Psychotherapy
College notes
Lecture 1: intro
A few concerns and a few praises
- Gap: academic psychology and clinical practice: small impact of research findings
- Strong effects for disorder-specific treatments
- Little theoretical integration across psychotherapy schools
So, let’s talk about theories
When we are talking about psychotherapy, we often talk about helping people who have
experiences they cannot control, if they could control it they wouldn’t need psychotherapy
Mental disorder
Experience of…
- Feelings (or lack thereof), thoughts (obsessed with something, ruminating), behavior
tendencies (urge to pull hair or drink etc.), bodily sensations
- As a problem (you experience it as a problem): unwanted, intolerable, abnormal,
uncontrollable, absurd
- ‘Who is in charge?’ fragmented sense of ‘self’, due to feeling like you aren’t in control
and can’t change something
What is the goal of psychotherapy?
- Correct: change unwanted patterns of subjective experiences
- Or – viewed from medical model – reduce agreed upon symptoms, disorders, etc.
- Wrong: make patients happy (again), being unhappy can be seen as something that is
part of life, the idea that a therapist can make someone happy again isn’t correct
- Wrong: help patients understand reality, a psychotherapist doesn’t know much more
about reality than every other person
It is quite difficult to change our internal experiences, but there are some means that we
have to try to change these internal experiences
Means: changing propositional representations?
Propositional representations = a part of information our brain is using which is symbolic and
language based. So, it is very much logical thinking without having the experience. E.g., you
can talk about the future without having experienced the future
- Language-based, symbolic, deductive, arguments. Are these reasonable arguments
going to help a person?
- Sometimes this can be important in situations where people a wrong propositional
representation, you can change that part
- Change is easy: provide information; reason, persuade: psycho-education, cognitive
therapy
- These types of reasoning can help a bit, but often a person knows that their problem
is absurd
- Problems: (1) therapist is authoritarian, reasoning stories can make a patient feel
quite alone; (2) patient is likely to be passive, can’t experience the words; (3)
persuasion is often ineffective or transient
,Means: discover who you are?
- Self-knowledge; classical philosophical proposition
- Core of psychoanalysis and client-centered therapy
- Problem 1: classical psychoanalysis (interpretations, ‘archaeology’, digging up the
remains of who you are) inefficient; client-centered therapy assumptions untenable
- Problem 2: unsupported by academic psychology: mental processes hardly
accessible, fragmented sense of self; instead ‘English butlers’ = sub routines that
happen automatically, afterwards we believe that we did it ourselves
Brain sub-programs (English butlers)
First it is a visual process, you see something happening, while
this is happening you may also smell something; olfactory
process, you also hear something and while this is happening
you also feel something happening inside yourself, you may get
tense, then your amygdala may decide if this man is dangerous
or not, certain brain structures in your brain will chose the motor program for e.g., running
away (but won’t happen yet). All these parallel processes are like stones you throw in water
and they spread the lake, all the information comes into the brain, there it connects with
memories that are already there and a lot of other information comes together in certain
regions and then we become aware. You already interpreted what was happening quite
early on, but later you become aware. Gazzaniga said ‘Consciousness is the last to know, it is
a mystery, can be seen as an attendant, feeling like you do something, but you are just the
actor of things that are happening inside your body’
Adaptation of English butlers
We all have these butlers, but they have to adapt to our surroundings. But how do we learn
and change these English butlers? Such a connection can change very quickly.
Synaptogenesis process = making connections between neurons, are easier with:
- Emotions help this process, when they are involved, we are better able to
change/learn
- Experience-based, the way we learn is by doing, then it is easier to learn
- Repeated encounters: ‘cells that fire together wire together’, associative
representations = stimulus triggers a response
Discover who you are (continued)?
How can you do this?
- Possibility 1: change schematic representations (dominant beliefs you have about
yourself, whether it is true or not) by simultaneously activating multiple neural
networks. E.g., induce emotions; connect past present future, images, and previous
experiences
- Experiential techniques: chair technique, imagery rescripting
- Problem: typically, it can only be done within sessions, you can’t give it as a
homework assignment, quite complicated work
- Possibility 2: changing narrative (propositional representations we have about
ourselves) may be helpful, treatment may work because of a belief (that is not true)
helps in itself
,Schema representation (dominant holistic, self-describing neural network)
Laura, 37 years, anorexia nervous
- ‘I need to be in control’ + emptiness
- Six sessions, starting with words and later on the cravings: mother/father (words),
uneasiness, anger (emotion), prisoner (image), craving freedom: go for it
- Lot of dominant strong networks are activated, and this way change is able within
treatment
Means: systematic exercise?
There are automatic processes, like being immediately scared when you see a dog. What is a
way to change this? Words do not connect with this fear.
- Change associative representations (stimulus leading to immediate fear) by
systematic exercise
- Core business in cognitive therapy, behaviour therapy, systems therapy
- Repetition of new learning in order to change the old associations
- In and between (homework assignments) sessions
- E.g., exposure, systematically challenging negative automatic thoughts, behavioural
rehearsal, assertiveness training, role playing, communication skills
- A lot of evidence for effectiveness
- Problem: patients have to participate, if patients doesn’t want to do the exercises or
is not getting involved there is no effect. Patient has to actively get along with the
exercise
Means: patient activation and involvement?
- Without involvement (of the brain) no change in the way we experience things
- Preferably in but also between sessions
- E.g., disclosure (patient), talking about or having emotional experience (optimal),
training, etc. All these things help the involvement within treatment
Means: high quality therapeutic alliance?
- Core ingredient in client-centered therapy and psychoanalysis, belief that offering a
patient a very empathic and respectful relationship is seen as the main mean to help
people change
- Used for motivation and involvement in behaviour therapy and cognitive therapy
- Consistently (but moderately strong) related to psychotherapy results, the way a
patient sees the quality of the relationship is almost always related to the effect of
treatment
- Problem: fuzzy and untested theories in clinical psychology, there is no actual proof
that only offering a good relationship will result in change, however it is important
- But: sound theories from social psychology and communication science about
(resistance to) social influence
Means: reorganizing environment and social interactions
- E.g., spouse and family support; enhance/increase social or daily activities; reduce
stress (e.g., moving); job-related interventions
- Also, (family) care plan (multiple professionals), alert plan, relapse prevention plan
, - Strong (and last resort) treatment packages for severe psychiatric disorders, in this
case it might be more efficient to change the environment instead of the patient
themselves. Like giving support to the family in taking care of the patient
Conclusion
Psychotherapy: undertaking aimed at changing unwanted patterns of experience: ‘That
things are otherwise’ has to be made available. Means:
1. Patients’ involvement
2. High quality therapeutic relationship
3. Providing information (propositional)
4. Systematic exercise (associative)
5. Simultaneous activation of meanings (schema)
For severe psychiatric disorders
6. Rearranging environment
Lastly,
‘That it can be otherwise’ implies…
… that the power of new insights or behaviours consists of letting go of the older ones
Lecture 2: behaviour therapy
Overview
- BT characteristics
- BT process
- Classical and operant conditioning
- Traditional versus modern views
BT: correct characteristics
- Psychopathology (psychological problems) based on S-R (stimulus response)
associations, that is, an interaction between person and environment
- Rather symptom – than person-oriented, changing the problem despite the person
you are
- Observation and self-monitoring are part of treatment and treatment
planning/evaluations, to see if the treatment is effective
BT: incorrect characteristics
- BT involves behaviour only, in the view of an behaviour therapist it also involves
emotions
- BT is cold and mechanical, a behaviour therapist can be seen more as an coach or
advisor and will give you support
- BT is fully evidence-based
BT 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
