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Summary Psychotherapy (SOW-PSB3DH50E)
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Week 1 (tue apr 9-thu apr 11)Lecture 1 Introduction: Psychotherapeutic change
Mental disorders
= disturbances in experience
3 characteristics of having a mental disorder:
1. Experience of feelings, thoughts, behaviour tendencies, bodily sensations
2. As a problem, unwanted, intolerable, abnormal, uncontrollable or absurd
3. That you do not have control over (fragmented sense of ‘self’)
Psychotherapy schools
1. Psychoanalysis (Freud) = symptoms of unconscious struggles
2. Directive treatments (Skinner) = strong associations learned reactions must be unlearned
3. Client-centered psychotherapy (Roger) = cannot change automatic behaviour because of alienation
4. Family and systems therapy = larger context
What is the goal of psychotherapy?
• Change unwanted patterns of subjective experiences (reality not important)
• Or reduce agreed upon symptoms, disorders, etc. (viewed from medical model)
Candidates of psychotherapy
(1) Changing propositional (semantic memory) representations
• Language-based, symbolic, deductive, arguments (to help get rid of the disorder)
• Change is easy: provide information, reason, persuade, psycho-education (changing the facts)
• Problems: (1) Therapist is authoritarian, (2) Patient is likely to be passive, (3) Persuasion often ineffective or transient (words in a
different level (language) are inefficient
(2) Discover who you are
• Self-knowledge (is a language component)
• Original assumption of psychotherapy, talking-cure, still layman’s-view
• Problems: (1) Too propositional, pub talk, although changing one’ s narrative may be moderately helpful. We cannot have access to
our own insights. ‘Me’ cannot be found and is a metaphor. We view ourself rather positively but with mental disorders we are more
realistic. (2) Unsupported by academic psychology: mental processes hardly accessible, fragmented sense of self. Instead ‘English
butlers’ (automated processes).
◦ Distancing oneself from a dominant schematic representation (autobiographical memories), e.g. ‘everybody hates me’
◦ Build up new (or reuse) salient experiences. Activate multiple schemas and integrate these (correct ideas). e.g. induce
emotions; connect past present future, images, and previous experiences.
◦ Experiential techniques: chair technique, imagery rescripting
◦ Problem: typically within sessions
(3) Systematic exercise
• Change associative (procedural memory) representations
• Core business in cognitive therapy, behaviour therapy, systems therapy
• In and between (homework assignments) sessions
• E.g. exposure (fear endurance; changes automatic behaviours), systematically challenging negative automatic thoughts, behavioural
rehearsal, assertiveness training, role playing, communication skills
• A lot of evidence for effectiveness
• Problem: patients have to participate
(4) Patient activation and involvement
• Patient involvement is very important
• Without involvement no change in the way we experience things (although, we also learn from observation!)
• Preferably in and between sessions using homework exercises
• E.g. disclosure (patient), emotional experiences (optimal), training, etc.
(5) High quality therapeutic alliance
• Very important for treatment success
• Core ingredient in client-centered therapy and psychoanalysis
• Random person for treatment is possible but alliances are used for motivation and involvement in behaviour therapy and cognitive
therapy. It is not about objective quality, but more about subjective quality according to the patient (e.g. trust, confidence, likeability)
• Consistently (but moderately strong) related to psychotherapy results.
,• Problem: fuzzy and untested theories in clinical psychology about therapeutic relationships
• But: sound theories from social psychology and communication science about (resistance to) social influence
(6) Reorganising environment and social interactions
• e.g. spouse and family support, enhance/increase social or daily activities, reduce stress (e.g. moving), job-related interventions. Can
be with client alone or with other professionals.
• Also, (family) care plan (mantelzorgers), multiple professionals, alert plan, relapse prevention plan
• Strong treatment packages for severe psychiatric disorders like bipolar disorder, and schizophrenia.
Conclusions
Psychotherapy is aimed at changing unwanted patterns of experiences.
Means:
1. Patients involvement
2. High quality therapeutic relationship
3. Providing information (propositional)
4. Systematic exercise (associative)
5. Induce new (or reuse) salient experiences
For severe psychiatric disorders
6. Rearranging environment
That it can be otherwise implies that the power of new insights or behaviours consists of letting go of the older ones.
Keijsers (2007). Psychotherapy: A brief note on schools of psychotherapy.
Non-directive forms of therapy
Aim: insight and improved self-knowledge.
No direct influence of therapist, advice, homework or assignments.
1. First principal school
Psychoanalysis: classical analysis with free association and interpretation.
Theoretical background derived from psychoanalysis (Freud).
Psychodynamic psychotherapy: Compact psychoanalysis of short duration and focused on clear goal. Therapist more active than in
classical psychoanalysis. Working method of Malan.
2. Second principal school
Clienct-centered therapy (Rogerian therapy/person-centered therapy). Contact between therapist and patient central. Therapist initiates
relationship with high empathy, acceptance and respect. Patients can become their true selves, discover their views and what suits them.
Other variants of Rogers views are humanistic psychotherapy and existential psychotherapy (= core themes of existence, finiteness,
meaninglessness and loneliness).
Directive forms of therapy
Aim: treatment procedures in which things are tested out or practices (not on therapeutic relationship). Practice takes place during and
outside the sessions. Therapist gives direction and has a collaborative relationship with the patient.
3. Third principal school
• Behaviour therapy = learning processes. How behaviour patterns are learned, and maintained. Systematic practice to change
undesired feelings, behaviour and views. Aimed at changing complaints/symptoms/disorders, not balance/personal growth/self-
insight.
• Cognitive therapy = many complaints persist because of automatic assumptions of the patient. We are scarcely aware of those
assumptions and views. With CT, these are brought into conciousness and replaced with more realistic/useful assumptions and
views. Aimed at changing complaints/symptoms/disorders, not personal growth/self-insight.
• Cognitive-behavioural therapy =
◦ Old variants include hypnotherapy and assertiveness training, relaxation and breathing exercises. Hypnotherapy uses hypnosis
to achieve relaxation, pain reduction, achievement of specific moods. Aim is for patient to eventually carry it out themselves.
◦ New variants are solution-focused therapy and acceptance and commitment therapy. Solution-focused therapy encourages to
look at possible solutions and less at the problems. Conceptualise condition or goal they want to achieve. ACT encourages
people to focus on relevant goals by means of practice or making certain choices . Has things in common with solution-
focused therapy but also includes a clear initial stage. Teaches people that control over many internal perceptions is possible
and that our desire of control is harmful. ACT makes use of exercises, stories and metaphors to help people admit to their
perception problems and accept them.
,Keijsers & Becker (2009). Psychotherapy and implicit mental processes.
Typical characteristics of people with mental problems
1. Mental problems involve undesired experiences
Examples of undesired experiences might include drinking, anxious feelings, obsessions, worries, shortness of breath, and fatigues.
Sometimes certain experiences are annoyingly absent, for example lack of feeling pleasure.
2. Psychological problems are seen as insoluble
Patients are unable to solve the problems on their own.
3. Mental problems are often perceived as absurd
For example, Maria (the client in the case) is aware there is no good reason to be afraid of going to a shop, but thinking this way does
not help her. Thoughts and advice of this type have no effect on the person’ s perception. The perception is the personal experience of
reality.
Implicit mental processes
A traditional concept is that mental disorders arise when people become alienated from themselves. Alienation is the consequence of
such things as far-reaching experiences in youth, restrictive learning experiences, or the inability to permit oneself certain feelings or
attitudes. The assumption is that psychopathology persists because of certain motives from a portion of someone’ s personality or ego
to which the patient has insufficient access.
Modern psychopathology holds the view that a mental disorder points to disturbances in patients’. Experiences which are considered as
alienated and involuntary. Makes use of biological, genetic, and neurocognitive research. Depends on empirical research. Modern
research offers little proof of a central and autonomous ego. Research shows that human experience consists of a large number o
complex mental operations that constantly proceed in an automatic and parallel manner, but independently of each other. Our
conciousness experiences are only a limited reflection of our mental operations. Conciousness occurs only at the end, after the
information from various routes has been integrated (see example page 3 - visual stimuli). Information processing are automatic
processes but not fixed. They must be attuned to the environment and can be flexibly employed in order to take advantage of changes
in the environment. (1) This takes place by concious learning. Concious learning allows us to acquire skills.This requires concious
attention at first. Repeated practice subsequently ensures that this behaviour is automatic and can be performed as a matter of routine.
(2) Implicit learning is important for interaction with the surroundings. In implicit learning, associations are mutually formed between
stimulus characteristics as well as between stimulus characteristics and our own behaviour, without any concious action on our part.
The repeated occurence leads to the formation of S-R associations; situational characteristics, emotions and behaviour are coupled to
one another. It is useful to quickly learn from biologically relevant emotional situations. Implicit learning can be both quick and very
powerful in emotional, biologically relevant situations.
Experiments in psychopathology are investigating more and more whether mental disorders involve disturbances in attention and
information processing when assessing emotional situations. We scarcely have access to the manner in which we think, interpret, or use
our memory.
For knowledge and personal views of ourselves and the world a distinction is drawn between:
1. Propositional representations, linguistic, symbolic and factual. They are easily expressed in language, e.g. Paris is the capital of
France or An orange is a fruit. They enable us to reason logically and to use deductions to arrive at a particular opinions.
2. Schematic representations, holistic by nature and consist of the integration of linguistic, visual, auditory, tactile, and somatosensory
information that we have acquired through experiences with a particular subject or situation. It is not so easy to express in words,
but is nonetheless often strikingly precise, e.g. we recognise an orange and know how it tastes and smells even if we have to search
for words to describe those sensations. We also have feeling for the shape and weight, and we can estimate how far we could throw
the orange even when we have never tried it before. Schematic representations contain emotional information. We feel things as a
resrult of it that are not supplied by propositional information.
Teasdale argues that depressed attitudes are formed by networks of schematic representations. The idea of hopelessness has more to do
with thought that reason. It is too propositional (too much at the level of rationality) and inefficient if a therapist reponds with ‘you
managed to find your way here, though’. According to him, psychotherapy must achieve to undermine the entire higher order network.
One must get patients to re-evaluate their holistic views of themselves, others and the future through offering experiences that place this
assemblage of associations in a new light.
Experimental psychopathology
The core of mental disorders lies in undesired experiences whose perseverance are attributable to adaptations to the implicit
information processing system. Biological and learning experiences also play a role. Adaptations can involve a shift of focus in
, perception and attention regulation, selective activation of emotional coloured memories or adjustments in the stress system. With
higher mental functions we seem to perform consciously, the actual manner in which we do this remains mostly unconscious.
Propositional representations can be effectively altered with logical reflection, but schematic representations cannot.
Examples of mental disorders and malfunctions of automatic information processing
• Anxiety an addiction, normal attention processes have been disturbed. Anxiety disorder record stimuli more often that warn danger
and can hardly keep themselves from paying attention to them. In mood disorders, negatively coloured memories are more
frequently activated. In PTSD, defective information storage in the memory during situations that were endured under great fear.
Sensory quality and accompanying emotions do not subside. In conversion disorders, intentional command of behaviour is disturbed,
while involuntary command is not.
Malfunctions or adaptations in automatic cognitive processes play a significant role in the origin and persistence of mental disorders.
These disturbances can be influenced to a limited extent during psychotherapy. Instead, specific and systematic training is needed:
reduction of fear by a specific phobia. Systematic exposure is a form of controlled alteration of perception in a safe environment.
Systematic and focussed practice
Psychotherapeutic change implies that patients are enabled to perceive their difficulties in a different way. The patient must practice to
develop a new perception. Specificity of treatment is impossible for effectiveness. Although, it is not the standard treatment that makes
the patient better, but the patient themself. Motivation, commitment.
Unfortunately, there are still many disorders for which no evidence-based treatments have been developed. The same is for comorbid
disorders. We rely on expertise, precision and inventiveness of therapists in these cases. The therapist must have freedom to investigate.
One important consideration should be taken into account. No more is asked of the patient than strictly necessary. It should not be the
goal to change someone’ s essence.
Insight
Therapy sessions are often tense and emotional. These are the moments that patients can arrive at a new views of themself or their
situation. Synaptogenesis is enabled when a large quantity of relevant associations, emotions, semantic information, and goals and
experiences are simultaneously activated.
Conclusion
Mental disorders are disturbances in experience. Patients often would like to perceive things differently, but cannot achieve this with
direct control. There is no access to the processes at the foundation of these experiences. Systematic practice is suitable. The brain
learns by means of experience, not through language, deduction, logic or analysis.
Lecture 2 Behaviour therapy
Correct characteristics
• Psychopathology (psychological problems) based on S-R associations (=interaction between person and environment)
• Symptom oriented
• Observation and self-monitoring are part of treatment and treatment planning/evaluations (e.g. note-taking)
Incorrect characteristics
• Behaviour therapy involves behaviour only (no, change of unwanted thoughts, emotions, and behaviours)
• Behaviour therapy is cold and mechanical (no, less emphasis on therapeutic relationships like in CBT but still relevant)
• Behaviour therapy is fully evidence-based (no, …)
Behaviour therapy process
(1) Problem inventory
(2) Position in holistic theory
(3) Problem selection, measurement and functional analysis
(4) Treatment plan and treatment execution
(5) Treatment evaluation
Problem inventory
• What is the problem? How often? How severe?
• How did it start? Course? Why treatment now?
• What elicits or exacerbates the problem?
• What prevents or reduces the problem?
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