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Summary of Psychotherapy from University of Leiden week 1 tm week 7
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Psychotherapy week 1Humans have long been looking for cures for mental disorders. Some examples include:
- Shamanistic societies' healing rituals that were unscientific yet not necessarily
ineffective;
- Pre-Christian, temple-like asklepeia and other retreat centers of the eastern
Mediterranean region used religio-philosophical lectures, meditation, and simple bed
rest outside of secular medicine in healing mental disorders;
- Hippocrates's humor-based four-factor theory of personality (he advocated that
illness should be addressed by natural means);
- Hellenist physicians understood that the brain was the source of depression,
delirium, and madness.
Psychotherapy as a domain of science emerged in the 18th century.
The unconscious was already examined by the Hellenists (Greek people who lived in the
time around 100 B.C.), and it became an essential construct in 19th century
psychotherapies. The first one to study this scientifically was Gottfried Wilhelm Leibniz
(1646-1716). He investigated the role of subliminal perceptions in our daily life. These are
visual stimuli that individuals are able to discriminate while they do not report consciously
seeing these stimuli. He also came up with the term dynamic forces to describe the forces
that operate in the unconscious.
His investigations were continued by Johann Friedrich Herbart (died 1841). Herbart
attempted to use mathematics to understand the passage of memories to and from the
conscious and the unconscious. He suggested that tacit ideas (i.e. non-codified ideas)
struggle with one another for access to consciousness. Dissonant ideas depress one
another, and associated ideas help draw each other into consciousness.
Mesmer and Schopenhauer
Their influence was huge on Sigmund Freud, Alfred Adler, Carl Gustav Jung, and others.
Mesmer was the pioneer of hypnotherapy. He did highlight the principle that rapport
between therapist and patient is important in therapy, and he modelled many important
personal traits of the therapist. He also stressed the influence of the unconscious, and he
demonstrated many phenomena that are still important in therapy today (e.g., spontaneous
remission, the influence of unconscious memories, the importance of patients' confidence in
treatment).
In the 19th century, three streams of the study of the mind emerged that built the foundation
for psychotherapies:
- Systematic, lab-bench empiricists;
- Philosophers of nature;
- Clinician researchers.
There were a couple of natural science empiricists that contributed to the development of
our understanding of psychology and psychotherapy.
Gustav T. Fechner (1801-1887)
,Fechner investigated the distinction between waking and sleeping states. He investigated
how much psychic stimulation is needed for ideas to cross the threshold from the
unconscious to full awareness and how intense the perception resulting from that will be. We
call this working memory today.
Herman von Helmholtz (1821-1894)
Helmholtz discovered the phenomenon of 'unconscious inference' which he described as
an unconscious reconstruction of what our past taught us about the object.
Emil Kraepelin (1856-1926)
Kraepelin focused on a psychological approach to mental illness. He classified, described,
and schematized the course of diseases - thus, he created the basis for the DSM.
The psychologist philosophers, also called philosophers of nature, had a greater influence
on the development of psychotherapies than lab-based scientists. Here are examples:
Arthur Schopenhauer
His book 'The World as Will and Representation' focused on human sexuality and the
unconscious. He proposed that we know things that we are unaware of, and that our
behavior is largely driven by irrational forces. He also proposed a pansexual view on human
sexuality.
Carl Gustav Carus (1789-1869)
He proposed that there are several levels of unconscious, and when humans interact, they
do so simultaneously on various levels of their unconscious and conscious minds. He
described therapist transference, which is the idea that the conscious and unconscious of
the therapist and the patient continuously communicate through a simultaneous, nonverbal,
organic process.
Friedrich Nietzsche
Nietzsche wrote about tacit cognitions driving the daily behavior of people. This is the
knowledge that we are unable to articulate or express, and that is acquired through
experience. He said that our conscious thinking is a more or less 'fantastic commentary' on
unknowable unconscious processes. He developed notions on self-deception, sublimation
(i.e. socially unacceptable impulses or idealizations are transformed into socially acceptable
actions), repression (i.e. the exclusion of distressing memories, thoughts, or feelings from
the conscious mind), conscience, and "neurotic" guilt. He proposed various defense
mechanisms that humans use to preserve their self-image. He believed that we lie to
ourselves more than we lie to others.
One of the great clinicians that contributed to psychotherapy was Moritz Benedikt. He
developed the concept of seeking out and clinically purging pathogenic secrets.
Practices we use today are very often rooted in historical practices. For instance, the
concept of mindfulness can be traced back to many Eastern traditions and the asklepeia of
Hellenic Greece. A more currently publicized lifestyle is the Japanese shisa kanko, which
leads to focus on what one is doing and experiencing in the moment.
,The Impact of the Biological Sciences on Psychotherapy
Every encounter with our environment causes changes in our neural functioning. These
permanent learnings are difficult (if not impossible) to unlearn. The task of the therapist in
most cases is to help the patient cultivate positive alternative memories. Neuronal decay and
lesions can undo memory. However, it is difficult to unlearn some things that were stored in
our permanent storage.
Past-oriented psychotherapies, such as psychodynamic approaches, can encourage
clients to ruminate about their past and reinterpret past traumas. However, others believe
that rumination can strengthen dysfunctional neural circuits.
Therefore, contemporary positive psychotherapy is future-oriented. It focuses on
teaching people how to avoid dysfunctional rumination and habits, and how to develop skills
that will advance their well-being. As humans, we have a certain neural plasticity throughout
our lives, especially in childhood. This phenomenon is called neoteny. Neural restructuring
(occurs through learning) utilizes this plasticity and is an objective of psychotherapy. Much of
the plasticity in our neural systems is achieved through epigenetic changes (genes are
turned on and off by proteins that connect to the genome).
Effective psychotherapies use two neural strategies:
1. Exposure to nurturing social events that lead to positive epigenetic changes;
2. Neural circuit-altering placebo-laden talk.
It has been proposed that psychotherapies need to be indigenized. This means we should
not export Euro-American therapies all over the world but let local healers develop
psychotherapies that reflect their specific philosophy, values, religion and social objectives.
The biggest issue in therapeutic credibility is that of context-dependent stochastologicals.
These are a complex interplay of external and internal variables (e.g., job stresses, financial
concerns, troubled children, bad weather, physical illness) that are out of the clinician's
control. All patients have a unique set of such variables, and they are often afflicted by many
comorbid disorders, so it is almost impossible to make confident prognoses.
Each client the clinician will be faced with will manifest varying degrees of anxiety, coping
skills, and emotional stability, and different methods of treatment will fit their unique
constitution. For instance, for some, a manual-based strict therapy works while for others, a
more intuitive approach is better.
Manualization of therapy, refers to a creation of sequential, algorithmized steps for
proceeding through phases of therapy. The advantage of manualization is that it specifies
steps and layers that build on each other, so that the patient can be guided through. It also
integrates and mobilizes several variables and resources that play a role in the patient's life.
Especially in an applied setting, what works is more important than how it works. Also, art
and science in psychotherapy are not incompatible - they are both valid and they both
appear in every clinical session. In some therapies (such as cognitive behavioral therapy
and dialectical behavior therapy) it is easier to adopt manualization. However, there is still
room for spirituality, spontaneity, sentiment and free will which leaves room for human self-
, discovery and growth. As the writers put it: 'there should be no tension between getting
better and feeling better'.
The author proposes that each individual going into counselling or therapy should choose
their own approach based on what fits their personality and what speaks to them. There are
some issues with this statement:
1. Treatment efficacy: There are certain disorders that are most effectively treated by a
particular approach. Of course, the personality of the therapist is a really powerful
influence, and it can even be more influential on efficacy than the specific procedure
they use;
2. Therapist aptitudes: some studies suggested that certain therapists achieve clinical
success superior to others when they treat one kind of disorder but inferior to others
when they treat a different disorder.
3. Diagnosis and diagnostic coding: Clients need an accurate diagnosis in order to get
the most appropriate treatment. Treating the wrong disorders can cause even more
psychiatric problems.
Chapter 1 - Introduction: The Challenge of Research
The Limitations of Research
Research findings can only ever tell us about what is most likely to happen, not what is
certain to happen. Research also has its limitations, and it is important to be aware of them:
- Research talks in generalities rather than specifics.
- Research findings will inevitably be influenced by the researchers' own assumptions
and agendas. So, we always have to read research findings in a critical way.
- Researchers make use of some particular tool, measure or procedure, and these will
inevitably influence the kinds of things that are 'found'. For instance, if we define
mental illness in different ways, we will inevitably find different results for each
definition.
- We cannot prove that science itself is the best way to understand the world.
- Research is always conducted with a particular sample which limits the
generalizability of the findings.
A Research-Informed Approach to Therapy
The American Psychological Association's latest definition of 'evidence-based psychological
practice' is the following: 'the integration of the best available research with clinical expertise
in the context of patient characteristics, culture, and preferences'. Therefore, therapy should
be 'research-informed', not 'research-directed'.
Quantitative research refers to number-based research that generally incorporates
statistical analysis. Qualitative research is language-based research in which experiences
and perceptions are not reduced to numerical form.
Chapter 3 - Does Orientation Matter? The Great Psychotherapy Debate
Some researchers believe that some forms of psychotherapy are better than others
(especially for specific disorders). Others believe that it is other factors, such as the
therapeutic relationship, that determine outcome more than the type of psychotherapy. In
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