Critical issues in psychotherapy

⚫ Psychotherapy is the treatment, by psychological means, of problems of an emotional nature in

which a trained person deliberately establishes a professional relationship with the patient with
the object of
 removing, modifying, or retarding existing symptoms,
 mediating disturbed patterns of behavior, and
 promoting positive personality growth and development.
Wolberg, 1988,2013
Basic components

 ⚫ Psychotherapy is the treatment.

 ⚫ Psychological means

 ⚫ Problems of an emotional nature.

 ⚫ A trained person

 ⚫ Deliberately establishing a professional relationship.

 ⚫ The patient

 ⚫ The object is removing existing symptoms.

 ⚫ Modifying existing symptoms

 ⚫ Retarding existing symptoms

 ⚫ Mediating disturbed patterns of behavior

 ⚫ Promoting positive personality growth and development

Empirically Supported Therapy : Meyer and Scott (2008) in defining an EST, used the criteria
that “. . . efficacy had been established in two or more carefully designed and methodologically
reliable randomized controlled trials that evaluate the treatment of a specific disorder” .
Empirically Supported Therapy . Empirically supported therapy, otherwise known as evidence-
based treatments or evidence- based practices, are treatments and therapies that have
research-based medical and scientific evidence showing that they work. ESTs are theoretically
pure
Outcome vs Process issues

 ⚫ ESTs are mostly outcome focused and largely cognitive and behavioural- traditionally
more oriented to modifying psychiatric disorders

 ⚫ Traditionally process focused therapy like psychoanalytical, client centred etc, are
more oriented towards emergent themes, fantasies etc like structures of subjectivity
following a process of exploration and clarification.
 ⚫ Outcome – treatment & disorder

 ⚫ Process – therapist & client , broader context of client’ s lived realities

Biologisation of psychotherapy

 ⚫ Clinical area of psychology gradually adopted Medical model…

 ⚫ Making treatment more acceptable to public, Easy to eradicate taboo, being

accepted by fellow professional

 ⚫ Advancement of medical field started explaining disorders more explicitly and

maintain pace & rhythm of that biologisation of psychotherapy has been initiated

 ⚫ Biologisation in psychology is so alluring – it gives so called/ false promise of real

scientific credibility, unambiguous causes and

 ⚫ Concomitantly freedom from the mentalism , spiritualism, etc abstract concepts

 ⚫ Satisfies people as extending an explanatory ground sophisticated enough to

contemporary reductionist paradigm of illness explanation

 ⚫ Affinity towards substantive evidentiary basis of psychological process and

psychotherapeutic process as well.

 ⚫ Emergence of behavioual school

 ⚫ World war I & II led to research on behavioural sc from biological perspectives

 ⚫ Acceptance of the objectively verifiable knowledge (modernity and reductionism)

while parallely another stream existed in the contemporary field as the humanistic-
existential approach

 ⚫ Economical financial dominance of pharmaceutical companies , insurance issues

also provide the context of need of biologisation of psychotherapy- ESTs ,

biologically substantiation of psychotherapy models etc ⚫

 To argue against biologisation is not to claim that brains and chemicals are
irrelevant to psychological life.
Spirituality & Religiosity

 ⚫ Easy to avoid but difficult to ignore

 ⚫ Essential component for psychotherapy with caregivers & individuals suffering

from – ⚫ Terminal Illness

 ⚫ Other critical health related condition

Culture
 ⚫ Culture can be generally defined as an interrelated set of values, tools, and
practices that is shared among a group of people who possess a common social
identity;

 ⚫ it is the sum total of our worldviews or of our ways of living.

 ⚫ It affects a range of psychological processes, including perceptual, cognitive,

personality, and social processes, but are thought to most strongly influence social
psychological processes.

 ⚫ Psychopathology is a social event in the contemporary cultural context

 ⚫ The psychopathology breaks the standard social rules of society, either by the
person grossly exaggerating certain aspects of their role or society ' s core values
(i.e. when parents become over-intrusive or excessively promoting freedom). Or by
the person inverting their normal role (i. e. Parents become too much over-
permissive and ignore hierarchical concepts within family system).

 ⚫ The intervention of the healer who restores the person to a new role in the old
social context, or perhaps helps the person transfer to a new social context
altogether.

 ⚫ Cross-culturally, healing supplies restitution and recombination with others.

 ⚫ Cultural globalisation leads increasing interconnectedness among different

populations and cultures.

 ⚫ Therapist must be aware of the clients collective and individual identity

Multiculturalism

 ⚫ "Multiculturalism" is the co-existence of diverse cultures, where culture

includes racial, religious, or cultural groups and is manifested in customary
behaviours, cultural assumptions and values, patterns of thinking, and
communicative styles.

 ⚫ Understanding and acceptance of diversity in the context

Individualism & contextuality

 ⚫ The family, marriage, the nation-state, the labor market all are under
accelerated change and a new fluid, mobile, reflexive, globalized, “post-
traditional” order is emerged as an ever evolving influencing factor.

 ⚫ Ulrich Beck and Elisabeth Beck-Gernsheim identify a process of

“individualization” running through this change such that our very collectivity is,
paradoxically, defined by individualism (not to be confused with freedom)
Individualism & Social Context
 ⚫ Psychology and the human sciences are not made of facts, and this must also
include social constructionism itself.

 ⚫ Relationships between people according to stereotypes of social institutions as

idealised, which actual participants either conform to or differ from.

 ⚫ It questions the assumed values and morality of the day.

 ⚫ Conflict between idealised social institutions and changing broader context

Individualism

 ⚫ socially integrated or socially alienated

 ⚫ Collectivism and interdependent self-construal or the ground of self definition

 ⚫ The effects of interdependent self-construal was found to pervade the domains

of cognitions, motivations, and emotions

 ⚫ Communally and relationally- based coping

 Gender

 ⚫ Change in gender stereotype , Gender equality

 ⚫ human qualities such as ability to provide child care, assertiveness, a desire to

care for others at the expense of oneself are not innate natural qualities that
belong solely to either one sex or the other.

 ⚫ male dominated society controls the number of roles open to men and women
and controls the extent of each behaviour. Stereotypical men are credited with
an aggressive, rational and unemotional character whilst women are deemed to
be passive, caring, intuitive and emotional
Therapist –client interaction
Therapeutic alliance

 ⚫ Communication of meanings between the two as they read each other for
intentions and hidden agendas

 ⚫ The prior life of the therapist. It includes all his or her life experiences of
suffering and therapy which contribute to his or her current attitudes and refers
to the current social context in which the therapist finds his or her self

 ⚫ Empathy- professional concept but often experientially coloured

 ⚫ Non-judgemental attitude

The scientist –practitioner model

⚫ Researcher vs clinician : different paradigm

Diagnosis

 ⚫ Foucault and the 1960s anti-psychiatry movement argue that mental disorder
does not really exist and dismiss the discipline of psychiatry altogether as pure
discourse.

 ⚫ distinguish between treatment therapy (concerning mental disorder) and

therapy aiming to produce happiness (e.g. marriage counseling), personality
growth (e.g. being ‘ never moody’) and release of human potential (e.g. ‘ optimal

psychological functioning’) ⚫ Positive therapy focuses on expression of

reflexivity of self

 ⚫ The skillization of life

Ethical dilemmas

 ⚫ Therapy can and does address moral lacunae.

 ⚫ this is beyond the purview of therapy is incorrect

 ⚫ Psychology extends a secular worldview whereby anger, infidelity, impulsivity,

alcoholism and the like are redefined as “ symptoms” or “disorders” rather than
moral problems.

 ⚫ Sharing of personal information

 ⚫ Use of touch

 ⚫ Social media – professional vs social

 ⚫ Bohart et al. 1998 “the therapist is a disciplined improvisational artist, not a

manualdriven technician ”
Common factors

 ⚫ The notion was first introduced by Saul Rosenzweig (1907–2004) in 1936

(Rosenzweig 1936). He observed that all therapies resulted in comparable
outcomes, hence suggested that they probably worked through factors that were
common to them all

 ⚫ Client-therapist relationship / therapeutic alliance

 ⚫ confounding variables related to the client-therapist relationship, as the more

effective the therapy, the more likely it is that the client will view the therapist
favourably

 ⚫ the content of therapy, that is the principle of exposure (same technique

differently known)
 ⚫ Processing of emotions in therapy

Specific Factors ⚫ the specific factors that might account for the effects of psychotherapy,
mostly organized around specific forms of psychotherapy (e.g., CBT) and specific
psychological disorders (mostly depression and anxiety) Models of Common Factors 1.
Heart and Soul Model (Hubble et al. 1999) 2. Lundh 2014 mentioned following 2 Models
- 1. Relational- Procedural Persuation Model 2. Methodological Principles & Skills (MPS)
Model 3. Contextual Model (Wampold 2001, 2015; Wampold & Imel 2015) Heart and

Soul Model ⚫ On the basis of empirical studies of four decades Lambert conceptualized- ⚫

four overarching categories of therapeutic factors that accounted for outcomes: ⚫ a)

Extratherapeutic change, which includes both client qualities (e.g., ego strength) and
environmental variables (i. e., occurrences outside of the counseling room, such as

obtaining a new job); ⚫ b) Expectancy or placebo effects (i.e., the belief that treatment

will be efficacious); ⚫ c) Techniques (i.e., schools of counseling and specific

interventions); and ⚫ d) Common factors (i.e., similarities among major approaches, such

as empathy, the therapeutic relationship, support ⚫ (40%) of outcome variation came

from extratherapeutic factors and client characteristics. ⚫ Client expectancy for success

in treatment accounted for 15% of outcome variance in Lambert’ s model. ⚫ The largest
component of outcome attributed to practitioners was common factors (i.e., factors
common to all schools of counseling), which accounted for 30% of the variance in

outcomes. ⚫ Lambert estimated that techniques that were associated with particular

schools of counseling were only responsible for 15% of the outcome variance ⚫ Hubble
et al.(1999) to expand the model and postulate that all four factors delineated by
Lambert were common factors that reached across major therapy lines. They modified

category names for their conceptualization of the common factors: ⚫ (a)

Client/Extratherapeutic Factors, ⚫ (b)Placebo, Hope, and Expectancy Factors, ⚫ (c)

Relationship Factors, and ⚫ (d) Model/Technique Factors. Relational- Procedural

Persuasion Model- ⚫ RPP model and is primarily based on the writings of Frank and

Wampold; ⚫ According to this model effective psychotherapy requires a good

therapeutic relationship, a specified therapeutic procedure, and a rhetorically skilful
psychotherapist who persuades the client of a new explanation that provides new

perspectives and meanings in life. ⚫ The contents of these procedures and perspectives,
however, are less important – according to this model, the treatment procedures are
beneficial to the client because of the meaning attributed to these procedures rather
than because of the specific nature of the procedures. Methodological Principles & Skills

Model ⚫ MPS model, is based on the assumption that effective psychotherapy relies on
common methodological principles that are instantiated in various ways in different
forms of psychotherapy, and on the therapist’ s capacity of applying these principles in a

skillful way. ⚫ According to this model, method matters, and it is possible to improve

existing methods. Contextual Model ⚫ There are three pathways through which
Psychotherapy produces benefits. That is, psychotherapy does not have a unitary

influence on patients, but rather works through various mechanisms . ⚫ i) the real

relationship, ⚫ ii) the creation of expectations through explanation of disorder and the

treatment involved, and ⚫ iii) the enactment of health promoting actions. ⚫ Before these
pathways can be activated, an initial therapeutic relationship must be established.

Pathway-1:Real Relationship ⚫ it is an unusual social relationship in that: ⚫ a) the

interaction is confidential, with some statutory limits (e.g., child abuse reporting), and ⚫
b) disclosure of difficult material (e.g., of infidelity to a spouse, of shameful affect, and so

forth) does not disrupt the social bond. ⚫ In psychotherapy, the patient is able to talk
about difficult material without the threat that the therapist will terminate the

relationship. ⚫ 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 ⚫
Patients come to therapy with an explanation for their distress, formed from their own
psychological beliefs. These beliefs, which are influenced by cultural conceptualizations
of mental disorder but also are idiosyncratic, are typically not adaptive, in the sense that

they do not allow for solution ⚫ 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 . ⚫ A strong alliance indicates that the patient accepts the treatment
and is working together with the therapist, creating confidence in the patient that the

treatment will be successful. Pathway 3: Specific ingredients ⚫ Advocates of specific

treatments argue that these ingredients are needed to remediate a particular

psychological deficit. ⚫ The contextual model posits that the specific ingredients not only
create expectations (pathway 2), but universally produce some healthy and restorative

actions. ⚫ The therapist induces the patient to enact some healthy actions, whether that
may be thinkingabout the world in less maladaptive ways and relying less on
dysfunctional schemas (cognitive-behavioral treatments), improving interpersonal

relations (interpersonal psychotherapy )and so on. ⚫ Contemporary mental health

culture is generally dominated by diagnostics and a concomitant emphasis on the use of
specific techniques to eradicate particular symptoms (Hansen 2005). Clinicians,
therefore, may tend to minimize the importance of the common factors to treatment,
which have proven clinical efficacy. This paper has provided an empirically based

examination of the key components of a particular common factors model. ⚫ Techniques

are an important part of the model. However, these techniques are important because
they facilitate the emergence of the common factors that have been proven to be
associated with positive outcomes (e.g., hope), not because of their efficacy as stand-

alone prescriptive treatments for specific symptoms or disorders ⚫ In sum:

Psychotherapy is a complex, multifactorial process, and it is most likely that both
common factors and specific factors play a part in the process that leads to recovery,

most likely in complicated ways that cannot be captured by simple causal models. ⚫
“Psychotherapy is a complex, multifactorial process, and it is most likely that both
common factors and specific factors play a part in the process that leads to recovery,
most likely in complicated ways that cannot be captured by simple causal models. That
being said, the only empirical conclusion that can be drawn is that it is not known
whether therapies work through common factors, specific factors, or both, and that

more and better research is needed to establish this.” ⚫ Cuijpers,P; Reijnders, M. and
Huiber , M.J.H. Annu. Rev. Clin. Psychol. 2019. 15:207–31 It is an outline to facilitate your

study in the field of Psychotherapy. ⚫ Related study material / reference articles

attached with email.