Transcript PSY 402 CLINICAL PSYCHOLOGY

BAHAR BAŞTUĞ
Assist. Prof. Dr.
Psychotherapeutic Issues
Lecture Preview
 Does Psychotherapy Work?
 Long-Term Therapy versus Short-Term Treatment
 Who Stays In and Who Drops Out of Psychotherapy?
 Is One Type of Therapy Better Than Another?
 Do the Effects of Psychotherapy Last after Therapy Ends?
 Common Factors Associated with Positive Psychotherapy
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Outcome
Why Is Change Difficult?
Must Someone Be a Professional to Be an Effective
Therapist?
Does Psychotherapy Help Reduce Medical Costs?
Can Psychotherapy Be Harmful?
1.Does Psychotherapy Work?
the usefulness of psychotherapy.
This such question is difficult to answer and varies from
individual to individual and treatment to treatment.
Psychotherapy is one of the most common activities
conducted by clinical psychologists. Each patient, each
psychologist, and each psychotherapy experience are
unique.
Psychotherapy is a highly personalized experience. It
is impacted by the skills, interest, training,
motivation, and personality of the psychotherapist
and by the specific symptoms (e.g., etiology,
duration, severity), motivation, personality, and
resources of the patient.
The therapist-patient interaction is unique. Unique
therapist-patient interaction plays a significant
role in treatment outcome. Also, some factors such
as beliefs, attitudes, and expectations play a
significant role in treatment outcome.
Two patients with very similar symptoms seeing the
same psychotherapist may experience two very
different psychotherapies. Psychotherapy may be
helpful to one but not to the other. What works well
with one person may not work well with another.
Positive treatment outcome may be associated with the
passage of time (i.e., “time heals all wounds”).
1.Does Psychotherapy Work?
Merely asking patients the usefulness of
psychotherapy provides important answer, but it is
insufficient.
Determining whether psychotherapy is useful is a
research and clinical task. For this reason,
psychotherapy treatment outcome has become
one of the most common topics of investigation in
all psychology research.
1.Does Psychotherapy Work?
In his classic study, Hans Eysenck examined
24 research studies concerning both
psychodynamic and eclectic techniques
used for nonpsychotic patients. The results
of his study failed to demonstrate that
psychotherapy was effective. 72% of those
experiencing psychological distress would
improve without treatment.
1.Does Psychotherapy Work?
Smith and Glass examined 375 research studies on
psychotherapy treatment outcome by using metaanalysis. Results showed that patients receiving
psychotherapy tended to be more improved than
those who did not receive psychotherapy.
Smith and Glass (1977) examined the treatment
outcomes of different types of psychotherapy (e.g.,
behavioral and psychodynamic) and failed to find
superiority of one treatment approach over another.
1.Does Psychotherapy Work?
After some critics about first study, Smith, Glass, and
Miller (1980) extended the analysis to include 475 studies
and improved upon several of the procedures from the
earlier study. The study confirmed the earlier results and
found that those receiving psychotherapy tended to be
more improved than 80% of untreated persons.
Behavioral therapies were more effective than verbal
therapies.
1.Does Psychotherapy Work?
A large number of meta-analysis studies examining
psychotherapy treatment outcome have been conducted.
The majority of these studies conclude that
psychotherapy is generally effective.
Andrews and Harvey (1981) evaluated 475 controlled
psychotherapy outcome studies and concluded that a
patient receiving psychotherapy was better off than
untreated control subjects and that relapse rates were
small.
1.Does Psychotherapy Work?
An extensive review of all the research studies concludes
that psychotherapy does indeed work.
Both researchers and clinicians have been trying to
answer many follow-up questions such as: How does
psychotherapy work and what types of treatment and
therapists are effective for what types of problems and
patients?
Recent efforts by the APA have attempted to identify
specific treatment approaches for specific problem areas.
Seligman (1994) states that the depth of a problem
predicts if the problem can be altered through
psychotherapy. Problems that are biologically oriented
and pervade all aspects of life are less appropriate for
psychotherapy than problems that are learned and are
less pervasive. He suggests that problems such as panic
and phobia are much more responsive to therapy than
obesity and alcoholism.
2.Is Long-Term Therapy Better than Short-Term
Treatment?
Psychotherapy can last for one session or for hundreds of
sessions in many years.
The duration of psychotherapy depends on:
the symptoms, interest, motivation, and financial resources
of the patient and on the orientation and skills of the
therapist.
The average length of psychoanalysis is about 1,000 sessions.
Brief psychotherapies are of interest to both patients and
insurance companies. Patients seek psychotherapy during a
crisis and wish to obtain relief asap. They want relief
symptoms within 12 weeks.
2.Is Long-Term Therapy Better than
Short-Term Treatment?
The majority of patients terminate treatment before 10
sessions.
Between 25% and 50% of people fail to attend a second
session.
2.Is Long-Term Therapy Better than
Short-Term Treatment?
Research on more than 2,400 patients over 30 years
suggests that 50% of patients were significantly
improved by 8 sessions.
Another research using the 4,100 people found that most
people experienced significant improvement in
symptoms within the first 10 to 20 session.
Research has found that even a single session is
associated with positive outcomes such as a decrease
in medical office visits.
However, some meta-analysis research has
demonstrated that duration is not necessarily
associated with treatment outcome.
It is difficult to make generalizations regarding the
superiority of short- versus long-term treatment.
3. Who Stays In and Who Drops Out of
Psychotherapy?
About a third of
psychotherapy patients
do not attend a second
session.
What factors might predict
psychotherapy dropout?
3. Who Stays In and Who Drops Out of
Psychotherapy?
SES and educational level are associated with dropout.
Patients from lower SES and those who have less education
tend to be more likely to quit psychotherapy.
What characteristics of the therapist might also predict it?
The skill of the therapist is positively associated with
continuation of psychotherapy.
However, a therapist’s gender and whether being psychologist
or psychiatrist appear unrelated to dropout.
3. Who Stays In and Who Drops Out of
Psychotherapy?
Patients may feel that the crisis has passed, and their
motivation has significantly decreased.
Often patients feel better after one session and do not
wish or need to continue.
The therapist and patient may not “click” during the first
session as well. Patients who do not like their therapist
are less likely to attend next sessions.
4. Is One Type of Therapy Better than
Another?
Is psychodynamic psychotherapy better than CBT?
Is individual psychotherapy better than family systems
approaches?
Is any one type of psychotherapy superior to another?
Many research have been conducted to determine if
one type of psychotherapy is superior to others.
4. Is One Type of Therapy Better than
Another?
To ensure that these studies use pure forms of therapy
and do not mix and match techniques, most of these
research incorporate treatment manuals and ask
clinicians to follow treatment manuals.
Clinicians tend not to use treatment manuals in actual
practice. They use integrative approach, that’s mix and
match techniques and approaches from different
theories.
4. Is One Type of Therapy Better than
Another?
Most of the research have failed to find that one type of
psychotherapy is consistently superior to another.
Since the mid-1970s, some researchers have referred to the
equality of different types of psychotherapy as the “dodo bird
verdict.”
But, some researcher suggest that different types of
psychotherapy often result in different specific effects.
According to the studies, CBT tends to result in more positive
than psychodynamic or other verbal treatment types.
4. Is One Type of Therapy Better than
Another?
Studies have tried to determine whether
psychotherapy is as effective as medication in treating
anx, depr, and other. A study compared CBT,
interpersonal psychotherapy (a combination of
psychodynamic and humanistic psychotherapy),
medication, and a drug placebo condition. Results
indicated that all treatments, including the placebo
condition, resulted in improvement.
4. Is One Type of Therapy Better than
Another?
Although no one type of therapy is superior to another,
several specific disorders tend to be treated more
successfully using certain approaches.
Empirically supported treatments show:

exposure treatment for phobias and PTSD,

CBT for headache, depr, irritable bowel syndrome,
and bulimia,

insight-oriented dynamic therapy for depr and
marital discord.
5. Do the Effects of Psychotherapy Last after
Therapy Ends?
What happens when someone terminates
psychotherapy?
Do people generally turn back to the problematic
patterns of thinking, feeling, and behaving?
Do the gains obtained by psychotherapy last?
It may be unrealistic expectation that psychotherapy will
“cure” a problem or eliminate symptoms without any
relapse.
5. Do the Effects of Psychotherapy Last
after Therapy Ends?
Research generally supports the claim that gains
obtained in psychotherapy do last.
Jorm examined the results of studies treating anxiety
and found that anxiety reduction lasted up to 1 year
after treatment when compared with controls.
Feske and Chambless examined 21 research using CBT for
social anxiety and found improvements lasting up to 1 year
after treatment relative to controls.
5. Do the Effects of Psychotherapy Last
after Therapy Ends?
Similar findings have been reported when examining panic,
depr, alcohol, PTSD, and headache treatments.
Relapse is a common problem.
Researchers have developed programs and strategies to
maximize maintenance of psychotherapy gains.
6. What Common Factors Are Associated with
Positive Psychotherapy Outcome?
In sum, psychotherapy is effective in treating numerous
problems compared with receiving no treatment. No
one type of psychotherapy is superior to another.
If specific theories and techniques do not account for
treatment outcome, then what does? There are certain
commonalities among all types of psychotherapies and
these commonalities are associated with treatment
effectiveness.
6. What Common Factors Are Associated
with Positive Psychotherapy Outcome?
The search for common factors is important to understanding
how psychotherapy might work.
Karasu suggested that all useful psychotherapies include three
common patient factors:
 Affect experiencing: expressing feelings.
 Cognitive mastery: thinking about problems in a manner that
enables the patient to experience control over attitudes,
perceptions, and beliefs about problems.
 Behavioral regulation: developing strategies for controlling
impulses and problematic behaviors.
6. What Common Factors Are Associated with
Positive Psychotherapy Outcome?
According to Frank
a professional office associated with being helped;
a trained professional who is supportive;
enhanced hope that thoughts, feelings, and
behaviors can change;
fees associated with service;
the avoidance of dual relationships.
6. What Common Factors Are Associated with
Positive Psychotherapy Outcome?
Weinberger (1995) outlined 5 common factors:
therapeutic relationship: The relationship between the
therapist and patient should be positive and that
therapists should be empathetic, genuine, warm, and
professional. There is an alliance between therapist and
patient.
Connecting to a therapist whom the patient perceives as
helpful and accepting is a powerful common factor in all
types of psychotherapy.
6. What Common Factors Are Associated with
Positive Psychotherapy Outcome?
expectations of success: Expectancy is a strong
predictor of positive therapeutic outcome. Treatment
is more effective when patients believe that the
treatment is helpful. Belief that psychotherapy can
work is another important common factor.
confronting a problem: Facing or working on
problems rather than avoiding, escaping, or denying is
a common factor in all therapies. Only writing or
talking about a problem alone without a therapist
results in improvement. Working on problems are
powerful common factors.
6. What Common Factors Are Associated with
Positive Psychotherapy Outcome?
providing the experience of mastery or control
over the problem: Mastery, or a sense of control,
over a problem is a powerful predictor of therapy
outcome. It enhances sense of self-efficacy.
an attribution of success or failure: Patient’s
internal attributions about the factors that they
believe contribute to change are powerful
predictors of therapy success or failure.
«Positive outcome is due to my own effort»
In another study, getting advice and talking with
someone who understands and is interested in their
problems, and gives encouragement and hope, were
curative factors.
Lazarus (1971) found that the personal qualities of the
therapist were more important to patients than the
psychotherapy techniques used.
7. Why Is Change Difficult?
Behavioral change, with or without psychotherapy, is not
easy. Often patients are ambivalent about change and
may not be pleased with some of the results of change.
For example, a patient who successfully overcomes panic
attacks may be expected to develop more responsibility
at home or at work.
Resistance to change is very common among patients.
Prochaska’s transtheoretical model
has researched commonalities of behavioral change
among theoretical orientations by examining the
process of change across different types of
problems and different methods of treatment.
In his analysis of different orientations to behavioral
change, Prochaska isolated a variety of universal
stages, levels, and processes of change.
His theory includes five stages of change
 precontemplation,

contemplation,

preparation,

action, and

maintenance.
The desire to change is likely to be a very important
factor in explaining behavioral change.
Kleinke
outlined several important factors explaining why
change is difficult to achieve and why resistance is
so common in psychotherapy.
1. Change is threatening. Usual ways of thinking,
feeling, and behaving offer some degree of comfort
even if they are maladaptive.
2. Secondary gains (i.e., advantages to maintaining
problems)may be difficult to give up.
3. Potential interference from others. Although a patient may
wish to change behavior through psychotherapy, important
others in the life of the patient (i.e spouse) may be
motivated to maintain the status quo. The spouse of the
patient with agoraphobia may feel important and needed
by the patient. Increased independence may be
experienced by the spouse as a threat to his or her power.
As a result, many people resist change when they feel that
their freedom is threatened.
8. Must Someone Be a Professional to Be an
Effective Therapist?
Does someone really need to have a PhD to be an
effective psychotherapist? Aren’t many caring and
empathetic persons excellent “therapists” even if
they have no formal training? Aren’t a lot of
friends, neighbours, and grandparents excellent
“therapists”? Most people have had the experience
of talking over problems with their friends,
relatives, neighbours, or even strangers.
8. Must Someone Be a Professional to Be
an Effective Therapist?
Level of training for psychotherapists??
Does someone really need to have a PhD or other advanced
degree to be an effective psychotherapist?
Aren’t a lot of friends, colleagues, neighbours, and
grandparents excellent “therapists”?
Research indicates that the therapist’s psychological health,
skill and a sincere interest in helping others are necessary
qualities for being an effective psychotherapist.
8. Must Someone Be a Professional to Be an
Effective Therapist?
Several studies have failed to find a difference in
psychotherapy outcome between therapies provided
by professionals versus paraprofessionals. However,
other research has demonstrated that the experience
and training of the therapist is important for positive
therapeutic outcomes.
Some studies have found that the use of paraprofessionals
results in superior outcomes relative to professionals, but
they have been criticized for using poor quality research.
8. Must Someone Be a Professional to Be an
Effective Therapist?
Another study found that psychology interns under
supervision have better treatment outcomes than
professional therapists.
But, there are a lot of studies demonstrating that the
experience and training of the therapist is important for
positive outcomes.
8. Must Someone Be a Professional to
Be an Effective Therapist?
As a result, both well-trained and poorly trained
therapists can provide poor service and do harm. Poorly
trained therapists are more likely to provide a very
narrow range of treatment options. Well-trained
professionals are more likely to have a wide range of
treatment options and use integrative approaches based
on scientific support.
Psychiatrist analysing Freud.
9. Does Psychotherapy Help to Reduce Medical
Costs?
Because of biopsychosocial perspective, a more healthy
emotional life may result in a healthier physical life as
well. 50% of all deaths are due to behavioral and lifestyle
factors such as eating high-fat foods, being sedentary, and
misusing alcohol.
Changing health care behavior and attitudes by
psychotherapy may lead to healthier living and fewer
illnesses.
An important question for government agencies and
insurance companies is the association between
psychotherapy and health care costs.
9. Does Psychotherapy Help to Reduce Medical
Costs?
A person experiencing psychotherapy is less likely to
need or seek out medical attention. Psychotherapy
appears to reduce medical costs.
50% to 70% of patients who seek medical treatment
have no medical problems. Their symptoms are
primarily due to psychological factors such as anx,
stress, and depr.
9. Does Psychotherapy Help to Reduce Medical
Costs?
Emotional problems are associated with many medical
problems such as heart disease, diabetes, and cancer.
They are associated with psychophysiological diseases
such as dermatitis, irritable bowel syndrome, chronic
headaches, and asthma.
Treatment of psychological factors by psychotherapy
assists in the treatment of many of these medical
problems and symptoms.
9. Does Psychotherapy Help to Reduce Medical
Costs?
Those who experience a mental illness tend to use
medical services a lot. For example, about onethird of depressed patients experience somatic
complaints.
Psychotherapy increases psychological functioning
and well-being, also improves medical symptoms
and reduces health care costs.
10. Can Psychotherapy Be Harmful?
Psychotherapy is helpful for people. Therapy, unlike a
medical procedure such as surgery, does not seem to have
life-and-death consequences.
Psychotherapy may not be appropriate or useful for everyone.
Some people may get worse in functioning during or after
psychotherapy.
Freud’s most famous case example of Anna O. was a
treatment failure. She had more severe symptoms after she
began treatment with Freud.
10. Can Psychotherapy Be Harmful?
Many factors associated with treatment failure may or
may not be directly associated with the psychotherapy
experience. These factors include stressful life events
such as divorce, loss of job, development of physical
illness, and death of a loved one.
A number of both patient and therapist variables (e.g.,
patient diagnosis, therapist personality and technique)
have been found to be associated with negative
treatment outcome. Poorly trained therapists have been
found to be damaging when they offer inappropriate
therapies.
10. Can Psychotherapy Be Harmful?
Research has shown that many variables are associated with
poor treatment outcome such as characteristics of the patient
and the therapist, and the interaction between patient and
therapist.
Patient diagnosis, severity of symptoms, and some
psychotherapy approaches are associated with poor outcome
among certain patients.
10. Can Psychotherapy Be Harmful?
Patient characteristics have been associated with poor
outcome:
 with SCH, borderline personality disorder and OCD
 have little motivation for change,
 low tolerance for anxiety,
 a history of inability to maintain satisfying interpersonal
relationships.
 highly suspicious and hostile.
10. Can Psychotherapy Be Harmful?
In addition to patient variables, therapist characteristics have
been associated with poor outcome:
 lack empathy
 impatient and authoritarian
 fail to focus the session,
 fail to deal with negative feelings of the patient toward the
therapist or treatment,
 inappropriately use techniques
 unethical and incompetent therapists can certainly do a
great deal of harm to their patients.
Sexual relationships between therapist and patient can
be harmful.
Psychotherapy can be harmful if these factors are not
examined.