PSY 244 CLINICAL PSYCHOLOGY

1. PSY 244CLINICAL PSYCHOLOGY BAHAR BAŞTUĞ Assist. Prof. Dr.

3. Psychotherapeutic Issues

4. Lecture Preview • Does Psychotherapy Work? • Long-Term Therapy versus Short-Term Treatment • Who Stays In and Who Drops Out of Psychotherapy? • Is One Type of Therapy Better Than Another? • Do the Effects of Psychotherapy Last after Therapy Ends? • Common Factors Associated with Positive Psychotherapy Outcome • Why Is Change Difficult? • Must Someone Be a Professional to Be an Effective Therapist? • Does Psychotherapy Help Reduce Medical Costs? • Can Psychotherapy Be Harmful?

5. 1.Does Psychotherapy Work? the usefulness of psychotherapy. This such question is difficultto answer and varies from individual to individual and treatment to treatment. Psychotherapy is one of the most common activitiesconducted by clinical psychologists.Each patient, each psychologist, and each psychotherapyexperience are unique.

6. Psychotherapy is a highly personalized experience. It is impacted by the skills, interest,training, motivation, and personality of thepsychotherapist and by the specific symptoms(e.g., etiology, duration, severity), motivation,personality, and resources of the patient. The therapist-patient interaction is unique. Unique therapist-patient interactionplays a significant role in treatment outcome. Also, some factors such as beliefs, attitudes, and expectations play a significant role in treatment outcome.

7. Two patients with very similar symptoms seeing the same psychotherapist may experience two very different psychotherapies. Psychotherapy may be helpful to one but not to the other. What works well with one person may not work well with another. Positive treatment outcome may be associatedwith the passage of time (i.e., “timeheals all wounds”).

8. 1.Does Psychotherapy Work? Merely asking patients the usefulness of psychotherapy provides important answer, but it is insufficient. Determining whether psychotherapy is useful is a research and clinical task. For this reason, psychotherapy treatment outcome has become one of the most common topics of investigation in all psychology research.

9. 1.Does Psychotherapy Work? In his classic study, Hans Eysenck examined 24 research studies concerning both psychodynamic and eclectic techniques used for nonpsychotic patients. The results of his study failed to demonstrate that psychotherapy was effective. 72% of those experiencingpsychological distress would improve withouttreatment.

10. 1.Does Psychotherapy Work? Smith and Glass examined 375 research studies on psychotherapy treatment outcome by using meta-analysis. Results showed that patients receiving psychotherapy tended to be more improved than those who did not receive psychotherapy. Smith and Glass (1977) examined the treatment outcomes of different types of psychotherapy (e.g., behavioral and psychodynamic) and failed to find superiority of one treatment approach over another.

11. 1.Does Psychotherapy Work? After some critics about first study, Smith, Glass, and Miller (1980) extended the analysis to include 475 studies and improved upon several of the procedures from the earlier study. The study confirmed the earlier results and found that those receiving psychotherapy tended to be more improved than 80% of untreated persons. Behavioral therapieswere more effective than verbal therapies.

12. 1.Does Psychotherapy Work? A large number of meta-analysis studies examining psychotherapy treatment outcome have been conducted. The majority of these studies conclude that psychotherapy is generally effective. Andrews and Harvey(1981) evaluated 475 controlled psychotherapyoutcome studies and concluded that a patientreceiving psychotherapy was better offthan untreated control subjects andthat relapse rates were small.

13. 1.Does Psychotherapy Work? An extensive review of all the research studies concludes that psychotherapy does indeed work. Both researchersand clinicians have been trying to answermany follow-up questions such as: How does psychotherapy workand what types of treatment and therapists areeffective for what types of problems and patients? Recent efforts by the APA have attemptedto identify specific treatment approaches forspecific problem areas.

14. Seligman(1994) states that the depthof a problem predicts if the problemcan be altered through psychotherapy. Problemsthat are biologicallyoriented and pervade all aspects of life are less appropriate for psychotherapythan problems that are learnedand are less pervasive. He suggests thatproblems such as panic and phobia are muchmore responsive to therapy than obesity and alcoholism.

15. 2.Is Long-Term Therapy Better than Short-Term Treatment? Psychotherapy can last for one session or forhundreds of sessions in manyyears. The duration of psychotherapy depends on: the symptoms, interest, motivation, and financial resources of the patient and on the orientation and skills of the therapist. The average length of psychoanalysis is about 1,000 sessions. Brief psychotherapies are of interest to both patients and insurance companies. Patients seek psychotherapy during acrisis and wish to obtain relief asap. They want relief symptoms within 12 weeks.

16. 2.Is Long-Term Therapy Better than Short-Term Treatment? The majority of patients terminate treatment before 10 sessions. Between 25% and 50% of people fail to attend a second session.

17. 2.Is Long-Term Therapy Better than Short-Term Treatment? Research on more than 2,400 patients over 30 years suggests that 50% of patients were significantly improved by 8 sessions. Another research using the 4,100 people found that most people experienced significant improvement in symptoms within the first 10 to 20 session.

18. Research has found that even asingle session is associated with positive outcomes such as a decrease in medical officevisits. However, some meta-analysis research has demonstrated that duration is not necessarily associated with treatment outcome. It is difficult to make generalizations regarding the superiority of short- versus long-term treatment.

20. 3. Who Stays In and Who Drops Out of Psychotherapy? About a third of psychotherapy patients do not attend a second session. What factorsmight predict psychotherapy dropout?

21. 3. Who Stays In and Who Drops Out of Psychotherapy? SES and educational level are associated with dropout. Patients from lower SES and those who have less education tend to be more likely to quit psychotherapy. What characteristics of thetherapist might also predict it? The skill of the therapist is positively associated with continuation of psychotherapy. However, a therapist’s gender and whether being psychologist or psychiatrist appear unrelated to dropout.

22. 3. Who Stays In and Who Drops Out of Psychotherapy? Patients may feel that the crisis has passed, and their motivation has significantly decreased. Often patients feel better after one session and do not wish or need to continue. The therapistand patient may not “click” during the firstsession as well. Patients who do not like theirtherapist are less likely to attend next sessions.

23. 4. Is One Type of Therapy Better than Another? Is psychodynamic psychotherapy better than CBT? Is individual psychotherapy better than family systems approaches? Is anyone type of psychotherapy superior to another? Many researchhave been conducted to determine if one type of psychotherapyis superior to others.

24. 4. Is One Type of Therapy Better than Another? To ensure that these studies use pure formsof therapy and do not mix and match techniques, most of these research incorporate treatment manuals and ask clinicians to follow treatment manuals. Clinicians tend not to usetreatment manuals in actual practice. They use integrative approach, that’s mix and match techniques and approaches from different theories.

25. 4. Is One Type of Therapy Better than Another? Most of the research have failed to find that one type of psychotherapy is consistently superior to another. Sincethe mid-1970s, some researchers have referredto the equality of different types of psychotherapyas the “dodo bird verdict.” But, some researcher suggest that different types of psychotherapy often result in different specific effects. According to the studies, CBT tends to result in more positive than psychodynamic or other verbal treatment types.

27. 4. Is One Type of Therapy Better than Another? Studies have tried to determine whether psychotherapy is as effective as medication in treating anx, depr, and other. A study compared CBT, interpersonal psychotherapy (a combination of psychodynamic and humanistic psychotherapy), medication, and a drug placebo condition. Results indicated that all treatments, including the placebo condition, resulted in improvement.

28. 4. Is One Type of Therapy Better than Another? Although no one type of therapy is superior to another, several specific disorderstend to be treated more successfully using certain approaches. Empirically supported treatments show: • exposure treatment for phobias and PTSD, • CBT for headache, depr,irritable bowel syndrome, and bulimia, • insight-oriented dynamic therapy for deprand marital discord.

29. 5. Do the Effects of Psychotherapy Last after Therapy Ends? What happens when someone terminates psychotherapy? Do people generally turn back to the problematic patterns of thinking, feeling, and behaving? Do the gains obtained by psychotherapy last? It may be unrealistic expectation that psychotherapy will “cure” a problem or eliminate symptoms without any relapse.

31. 5. Do the Effects of Psychotherapy Last after Therapy Ends? Research generally supports the claim that gains obtained in psychotherapy do last. Jorm examined the results of studiestreating anxiety and found that anxiety reduction lasted up to 1 year after treatmentwhen compared with controls. Feskeand Chambless examined 21 researchusing CBT for social anxiety and found improvementslasting up to 1 year after treatment relative tocontrols.

32. 5. Do the Effects of Psychotherapy Last after Therapy Ends? Similar findingshave been reported when examining panic, depr, alcohol, PTSD, and headache treatments. Relapse is a common problem. Researchers have developed programs and strategies to maximize maintenance of psychotherapy gains.

34. 6. What Common Factors Are Associated with Positive Psychotherapy Outcome? In sum, psychotherapyis effective in treatingnumerous problemscompared with receiving no treatment. No one type of psychotherapy is superiorto another. If specific theories and techniques do not account for treatment outcome, then what does? There are certain commonalities among all types of psychotherapies and these commonalities are associated with treatment effectiveness.

35. 6. What Common Factors Are Associated with Positive Psychotherapy Outcome? The search for common factorsis important to understanding how psychotherapy might work. Karasu suggested that all useful psychotherapies include three common patient factors: • Affect experiencing: expressing feelings. • Cognitive mastery: thinking about problems in a manner that enables the patient to experience control over attitudes, perceptions, and beliefs about problems. • Behavioral regulation: developing strategies for controlling impulses and problematic behaviors.

36. 6. What Common Factors Are Associated with Positive Psychotherapy Outcome? According to Frank a professional office associated withbeing helped; a trained professionalwho is supportive; enhanced hope thatthoughts, feelings, and behaviors can change; fees associated with service; the avoidance of dual relationships.

37. 6. What Common Factors Are Associated with Positive Psychotherapy Outcome? Weinberger (1995) outlined 5 common factors: • therapeutic relationship: The relationship between the therapist and patient should be positive and that therapists should be empathetic, genuine, warm, and professional. There is an alliance between therapist and patient. Connecting to a therapist whom thepatient perceives as helpful and accepting is apowerful common factor in all types ofpsychotherapy.

38. 6. What Common Factors Are Associated with Positive Psychotherapy Outcome? • expectations of success: Expectancy is a strong predictor of positive therapeutic outcome. Treatment is more effective when patients believe that the treatment is helpful. Belief that psychotherapy can work is another important common factor. • confronting a problem: Facing or working on problems rather than avoiding, escaping, or denying is a common factor in all therapies. Only writingor talking about a problem alone withouta therapistresults in improvement. Working on problemsarepowerful common factors.

39. 6. What Common Factors Are Associated with Positive Psychotherapy Outcome? • providing the experience of mastery or control over the problem: Mastery, or a sense of control, over a problem is a powerful predictor of therapy outcome. It enhances sense of self-efficacy. • an attribution of success or failure: Patient’s internal attributions about the factors that they believe contribute to change are powerful predictors of therapy success or failure. «Positive outcome is due to my own effort»

40. In another study, getting advice and talking withsomeone who understands and is interested intheir problems, and gives encouragement and hope, were curative factors. Lazarus (1971) found that the personal qualities of the therapist were more important to patients than the psychotherapy techniques used.

41. 7. Why Is Change Difficult? Behavioral change, with or without psychotherapy, is not easy. Often patients are ambivalent about change and may not be pleased with some of the results of change. For example, a patient who successfully overcomes panic attacks may be expected to develop more responsibility at home or at work. Resistance to change is very common among patients.

43. Prochaska’s transtheoretical model has researched commonalities of behavioral change among theoretical orientations by examining the process of change across different types of problems and different methods of treatment. In his analysis of different orientations to behavioral change, Prochaska isolated a variety of universal stages, levels, and processes of change.

44. His theory includes five stages of change • precontemplation, • contemplation, • preparation, • action, and • maintenance. The desire to change is likely to be avery important factor in explaining behavioralchange.

46. Kleinke outlined several important factors explaining why change is difficult to achieve and why resistance is so common in psychotherapy. 1. Change is threatening. Usual ways of thinking, feeling, and behaving offer some degree of comfort even if they are maladaptive. 2. Secondary gains (i.e., advantages to maintaining problems)may be difficult to give up.

47. 3. Potential interference from others. Although a patient may wish to change behavior through psychotherapy, important others in the life of the patient (i.e spouse) may be motivated to maintain the status quo. The spouse ofthe patient with agoraphobia may feel importantand needed by the patient. Increasedindependence may be experienced by thespouse as a threat to his or her power. As a result, many people resist change when they feel that their freedom is threatened.

48. 8. Must Someone Be a Professional to Be an Effective Therapist? Does someone really need to have a PhD to be an effective psychotherapist? Aren’t many caring and empathetic persons excellent “therapists” even if they have no formal training? Aren’t a lot of friends, neighbours, and grandparents excellent “therapists”? Most people have had the experience of talking over problems with their friends, relatives, neighbours, or even strangers.

49. 8. Must Someone Be a Professional to Be an Effective Therapist? Level of training for psychotherapists?? Does someone really need to have a PhD orother advanced degree to be an effective psychotherapist? Aren’t a lot of friends, colleagues, neighbours, and grandparents excellent “therapists”? Research indicates that the therapist’spsychological health, skill and a sincereinterest in helping others are necessaryqualities for being an effective psychotherapist.

50. 8. Must Someone Be a Professional to Be an Effective Therapist? Several studies have failed to find a difference in psychotherapy outcome between therapies provided by professionals versus paraprofessionals. However, other research has demonstrated that the experience and training of the therapist is important for positive therapeutic outcomes. Some studies have found that the use of paraprofessionals results in superior outcomes relativeto professionals, but they have been criticizedforusing poor quality research.