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Assessment and Therapy

Assessment and Therapy. Major methods of clinical assessment Therapeutic approaches 1. Psychoanalysis 2. Cognitive Behavioural Therapy 3. Gestalt Therapy 4. Solution-focussed Therapy. Major methods of clinical assessment. Clinical interview

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Assessment and Therapy

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  1. Assessment and Therapy Major methods of clinical assessment Therapeutic approaches 1. Psychoanalysis 2. Cognitive Behavioural Therapy 3. Gestalt Therapy 4. Solution-focussed Therapy

  2. Major methods of clinical assessment • Clinical interview • Unstructured • Structured or semi-structured, e.g. for OCD, Anxiety Disorders, Pervasive Developmental Disorders • Psychological tests • Self-report e.g. personality inventories (MMPI), depression, self-esteem etc.etc.etc. • Clinician administered, e.g. intelligence tests, neuropsychological tests, projective tests (Rohrschach, TAT) • Observation = direct observation of behaviour; structured or unstructured • Biological and Physiological testing, e.g. physiological indicators (GSR, heart rate) or neurological mapping (MRI, PET & CT etc.)

  3. Major Research Methods • Case Studies • Epidemiological Research • Correlational Studies • Experimental studies: vary with regard the amount of control and randomisation • Single-case experimental design

  4. Psychoanalysis (Freud & others) • Personality is an organised system of drives or instincts which must be regulated. • Pleasure Principle: Individuals are driven to seek pleasure and avoid pain • Personality/behaviour is guided by the conflict between life instincts (Eros) and death instincts (Thanatos) • ANXIETY arises out of the tension between the id, ego and superego. This tension motivates us to do something. • Three types of anxiety according to Freud: • Reality – anxiety is realistic and appropriate to the situation • Neurotic – fear of uncontrollable instincts • Moral – fear of violating one’s own conscience (built on the standards of parents or society).

  5. Defence Mechanisms: • Repression • Denial • Reaction Formation • Projection • Displacement • Sublimation • Rationalisation • Regression • Identification • Intellectualisation

  6. Assessment: Projective techniques • Rorschach (1921) - 10 cards with ambiguous material (ink blots) presented and clients project feelings and motivations • Thematic Apperception Test (Morgan & Murray, 1935) - Series of 31 drawings and clients make up a story about what is occurring in the drawing • Research conducted by Craig and Horowitz (1990) TAT and Rorschach top 4 tests commonly used

  7. Goals of Therapy: • Make the unconscious, conscious • Awareness of past experiences • Acknowledgment of anxiety and threat • Gain insight into patterns of behaviour • Strengthen the ego • Behaviour in tune with reality • Able to withstand impulses of ID & Superego • No need for reliance on defence mechanisms

  8. Therapeutic Process Goals are achieved through analysis of childhood experiences. These experiences are: • Reconstructed • Interpreted • Analysed

  9. Analyst - Therapist • Therapist-client relationship is key • Neutrality (blank screen) and empathy • Allows free expression of thoughts, images, feelings without distortion or censorship • Attitude is non judgemental with ‘benign curiosity’ • Encourages client to reflect upon significance and to make connections • Transference is central to therapy

  10. Transference • Transference occurs when clients earlier relationships contribute to their distorting of the present. Clients react to the therapist as they did to some other, significant person. • Analysis of transference assists to distinguish reality from fantasy, past from present, and bring aspects of unconscious into consciousness • Therapist listens for gaps, inconsistencies and draws meaning from associations and dreams • Therapist examines relationships and motivations occurring before age 5 that affect current functioning

  11. Techniques and Procedures • Free association: relate everything they are aware and this allows for unconscious material to arise • slips of the tongue • meanings • disruptions • omitted material • interpreting behaviour and material presented • Dream Analysis: • Dreams are the “royal road to a knowledge of the unconscious activities of the mind” (Freud, 1900). • Dreams can reveal wishes, needs, and fears • Representation of content (manifest and latent) unacceptable to the ego

  12. Interpretation: • Analysts present material to client arising during sessions • Analysts attend to content of material and process of conveying material to client • Clients may resist therapy at times and this may be interpreted • Encouragement of Regression: • Returning to an earlier way of reducing threat, anxiety or pain

  13. Cognitive Therapy • In the 1950s behavioural theory and therapy (Skinner etc.) was prominent • In the 1960s other theorists (esp. Aaron Beck) proposed the importance of thoughts/cognitions • Albert Ellis added the emotional dimension and the “rationalisation” of thoughts and feelings • Since then, many other theorists and models

  14. The Main Elements in Cognitive Theory • Negative Automatic Thoughts • Negative schemas/negative schema content • Leads to process oflogical errors/cognitive distortions • Content negative with respect to • Self • World • Future

  15. Automatic Thoughts • Are transient phenomena; quick but can be “caught” (like a spoken sentence) • Occur in the stream of consciousness • They are short and specific. • They occur extremely rapidly, immediately after the event. • They do not occur in sentences, but may consist of a few key words or images. • They do not arise from careful thought. • They do not occur in a logical series of steps such as in problem solving. • They seem to happen just by reflex

  16. Schemas • Are permanent entities/scripts stored somewhere in your brain • Long term reference material about things in the world • A schema is like a box that contains the results of previous experiences as interpreted by the person • The content of the schema can be positive or negative or a mixture EXPECTATIONS MEMORIES ASSOCIATED EMOTIONS ACTION TENDENCIES (Behaviours)

  17. STREAM OF CONSCIOUSNESS (Includes awareness of sensations) AUTOMATIC THOUGHTS ACTIVATING EVENT Emotional Response SCHEMAS Behavioural Response

  18. Logical Errors • Errors in making conclusions from sensory input • Also known as “cognitive distortions” • Not errors in perception, but errors in interpretation • Misinterpretation or non-objective interpretation

  19. Catastrophisation More dire than justified Unjustified negative prediction Overgeneralisation Personalisation Invalid assumption of responsibility Mindreading Selective Abstraction Biased weighting Not considering all the facts Black & White thinking False Absolutes Arbitrary Thinking (Shoulds) Emotional Reasoning Types of Logical Errors

  20. Which Logical Error? Emotional Consequence Activating event Belief or thought Referee awards Penalty He’s useless Anger - Must or Should Emotional Reasoning - Invalid allocation of responsibility - Overgeneralisation - Biased Weighting

  21. Which Logical Error? Emotional Consequence Activating event Belief or thought Bike Smash My career is over, this is the end Depression • Catastrophisation • More dire than justified • Unjustified negative prediction • - Overgeneralisation • (External attribution)

  22. Which Logical Error? Emotional Consequence Activating event Belief or thought I’ll probably embarrass myself Going to a party Anxious Catastrophisation - More dire than justified - Unjustified Negative Prediction - Biased Weighting

  23. Common negative schema content • Nature of self: I am no good • Integrity of self: I am unsafe/will come to harm • Nature of social world: I am or will be alone • Nature of the world: The world is bad/against me • Nature of others: Other people are bad/against me

  24. Which Schema Theme? Emotional Consequence Activating event Belief or thought Referee awards Penalty He’s useless Anger Nature of self: I am no good Integrity of self: I am unsafe Nature of social world: I am or will be alone Nature of the world: The world is bad/against me Nature of others: Others are bad/against me

  25. Which Schema Theme? Emotional Consequence Activating event Belief or thought Bike Smash My career is over, this is the end Depression Nature of self: I am no good Integrity of self: I am unsafe Nature of social world: I am or will be alone Nature of the world: The world is bad/against me Nature of others: Others are bad/against me

  26. Which Schema Theme? Emotional Consequence Activating event Belief or thought I’ll probably embarrass myself Going to a party Anxious Nature of self: I am no good Integrity of self: I am unsafe Nature of social world: I am or will be alone Nature of the world: The world is bad/against me Nature of others: Others are bad/against me

  27. What goes Wrong? • We make logical errors in our childhood • We develop Early Maladaptive Schemas • We make logical errors after Activating (Critical) Events • Activate negative emotion from an EMS • Have frequent negative automatic thoughts • We believe in and use dysfunctional strategies

  28. Which counterproductive strategy? • Avoidance? • Surrender? • Overcompensation? Cognitive Behavioural Therapy: adds a behavioural or ‘change to strategy’ element

  29. Goals of Therapy In the Moment • Change logical errors to appropriate logic • Reduce the frequency of automatic thoughts • Change the balance of schema content from negative to positive • Help the client change their behaviour Later in Therapy • Change logical errors to appropriate logic in more pervasive way • Change schema content • Build new schema content • Revise memories • Change meta-cognitions regarding behavioural strategies

  30. Therapeutic process • Summarizing and questioning can lead to change in beliefs • Making your questioning specific can make the logical errors apparent • Summarising • Comparing incompatible information or values • Psychoeducation • Investigation • Experiment Funnelling your questions leads to automatic thoughts BROAD SPECIFIC

  31. Gestalt Therapy • Gestalt - German word meaning “pattern” or “whole” • Fritz Perl’s Gestalt Prayer I do my thing, and you do your thing I am not in this world to live up to your expectations And you are not in this world to live up to mine. You are you, and I am I, And if by chance we find each other, it’s beautiful If not, it can’t be helped. (Source: Fritz Perls, as quoted in Shepard, 1975, p.3.)

  32. Personality - Five Layers Implosive layer Cliché layer (Phony) Role playing layer (Phobic) Impasse layer Explosive layer Genuine personality

  33. Key concepts • Gestalt - exists through the inter relation of parts. • Healthy functioning: parts form a meaningful whole • Awareness: contact within self and with others. Ability to focus on what exists in the now. • Becoming aware of : • Sensations - senses: seeing, hearing, touching etc.. • Feelings - emotional and physical • Future events - wants and desires • Values - social, spiritual, and relationship issues

  34. Key concepts cont... • Unfinished business- unexpressed feelings from the past • The Now- present focus- incorporating bodily and sensing systems • Responsibility- core of Gestalt Therapy. • Holism

  35. Assessment • Focus is on “moments in therapy” • Gestalt contact style questionnaire (how the “I” comes into contact with others and the world in terms of body, values, emotional expression etc.)

  36. Goals of Therapy • Increase awareness • body, feeling, environment, experiences, needs, skills, senses, power to care for oneself, actions and consequences, fantasies • Accept responsibility • Increase personal growth and autonomy

  37. Therapeutic change “Change occurs when one becomes what one is, not when one tries to become what one is not” (Beisser, 1970) • 3 stage sequence of integration (Polster, 1987) • Discovery • Accommodation • Assimilation

  38. Gestalt Techniques • The dialogue exercise • Playing the projection • I take responsibility for • May I feed you a sentence • The rehearsal exercise • Experiments

  39. Solution Focussed Therapy Overview of Philosophical Approach • Serious optimism • Client as expert • Collaborative • Customers and complaints • Power of language • No absolute truths • Constructivist

  40. Assumptions of solution focussed therapies(O’Hanlon & Weiner-Davis (1989) • Clients have resources and strengths to solve complaints • Change is constant • The SF therapist’s job is to identify and amplify change • It is usually unnecessary to know a great deal about the complaint to resolve it • It is not necessary to know the cause or function of a complaint to resolve it • A small change is all that is necessary; a change in one part of the system can effect change in another part of the system • Clients define the goal • Rapid change or resolution of problems is possible • There is no one “right” way to view things; different views may be just as valid and may fit the facts just as well • Focus on what is possible and changeable rather than what is impossible and intractable

  41. Central constructs • Exceptions • regardless of the severity of a problem, there are always times when the problem does not happen • helps consumers see they are already successful • Work to find ways to increase exceptions • Change talk • Strengths and resources • Solutions • Focus is on what would be perceived as acceptable solutions – “a difference that would make a difference”

  42. Therapy • Roles • Client is expert on the problem • Therapist expert on change and solutions • Assessment • Traditional assessment belongs in the medical, problem focused models • Focus is on interviewing for solutions • How were you hoping I could help you? • Have you tried anything to solve this? • What do you notice when it isn’t happening?

  43. Therapy continued… • Goals • Need to be specific, attainable, observable and concrete • Good goals: • Change the doing of the problem • Change the viewing of the situation • Evoke resources, strengths and solutions • The best goals are those that specify what replaces unwanted behaviours

  44. Therapeutic techniques • Questions • Heavily relied upon • Special tactic: The pre suppositional question • When the problem is not present, how are things different? • Assumes that success already occurs

  45. Some solution focused questions (Hudson, OHanlon & Weinrer-Davis, 1989) • What is different about the times when (the exception) happens? • How did you get that to happen? • How does it make your day go differently when (the exception) happens? • How did you get her/him to stop? • How is it different from the way you might have handled it (one week, one month etc..) ago? • Have you ever had this difficulty in the past? What did you do to resolve it then? What would you need to do to get that to happen again?

  46. Techniques continued… • Externalisation of the complaint • The person is not the problem • The problem is not the person • The problem is labelled as the complaint (or given a name) • Questions asked about the impact of the complaint • The complaint is broken down into small and specific components • The complaint is reframed as habits

  47. Normalising the problem • SFT may ask the client something like “How can you tell the difference between (stated complaint) and (normalised explanation)? • Compliments • Drawing out personal qualities that can be useful in resolving current difficulties • Not motivated to be kind to clients • Used to reinforce what is of importance to a client • The miracle question • Help identify goals without focusing on problems and causes

  48. The Miracle question Set the scene: I’m going to ask you a question, it may seem a little weird, but I think it may be really helpful. Are you ready? The Miracle question (de Shazer, 1988): “Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is that the problem which brought you here today is solved. However, because you are sleeping, you don’t know what the miracle has happened. So, when you wake up tomorrow morning, what will be different that will tell you a miracle has happened and the problem which brought you here is solved?

  49. Techniques continued…. • Scaling questions • “On a scale from 0 – 10, with 0 being the worst the problem has ever been and 10 being the problem is completely solved, where are you today?” • “What one or two things could you do this week to being you up one or two points?”

  50. Altering the complaint • Changing when the complaint is performed • Changing the duration of the complaint • Changing the location of the complaint • Adding at least one new element to the complaint pattern • Linking the complaint to some burdensome activity • Changing the context of the complaint • Surprise task • Do one or two things that will surprise (partner, parents) don’t tell them what it is, (Partner or parents) job is to find out what it is. Don’t compare notes, we will do that at next session

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