Literatuur Behandelmethoden
The Efficacy of psychotherapies and pharmacotherapies for mental
disorders in adults: an umbrella review and meta-analytic evaluation of
recent meta-analyses (Leichenring et al.)
The effect sizes of both psycho-therapies and pharmacotherapies in comparison to TAU
(treatment as usual) or placebo were small (SMD<0.50) for most disorders and treatments.
Medium effect sizes were found only for pharmacotherapies of obsessive-compulsive disorder
(OCD) (SMD=0.56), bulimia nervosa (SMD=0.61), and somatoform disorders (SMD=0.50), and
for psychotherapies of post-traumatic stress disorder (PTSD) (SMD=0.54) and borderline
personality disorder (SMD=0.57). Large effect sizes were only reported for psychotherapy of OCD
(SMD=1.03), with, however, a substantial proportion of patients taking concomitant
pharmacotherapy.
How important are the common factors in psychotherapy? An update
(Wampold)
Contextual model: there are three pathways through which psychotherapy produces benefits. The
mechanisms underlying the pathways entail evolved characteristics of humans as the ultimate social
species. The three pathways involve:
1. The real relationship
2. Creation of expectations though explanation of disorder and the treatment involved
3. Enactment of health promoting actions
Before they can be activated, an initial therapeutic relationship must be established.
The initial meeting of patient and therapist is essentially the meeting of two strangers, with the patient
making a determination of whether the therapist is trustworthy, has the necessary expertise, and will
take the time and effort to understand both the problem and the context in which the patient and the
problem are situated. The formation of the initial bond is a combination of bottom-up and top-down
processing. The initial interaction between patient and therapist is critical, it seems, because more
patients prematurely terminate from therapy after the first session than at any other point.
Pathway 1: The real relationship
Real relationship: personal relationship between therapist and patient marked by the extent to which
each is genuine with the other. It is an unusual social relationship in that:
- Interaction is confidential, with some statutory limits.
- Disclosure of difficult material does not disrupt the social bond.
Psychotherapy provides the patient a human connection with an empathic and caring individual,
which should be health promoting, especially for patients who have impoverished or chaotic social
relations.
Pathway 2: expectations
Expectations in psychotherapy work in several possible ways:
- Remoralization: patients present to psychotherapy demoralized not only because of their
distress, but also because they have attempted many times and in many ways to overcome
their problems, always unsuccessfully.
- According to the contextual model, patients come to therapy with an explanation for their
distress, formed from their own psychological beliefs (folk psychology). These beliefs are
typically not adaptive. Psychotherapy provides an explanation for the patient’s difficulties that
is adaptive, in the sense that it provides a means to overcome or cope with the difficulties.
Critical is that patients believe that the explanation provided and the concomitant treatment actions
will be remedial for their problems. The patient and therapist will need to be in agreement about the
goals of therapy as well as the tasks, which are two critical components of the therapeutic alliance
Pathway 3: specific ingredients
The contextual model stipulates that there exists a treatment, particularly one that the patient finds
acceptable and thinks will be remedial for the problems, creating the necessary expectations that the
patient will experience less distress. Every treatment that meets the conditions of the contextual
, model will have specific ingredients. The question is how the specific ingredients work to produce the
benefits of psychotherapy. The contextual model posits that the specific ingredients not only create
expectations (pathway 2), but universally produce some salubrious actions. That is, the therapist
induces the patient to enact some healthy actions.
Common factors:
- Alliance: composed of three components (bond, agreement about the goals of therapy and
the agreement about the tasks of therapy). Is a critical common factor, instrumental in
pathway 2 and 3. A construct related to alliance is goal consensus/collaboration.
- Empathy: complex process by which an individual can be affected by and share the
emotional state of another, assess reasons for another’s state, and identify with the other by
adopting his or her perspective, is thought to be necessary for the cooperation, goal sharing,
and regulation of social interaction.
- Expectations: In psychotherapy, creating the expectations, through explanation of the
patient’s disorder, presenting the rationale for the treatment, and participating in the
therapeutic actions, is part of therapy. It is difficult to study it experimentally.
- Cultural adaptation of evidence-based treatments
- Therapist effects: exist if some therapists consistently achieve better outcomes with their
patients than other therapists, regardless of the nature of the patients or the treatment
delivered. Therapist effects in naturalistic settings are greater than in clinical trials. Studies
have shown that effective therapists (visa-vis less effective therapists) are able to form
stronger alliances across a range of patients, have a greater level of facilitative interpersonal
skills, express more professional self-doubt, and engage in more time outside of the actual
therapy practicing various therapy skills.
Hoofdstuk 3: Klassieke conditionering
Gedrag: zinvolle reactie op een betekenisvolle situatie.
Interventies in de gedragstherapie vergen een goed begrip van de functie van het gedrag.
Functieanalyse: analyse van gedrag in termen van betekenisvolle situaties/stimuli, zinvolheid en
doelgerichtheid.
Klassieke conditionering: leren van betekenissen.
Operante conditionering: leerprocessen die betrokken zijn bij het zinvol en doelgericht omgaan met
deze verworven betekenissen.
Little Albert (Watson): in de eerste fase werd Albert met een wit ratje geconfronteerd, er waren geen
(emotionele) responsen. Ook bij vergelijkbare dieren en voorwerpen waren geen responsen. In de
tweede fase werd het ratje gecombineerd met een opschrikkend geluid, waardoor Albert schrok. In de
laatste fase werd alleen het ratje getoond. In vergelijking met de eerste fasen was er een duidelijke
gedragsverandering (angst). Ook op transfer stimuli had het effect. Hierbij is:
- Ongeconditioneerde prikkel (US): luide knal
- Ongeconditioneerde respons (UR): opschrikreflex
- Geconditioneerde prikkel (CS): witte ratje
- Geconditioneerde respons (CR): vreesreactie.
In dit geval is er sprake van aversieve
conditionering US is een onaangename,
aversieve stimulus. Bij aangename US’en is er
sprake van appetitieve conditionering.
Acquisitie: fase waarin de vrees voor een
voorheen neutrale stimulus wordt verworven.
Differentiatie: leren onderscheiden van wat veilig is en wat eerder onveilig is.
Generalisatie: ook de geconditioneerde respons ontwikkelen voor vergelijkbare stimuli/situaties.
Belangrijk omdat we zelden/nooit worden geconfronteerd met exact dezelfde situatie als voorheen.
Standaard wordt gevonden dat de geconditioneerde respons afneemt, naarmate de
generalisatiestimuli minder lijken op de oorspronkelijke CS.
Contextconditionering: conditionering aan grotere gehelen dan specifieke stimuli.
