic Joseph Breuer, a colleague of Freud’s, recommended that hypnosis and the cathartic

method be used to treat neurotics.method be used to treat neurotics.

Breuer had a patient (Anna O.) come to him complaining of (headaches, cough, neck & Breuer had a patient (Anna O.) come to him complaining of (headaches, cough, neck & arm paralyses) that originated shortly before her father’s death, but became worse arm paralyses) that originated shortly before her father’s death, but became worse afterwards.afterwards.

Breuer, noticed Anna when into “Breuer, noticed Anna when into “trance-like states” that resembled hypnosistrance-like states” that resembled hypnosis. During . During one of these “trances” he encouraged his patient to describe the events that occurred 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 during her day. This resulted in a short-term improvement in her symptoms immediately following the trance.following the trance.

On one session, Breuer noticed that one of her “symptoms” that was linked with a 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. 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 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. or was simply unaware of during the day and her neurological symptoms.

Using hypnosis, Breuer encouraged Anna to recall everything about her 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 and the events in her life. This seemed to work as symptoms continued to disappear with these “therapeutic sessions.”with these “therapeutic sessions.”

Freud’s use of hypnosis & other treatments:Freud’s use of hypnosis & other treatments:

Freud took Breuer’s advice & used hypnosis to treat neurotics.Freud took Breuer’s advice & used hypnosis to treat neurotics.

However, because not all patients could be easily hypnotized, he However, because not all patients could be easily hypnotized, he started simply requiring patients to close their eyes and recall started simply requiring patients to close their eyes and recall emotions, thoughts, feelings, and events that came to mine.emotions, thoughts, feelings, and events that came to mine.

Later, he simply asked the to mention whatever they were Later, he simply asked the to mention whatever they were thinking. thinking.

He also started to ask patients to describe their He also started to ask patients to describe their dreamsdreams as he felt as he felt dreams may divulge hidden motives/events that were the route of dreams may divulge hidden motives/events that were the route of their problems. their problems.

Goals of PsychoanalysisGoals of PsychoanalysisGoals of PsychoanalysisGoals of Psychoanalysis

The goal of psychoanalysis is to make a client’s The goal of psychoanalysis is to make a client’s unconscious motives, drives, and conflicts available to unconscious motives, drives, and conflicts available to them so they can deal with it.them so they can deal with it.

Freud reasoned that if individuals were confronted with Freud reasoned that if individuals were confronted with the reasons why they behaved in maladaptive ways, the reasons why they behaved in maladaptive ways, they would be forced to change their behaviors. they would be forced to change their behaviors.

However, the client must figure these things out for However, the client must figure these things out for himself/herself, with the therapist as a guidehimself/herself, with the therapist as a guide. .

Three main goals of Psychoanalytic treatment:Three main goals of Psychoanalytic treatment:

1. 1. Intellectual & emotional insight into the Intellectual & emotional insight into the underlying causes of the client’s issues.underlying causes of the client’s issues.

2. Working through the implications of these insights.2. Working through the implications of these insights.

3. Strengthening the ego’s control over the id & 3. Strengthening the ego’s control over the id & superego. superego.

This takes on average (3-5 sessions per week for 2-15 This takes on average (3-5 sessions per week for 2-15 years) with a psychoanalyst.years) with a psychoanalyst.

Psychoanalytic Treatment Methods:Psychoanalytic Treatment Methods:

1. 1. Free AssociationFree Association – Evolved from a non-hypnotic way for – Evolved from a non-hypnotic way for Freud’s patients to “Freud’s patients to “consciouslyconsciously” recover emotional memories.” recover emotional memories.

The client needs to say everything that comes to mind The client needs to say everything that comes to mind without editing or censorship (Neitzel et al., 2003). This without editing or censorship (Neitzel et al., 2003). This should allow bits & pieces of unconscious material to appear.should allow bits & pieces of unconscious material to appear.

The therapist will have to look for “patterns of association” that The therapist will have to look for “patterns of association” that indicate something important. indicate something important.

Clients who only talk about trivial issues (small-talk) are seen as Clients who only talk about trivial issues (small-talk) are seen as constructing barriers that impedes their progress. Thus, there constructing barriers that impedes their progress. Thus, there should be something of substance mentioned in the session. should be something of substance mentioned in the session.

2. Dream Analysis2. Dream Analysis Freud believed dreams represented repressed memories, wishes, and Freud believed dreams represented repressed memories, wishes, and

desires. desires.

Freud argued dreams contained two kinds of content:Freud argued dreams contained two kinds of content:****Manifest content-Manifest content- the actual events or images that occur in the dream. the actual events or images that occur in the dream.****Latent contentLatent content – the unconscious information in the dream that occurs in – the unconscious information in the dream that occurs in

the forms of symbols. the forms of symbols.

Freud had client’s recall the manifest content of their dreams, to see if he Freud had client’s recall the manifest content of their dreams, to see if he could detect the could detect the unconscious material masked in the dream’s images and unconscious material masked in the dream’s images and actionsactions. .

Psychoanalysts may examine several dreams produce by a given client to see Psychoanalysts may examine several dreams produce by a given client to see if any common themes develop and how these may relate to their if any common themes develop and how these may relate to their problems in daily life.problems in daily life.

3. Transference3. Transference

The client’s feelings toward the therapist and their relationship is known as The client’s feelings toward the therapist and their relationship is known as transference.transference.

Freud argued the unconscious information regarding authority figures from childhood Freud argued the unconscious information regarding authority figures from childhood lie at the root of many clients’ current problems. lie at the root of many clients’ current problems.

Therapists will try to remain a bit detached & divulge very little about themselves to Therapists will try to remain a bit detached & divulge very little about themselves to their clients their clients to encourage clients to project onto them unconscious attributes & to encourage clients to project onto them unconscious attributes & motives associated with parents, spouses, & other people in their lives (e.g., motives associated with parents, spouses, & other people in their lives (e.g., client may see therapist as neglectful parent, loving spouse, jealous lover, etc.).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 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 the client to discover the issues that are bothering them with other people in their lives. lives.

Therapists need to be careful that they don’t project their own unconscious Therapists need to be careful that they don’t project their own unconscious desires, feelings, & so forth onto their clients, something called desires, feelings, & so forth onto their clients, something called countertransferencecountertransference. .

Behavior TherapiesBehavior TherapiesBehavior TherapiesBehavior Therapies A. Assumptions of behavior therapies:A. Assumptions of behavior therapies:

1. Behavior disorders are assumed to have developed through 1. Behavior disorders are assumed to have developed through learning learning (conditioning, modeling, etc.).(conditioning, modeling, etc.).

2. Therapies should be based on 2. Therapies should be based on results of research in learning based results of research in learning based methods.methods.

3. The goal of behavior therapies is to 3. The goal of behavior therapies is to modify overt, maladaptive modify overt, maladaptive behaviors.behaviors.

4. Therapies should focus on clients’ current problems in their natural 4. Therapies should focus on clients’ current problems in their natural environments.environments.

5. Treatment should be based on carefully 5. Treatment should be based on carefully controlled empirical studies controlled empirical studies examining the efficacy of therapies on treatment outcomesexamining the efficacy of therapies on treatment outcomes. .

B. Origins of Behavior TherapyB. Origins of Behavior Therapy The link between behavioral methods & psychopathology The link between behavioral methods & psychopathology

actually began in the 1920s and 30s when Pavlov examined actually began in the 1920s and 30s when Pavlov examined experimental neuroses in dogsexperimental neuroses in dogs after exposing them to electric after exposing them to electric shock. shock.

The dogs’ symptoms included: agitation, barking, biting the The dogs’ symptoms included: agitation, barking, biting the equipment, & forgetting previously learned events (Nietzel et al. equipment, & forgetting previously learned events (Nietzel et al. 2003). 2003).

Watson & Raynor’s work on Little Albert was a follow-up to Watson & Raynor’s work on Little Albert was a follow-up to Pavlov’s work described above. They showed you could Pavlov’s work described above. They showed you could condition “fear” responses in an 11-month old infant through condition “fear” responses in an 11-month old infant through classical conditioning.classical conditioning.

Origins (contd.)Origins (contd.)

By the 1950s & 60s behavior treatment was used to By the 1950s & 60s behavior treatment was used to treat a variety of problems (anxiety disorders, sexual treat a variety of problems (anxiety disorders, sexual disorders, schizophrenia, etc.). disorders, schizophrenia, etc.).

Today, behavior therapies rank high among treatments Today, behavior therapies rank high among treatments for a variety of psychopathology and is the gold for a variety of psychopathology and is the gold standard for treating certain disorders (phobias, anxiety, standard for treating certain disorders (phobias, anxiety, autism).autism).

Behavior therapy treatment methods:Behavior therapy treatment methods: 1. 1. Systematic DesensitizationSystematic Desensitization: first developed by Joseph Volpe : first developed by Joseph Volpe

in 1958, the goal of this treatment is to extinguish fear and/or in 1958, the goal of this treatment is to extinguish fear and/or anxiety in individuals (and organisms).anxiety in individuals (and organisms).

This is accomplished by systematically exposing individuals to This is accomplished by systematically exposing individuals to fear-eliciting stimuli that are gradually increased in intensity fear-eliciting stimuli that are gradually increased in intensity over trialsover trials. .

Therapy consists of three parts: Therapy consists of three parts: ***Relaxation training*** ***Relaxation training*** ***Creating a graduated hierarchy of fear-evoking events******Creating a graduated hierarchy of fear-evoking events*** ***Imagined /virtual reality desensitization*** ***Imagined /virtual reality desensitization***

Formula for Systematic Desensitization:Formula for Systematic Desensitization: Part IPart I: : Clients are trained to employ a relaxation method to reduce anxiety. Clients are trained to employ a relaxation method to reduce anxiety.

Progressive relaxation trainingProgressive relaxation training, a common relaxation method, requires that clients voluntarily , a common relaxation method, requires that clients voluntarily tense specific muscle groups (hands, arms, etc.) for a period of time & then focus on the tense specific muscle groups (hands, arms, etc.) for a period of time & then focus on the sensations of relaxation that follow muscle release.sensations of relaxation that follow muscle release.

E.g., require clients to clench the fist for several seconds followed by release.E.g., require clients to clench the fist for several seconds followed by release.

Part II:Part II: The therapist creates a graduated hierarchy of events/situations the The therapist creates a graduated hierarchy of events/situations the client finds as increasingly anxiety-provoking. Each event (or stimulus) should be client finds as increasingly anxiety-provoking. Each event (or stimulus) should be perceived as more anxious than the preceding eventperceived as more anxious than the preceding event. .

Part IIIPart III: : The client may use either imagined desensitization or more realistic The client may use either imagined desensitization or more realistic desensitization. On the first trial on desensitization. On the first trial on imagined desensitizationimagined desensitization, the client mentally , the client mentally ““visualizesvisualizes” the first event on the graduated hierarchy and tries to remain relaxed ” the first event on the graduated hierarchy and tries to remain relaxed until fear/anxiety is extinguished. If they can do this for until fear/anxiety is extinguished. If they can do this for 10 seconds10 seconds, the therapist , the therapist encourages them to visualize the next event on the hierarchy, and so forth.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 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, 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 they are then exposed to a slightly more intense version of the fear-eliciting stimulus, and so forth.forth.

Desensitization HierarchyDesensitization Hierarchy

1. Imagine writing the word, spider.

2. Image while reading a book you notice a small spider on the cover.

3. Imagine a spider the size of your hand across the room from you.

4. Imagine the big spider has crawled closer to you; it’s about 3 feet from you.

5. Imaging the spider is now 1 foot away and crawling towards your hand.

6. Imagine the spider is crawling onto your hand.

2. 2. Exposure techniquesExposure techniques::

The goal of exposure therapy is to The goal of exposure therapy is to fully exposefully expose the client to the the client to the fear-eliciting stimuli so that they experience anxiety and wait fear-eliciting stimuli so that they experience anxiety and wait until it finally extinguishes. One common exposure method is until it finally extinguishes. One common exposure method is flooding.flooding.

Flooding—requires that client is exposed to a maximally Flooding—requires that client is exposed to a maximally intense “level” of the fear-eliciting stimulusintense “level” of the fear-eliciting stimulus . . This should This should cause a severe anxiety response that with prolonged exposure cause a severe anxiety response that with prolonged exposure (time) should diminish, thus extinguishing the association (time) should diminish, thus extinguishing the association between anxiety & the fear-eliciting stimulusbetween anxiety & the fear-eliciting stimulus. .

E.g., putting a tarantula in the hand of E.g., putting a tarantula in the hand of

a client with arachnophobia!!!!a client with arachnophobia!!!!

Important points for exposure methods:Important points for exposure methods:

Exposure methods will only work if Exposure methods will only work if enough time is enough time is allowed for the anxiety responses to extinguishallowed for the anxiety responses to extinguish..

Removing the fear-eliciting stimulus too early will Removing the fear-eliciting stimulus too early will only reinforce avoidance behavioronly reinforce avoidance behavior, thus strengthening , thus strengthening the association between the anxiety & fear-eliciting the association between the anxiety & fear-eliciting stimulus. stimulus.

Therefore, exposure therapies require a strong Therefore, exposure therapies require a strong commitment on the part of both client & therapist.commitment on the part of both client & therapist.

Efficacy of Exposure treatments:Efficacy of Exposure treatments: Exposure treatments have been shown to be successful Exposure treatments have been shown to be successful

in treating obsessive-compulsive disorder (OCD), in treating obsessive-compulsive disorder (OCD), phobias, & panic disorder.phobias, & panic disorder.

In treating OCD, clients are exposed to the stimulus In treating OCD, clients are exposed to the stimulus linked with their obsessive thoughts (e.g., dirt) & linked with their obsessive thoughts (e.g., dirt) & not not allowed to engage in the ritualistic behaviors that allowed to engage in the ritualistic behaviors that usually reduce their anxietyusually reduce their anxiety (e.g., compulsive hand- (e.g., compulsive hand-washing). washing).

This is called This is called exposure and response prevention exposure and response prevention (ERP). (ERP).

3. Modeling3. Modeling Has been used to treat phobias, social withdrawal, Has been used to treat phobias, social withdrawal,

OCD, antisocial conduction, aggressiveness, & autism.OCD, antisocial conduction, aggressiveness, & autism.

A client with a clinical problem, can observe live or A client with a clinical problem, can observe live or videotaped models performing behaviors that the client videotaped models performing behaviors that the client avoids avoids with no negative consequences experiencedwith no negative consequences experienced. .

Treatment is most effective when are Treatment is most effective when are very similar to very similar to the client, have high status, & are reinforced for the client, have high status, & are reinforced for their responsestheir responses (Neitzel et al., 2003). (Neitzel et al., 2003).

Contingency managementContingency management Refers to operant conditioning methods where behaviors are strengthened or Refers to operant conditioning methods where behaviors are strengthened or

reduced based on consequences. reduced based on consequences.

**Shaping****Shaping** - develops new behaviors by strengthening successive - develops new behaviors by strengthening successive approximations of desired responses.approximations of desired responses.

**Time out***-**Time out***- reduces frequency of undesirable behaviors by removing reduces frequency of undesirable behaviors by removing client from setting where being has been reinforced.client from setting where being has been reinforced.

**Contingency contracting**-**Contingency contracting**-a formal contract is written out by a therapist a formal contract is written out by a therapist & client stating what consequences will be for undesirable behaviors.& client stating what consequences will be for undesirable behaviors.

**Token Economies**-**Token Economies**- tokens are earned for desired behaviors, lost for tokens are earned for desired behaviors, lost for unwanted behaviors. Tokens may be used to obtain something else (e.g., like unwanted behaviors. Tokens may be used to obtain something else (e.g., like money to buy things).money to buy things).

Cognitive-Behavioral TherapyCognitive-Behavioral TherapyCognitive-Behavioral TherapyCognitive-Behavioral Therapy All cognitive therapies attempt to modify individuals’ thoughts All cognitive therapies attempt to modify individuals’ thoughts

(cognitions), thereby resulting in changes in the clients’ (cognitions), thereby resulting in changes in the clients’ responses.responses.

Cognitive approaches assume psychopathology results from Cognitive approaches assume psychopathology results from faulty/inaccurate cognitions (beliefs, schemas, problem-solving faulty/inaccurate cognitions (beliefs, schemas, problem-solving strategies) that are linked with our affectivity (emotions).strategies) that are linked with our affectivity (emotions).

E.g., depression results from negative thoughts & beliefs about the E.g., depression results from negative thoughts & beliefs about the self (“self (“I am worthless,” “No one loves me,” “I’m a failureI am worthless,” “No one loves me,” “I’m a failure,” etc.). ,” etc.). These negative beliefs result in negative affectivity, thereby These negative beliefs result in negative affectivity, thereby leading to depressive symptomsleading to depressive symptoms. .

If you change the faulty perception, the maladaptive actions & If you change the faulty perception, the maladaptive actions & underlying affectivity resulting in depressed mood will dissipateunderlying affectivity resulting in depressed mood will dissipate..

The combination of behavior & cognition in The combination of behavior & cognition in cognitive-behavioral therapycognitive-behavioral therapy

Cognitive-Behavioral therapy represents the Cognitive-Behavioral therapy represents the blending of blending of cognitive & behavioral techniquescognitive & behavioral techniques to treat to treat psychopathology. psychopathology.

Therapists with a behavioral orientation, recognized the Therapists with a behavioral orientation, recognized the importance of perception & thoughts in treating importance of perception & thoughts in treating disorders, while cognitive therapists recognized the disorders, while cognitive therapists recognized the significance of change maladaptive actions in significance of change maladaptive actions in improving self-esteem. improving self-esteem.

Cognitive-Behavioral treatment methods:Cognitive-Behavioral treatment methods: 1. 1. Beck’s Cognitive TherapyBeck’s Cognitive Therapy: Developed by Aaron Beck, this : Developed by Aaron Beck, this

method attempts to improve mental problems by identifying & method attempts to improve mental problems by identifying & correcting the distorted beliefs (thoughts) that result in the correcting the distorted beliefs (thoughts) that result in the abnormal behaviors. abnormal behaviors.

Beck argues that logical errors & distortions in thinking result Beck argues that logical errors & distortions in thinking result in depression & other forms of negative affectivity. in depression & other forms of negative affectivity.

E.g., A man concludes that he’s worthless, because a woman he E.g., A man concludes that he’s worthless, because a woman he asked on a date turns him down. There may be multiple reasons 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 for her response that has nothing to do with him, but he focuses on his unworthiness. on his unworthiness.

Applying Beck’s therapyApplying Beck’s therapy Distorted & inaccurate beliefs are identified & corrected by Distorted & inaccurate beliefs are identified & corrected by

therapists using these strategies (see Neitzel et al., 2003, p255).therapists using these strategies (see Neitzel et al., 2003, p255).

1. 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.

2. 2. Rational Emotive Behavior TherapyRational Emotive Behavior Therapy:: REBT, developed by Albert Ellis, attempts to treat abnormal behavior REBT, developed by Albert Ellis, attempts to treat abnormal behavior

that results from irrational thoughts & beliefs. that results from irrational thoughts & beliefs.

Individuals with irrational, self-defeating thoughts, develop unrealistic Individuals with irrational, self-defeating thoughts, develop unrealistic expectations of what is needed for them to be happy. When these expectations of what is needed for them to be happy. When these expectations/beliefs are unmet, depression & anxiety result.expectations/beliefs are unmet, depression & anxiety result.

The goal of REBT is to replace the client’s irrational & self-destructive The goal of REBT is to replace the client’s irrational & self-destructive beliefs with rational, logical thinking patterns that do not result in beliefs with rational, logical thinking patterns that do not result in negative affectivity. negative affectivity.

Therapists need to be Therapists need to be strong, direct, and focusedstrong, direct, and focused when when working with clients. working with clients.

Humanistic TherapiesHumanistic TherapiesHumanistic TherapiesHumanistic Therapies These therapies focus on helping clients deal with their These therapies focus on helping clients deal with their

anxieties, focus on clients’ positive/healthy thoughts & anxieties, focus on clients’ positive/healthy thoughts & behaviors, and strive to help client’s recognize their full behaviors, and strive to help client’s recognize their full potential as individuals.potential as individuals.

Behavior problems result from anxieties, which impair Behavior problems result from anxieties, which impair an individual’s ability to grow & develop into health an individual’s ability to grow & develop into health well adjusted adults.well adjusted adults.

Clients are seen as in charge of their own therapeutic Clients are seen as in charge of their own therapeutic intervention & intervention & basically good peoplebasically good people. .

Humanistic Therapy Methods:Humanistic Therapy Methods: 1. 1. Client-Centered TherapyClient-Centered Therapy: Carl Rogers developed this form : Carl Rogers developed this form

of treatment which views the client as the one in charge of his or of treatment which views the client as the one in charge of his or her therapeutic outcome.her therapeutic outcome.

He argued that therapists need to enable client’s to discover for He argued that therapists need to enable client’s to discover for themselves the cause of their problems as well as the themselves the cause of their problems as well as the mechanisms by which the client could resolve their problemsmechanisms by which the client could resolve their problems ..

IfIf the therapist provides a comfortable, empathetic environment the therapist provides a comfortable, empathetic environment for the client to focus on their problems, for the client to focus on their problems, thenthen client will improve client will improve ((if-then statementsif-then statements).).

Therefore, the goal of client-centered therapy is to Therefore, the goal of client-centered therapy is to provide theprovide the client with an opportunity to further his/her personal growth. client with an opportunity to further his/her personal growth. Therapists need to express Therapists need to express unconditional positive regard, unconditional positive regard, empathy, & congruence to help their clientsempathy, & congruence to help their clients. .

Unconditional Positive RegardUnconditional Positive Regard According to Rogers, this conveys three important pieces of According to Rogers, this conveys three important pieces of

information to clients:information to clients:

1. 1. The therapist cares about the client.The therapist cares about the client.

2. The therapist accepts the client (for who they are). 2. The therapist accepts the client (for who they are).

3. The therapist trusts the client’s ability to change. 3. The therapist trusts the client’s ability to change.

In a nutshell, unconditional positive regard, In a nutshell, unconditional positive regard, means not placing means not placing conditions of worth on othersconditions of worth on others. Rather, people are cared about . Rather, people are cared about and accepted as they are. You don’t need to “earn” someone’s and accepted as they are. You don’t need to “earn” someone’s love, but are given it freely, regardless of your behavior. love, but are given it freely, regardless of your behavior.

EmpathyEmpathy Therapists can only help their clients if they possess the ability to Therapists can only help their clients if they possess the ability to

place themselves in their clients’ positions. place themselves in their clients’ positions.

That is, the therapist must try to see the world as the client does That is, the therapist must try to see the world as the client does to understand what the client is feeling.to understand what the client is feeling.

Empathy is conveyed via active listeningEmpathy is conveyed via active listening. In particular, . In particular, therapists, “therapists, “reflectreflect” what the client has said to the client. ” what the client has said to the client.

This serves two purposes:This serves two purposes: **Communicates the therapist’s knowledge of the client’s **Communicates the therapist’s knowledge of the client’s

problems.problems. ***Indicates the therapists desire to understand the client’s ***Indicates the therapists desire to understand the client’s

problem. problem.

CongruenceCongruence Therapists’ responses to clients should be Therapists’ responses to clients should be consistentconsistent with their with their

feelings.feelings.

That is, therapists need to be honest & open with their own That is, therapists need to be honest & open with their own feelings so as to be sensitive and genuine with their clients.feelings so as to be sensitive and genuine with their clients.

Clients need to be able to “trust” their therapists. If the therapist Clients need to be able to “trust” their therapists. If the therapist makes a comment to the client, they should feel they can makes a comment to the client, they should feel they can “believe” the therapist. “believe” the therapist.

Thus, actions should reflect real the therapists’ real feelings Thus, actions should reflect real the therapists’ real feelings and thoughts.and thoughts.