Road to therapy


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  • Figure 11.05 of
    Wade, C., & Tavris, C. (2002). Invitation to Psychology, 2nd Ed. Upper Saddle River, NJ: Prentice Hall.
  • Road to therapy

    1. 1. Road to Psychotherapy
    2. 2. Definition • Psychotherapy is the treatment of psychological disorders or maladjustments by a psychological technique, as a psychoanalysis, group therapy, or cognitive and behavior therapy, etc.
    3. 3. Myths about Psychotherapy • There is one best therapy • Therapy simply does not work • Therapy is just talking or nagging • Therapists can “read minds” • People who go to therapists are crazy or just weak • Only the rich can afford therapy • Psychotherapy is to change people
    4. 4. Reception of Patient • Impression at the door • Receptionist (knows the name), • Euphemism (Mr., Mrs., madam, Abu, Um, etc) • Confidentiality • Privacy
    5. 5. What does this mean? - Can I help - Trust me - You are in good hands - Help me
    6. 6. Physical Environment Physical Environment (setting) •Work environment •Free from distractibility •intermittent noise is more distracting than continuous noise. •Meaningful sounds, such as conversation in next office, are more distracting than non-meaningful sounds such as street noise •Some patients are more noise sensitive than others, and therefore more adversely affected by noise (p. 70) •Physical consistency •Human consistency
    7. 7. Motivational Environment Intrinsic vs. Extrinsic motivation: • Environment of intrinsic vs. extrinsic motivation is sometimes useful: • Intrinsic reinforcement (e.g., feeling of pride, respect, accomplishment and satisfaction) is sometimes more important for motivation than extrinsic reinforcement (e.g., reward) which tends to reduce motivation • When extrinsic rewards used, the person believes that his or her behavior is motivated by external factors • Consequently, when the rewards are taken away, the person is no longer motivated to engage in the behavior • It is known that when volunteer work is motivated by given rewards, enthusiasm decreases.
    8. 8. Symptoms of disorganized physical setting: • Environmental reinstatement effect – short-term or long-term • helps with memory.. • Contextual environment … keep the patient in the same room if possible • state-dependent anxiety treatment, especially with GAD people • Fatigue is associated with performance decrements (homework assignments), especially complex tasks that provide little feedback • Hippocampus Activation In context Dependent state Prefrontal cortex
    9. 9. Accommodation Accommodation: • therapist adjustment when interacting with family structure. • Mirroring the style and affect of the members • Posture mirroring Salvador Minuchin (1921) • He smokes a cigarette if client starts smoking a cigarette Research on Quality of life(QOL) • Our QOL research, family caregiver rating matching well patient’s subjective rating of him or herself . Diabetes, Cancer, psychiatric
    10. 10. Empathy: Effective Communication Techniques Sympathy vs. empathy Listen Actively • Be attentive: • Carl Rogers: Understanding, listening caring, unconditional regards •Be impartial: don't form an opinion, just listen. •Reflect back: restating what has been said helps to know that you understand the patient – don’t talk more than it is needed •Summarize: helps to recognize what was important during session • Avoid being preacher – clergyman or sheikh •Understand resistant vs. reluctant •Transferences • Unrequited love (non reciprocal).. Not transference, and represented in anxiety and depression.. You many feel it and then address it indirectly •Compassionate vs. passionate love •Puppy love
    11. 11. Empathy: Effective Communication Techniques Nonverbal Message •Posture: let your body show that you are interested by sitting up and leaning toward patient. •Equal positioning: if the patient is standing, you stand. If the patient is sitting, you sit as well •Facial expression: Feelings are reflected in facial expressions. •Gestures: your body language reveals a lot about how you interpret a message, •Avoid sending signals that make patient believe that you are angry, in a hurry, bored, etc. •Nonverbal consistency throughout sessions
    12. 12. Effective Communication (cont..) Express Thoughts and Feelings •Be open and honest: •Trusting •Warmth •Speak clearly: don't mumble, jargon or talk too quietly or quickly. • Avoid professional terminology •Professionalism vs. humbleness or simplicity • Avoid being layperson vs. professional (e.g., homosexuality) •Avoid bias : YAVIS (young attractive verbal intelligent and successful) Communicate Without Being Adversarial ‫مخاصم‬ ,‫منازع‬ ,‫معاد‬ •Non-judgmental: talk about your concern without blaming the client. •Don’t evaluate thoughts, feelings, and actions. Such as good, bad.. I have been drinking all night (oh, that’s bad) •For example, you might be upset that your client is not carrying out homework assignment. •Rather than talking about the patient not doing his/her job, discuss your idea of how noneffective session would be without doing assignment •Use "I" messages: Rather than say, "You didn't do your homework ," say, "I didn't understand what happened to that assignment •“ I feel disappointed” instead of “you disappoint me”
    13. 13. Empathy is not a uniquely human trait. Animals demonstrate empathy, which suggests a deep-rooted propensity for feeling the emotions of others. An example of consolation among chimpanzees: A juvenile puts an arm around a screaming adult male, who has just been defeated in a fight with his rival. Consolation probably reflects empathy, as the objective of the consoler seems to be to alleviate the distress of the other
    14. 14. Mirror Neurons and Empathy ‫العاكسة‬ ‫العصبية‬ ‫الخلايا‬ Sympathy vs. empathy • Mirror neurons exist in humans and macaque monkeys, • Activate when an action is observed, and also when it is performed. • mirror neurons in humans fire when sounds are heard. • If you hear someone eating an apple, some of the same neurons fire as when you eat the apple yourself. • "How empathetic seems to be related to how strongly our mirror neuron system is activated," • Classical conditioning • Authors: Valeria Gazzola, at the school of behavioral and cognitive neurosciences neuroimaging centre at the University of Groningen, the Netherlands
    15. 15. Mirror Neuron (motor mimicry) • Neuron "mirrors" the behavior of the other, as though the observer were itself acting. • Found in the premotor cortex, the supplementary motor area, the primary somatosensory cortex and the inferior parietal cortex. • Important for imitation and language acquisition.for understanding the actions of other people, and for learning new skills by imitation. • Involves in language, and autism. • Thinner in Autistic than normal
    16. 16. Postcentral Gyrus • It is the location of primary somatosensory cortex, the main sensory receptive area for the sense of touch • Central sulcus in the front postcentral gyrus • Parietal lobe (in yellow)
    17. 17. Verbal Communication Verbal Communication (Mehrabian 1971) 7% Verbal • What we say, • Words, phrases and content 38% Vocal • How we say it, • Tone, intonation, pitch and pace • Sarcasm comes into this category Bluck/Bennett
    18. 18. Nonverbal Communication 55% • Body movement • Body language • Gestures • Facial expressions • Eye contact Bluck/Bennett
    19. 19. Nonverbal Communication (cont.…)
    20. 20. LABELS GIVEN TO MENTALLY ILL • Lunatics • Crazy • Insane • Idiots • Feeble-minded • Brain-sickness • Beast • Animals • Witches • Sorcerers • Werewolves‫مستذئب‬ • Madness • Possessed • Disturbed • Maniac • Unbalanced
    21. 21. Pejorative Terms and Preferred Terminology Avoid using these terms: Use Instead Able bodied person Non-disabled person implies that the person with the disability is not ‘able’. ; Afflicted; Afflicted by; Person with/ Crippled by; Person who experiences Condition Impairment Deaf-dumb, deaf-mute Speech impaired person A person does not hear and speak/voice. A person who is mute may be able to hear. Defect, defective disability is appropriate. She suffers from a birth "she has a congenital disability." defect." (offensive) Deformed Disability is appropriate.
    22. 22. Treatment Variable Therapeutic alliance • Most important treatment variable • Patient’s ability to establish interpersonal and trust relationship • Patient starts thinking of session outside therapy room * Duration • Around 26 session, showing fairly linear positive relation • If curve becomes flattened, you should refer patient Type of treatment • No type of treatment or approach is viewed as superior to the other
    23. 23. Client Variables Are better predictors of therapy outcome than are therapist variables or treatment variables (Luborsky et al., 1980) Intelligence • Highly intelligent patients seem to benefit from psychotherapy • Intelligence is the ability to function adaptively in the environment • patients with low intelligence are more likely to have trouble incorporating and deploying new learning • Strengths and weaknesses
    24. 24. Personality Characteristics: •Passive aggressive: - angry, sarcastic, critical patient •Borderline: - promiscuity, attachment •Paranoid: - avoid asking sensitive information at the beginning of session - Don’t like to reveal confidential information in the first session - After 5- 6 sessions, it is appropriate to probe more.. -Or after establishment of therapeutic alliance •Histrionic: - promiscuous, seeking attention -can impress you and then you assume that their problem is minor -Present himself or herself in a favorable light.. •Depressed: -Take their complaints seriously
    25. 25. Patient Variables (cont..) • Antisocial: manipulative, lack remorse, • Obsessive Compulsive: - intellectual and can test your competence • Narcissistic: - will drop out if you don’t acknowledge his or her self love, entitlement, or importance during the first few sessions • Dependent and Avoidant: - depend on you absolutely to make decision and solve their problems • Differentiate between whether male patient is love-shy or avoidant PD Three personality factors that are related to positive outcome: 1. Ego strength - Ability to benefit from a psychotherapy and withstand stress 2. suggestibility - Tendency to accept and act on the suggestions of others. - A patient’s intense emotions to be more receptive to ideas. - Suggestibility decreases as age increases. - levels of self-esteem, assertiveness, and other qualities can make some people more suggestible
    26. 26. 3. Anxiety tolerance - Handle anxiety-provoking situations without having them adversely affect ability to function Openness/Nondefensiveness: • Cooperative patients achieve the best results • Defensive, non-cooperative and hostile patient tend to have unsuccessful experience Motivation: • Motivation to change at the beginning of therapy is found not to be as important as the development of motivation during therapy. • Patient learns more about motivation from therapy Understanding of Goals; • Both therapist and client being clear on goals of treatment is the moderate predictor of treatment success
    27. 27. Socioeconomic Status (SES): • people from lower SES were considered poor candidates for therapy • This is more related to therapist low expectations than a function of the patient him or herself • Lower class clients are usually referred to less-experienced therapists and to terminate prematurely Expectations: • Patients with high expectations about therapy Tend to not do as well as patients with moderate expectations • Expectancy of 15%
    28. 28. Therapist variable Age: • Therapist – patient age similarity is associated very weakly with treatment outcome Ethnicity: • Therapist ethnicity factor does not affect outcome • Therapist-patient similarity is sometimes associated with early termination and drop-out • My experience with a Mexican man who interviewed me for citizenship… OR American Indians who just involve in drugs • Similarity of values, life styles, and experiences have a greater positive impact Emotional Well-Being: • therapist emotional stability and well-being has a clear modest relationship to therapy success Expectation • Therapist-patient shared expectancy about what therapy will be like, increases positive outcome
    29. 29. Self-Disclosure • Revealing of information will not produce increased treatment effectiveness • Excessive self-disclosure early in therapy relationship may result in a negative first impression. • Should be moderate, appropriate to situation, and similar or reciprocal • Could be harmful if negative Orientation • Therapist orientation accounts for very little variance • Gender • No significant relationship between therapist-client gender similarity and outcome Competence • The most important of therapist variables
    30. 30. Responses to Avoid Avoid - Judgmental and evaluative statements (feeling, thought, action) - Philosophical Probing statements Hostile responses False reassurance statements (don’t ok)
    31. 31. Effective Probing Statements POOR BETTER Why did you yell at him? Why did you say that? Why can’t you sleep Do you drink? 1. Tell me more about what happened 2. How did you happen to yell at home? 3. What led up to the situation? 1. Can you tell me what you mean? 2. I’m not sure I understand 3. How did you happen to say that? 1. Tell me more about your sleeping problem 2. Can you identify what prevents you from sleeping? 3. How is it that you are unable to sleep? 1. How often you drink? 2. Tell me more about your drinking habit 3. How many times your drink per day, week, etc?
    32. 32. Example of False Reassurance Response: • A Saudi student in an applied school is dismissed from college, loses his job, and starts fighting with parents. • You lie to him when you say “Don’t worry, no problem, it’s Okay. • Will think of you as not wanting to assist. • What happen to this student requires specific action from his part to prevent even more disastrous developments • Person who gives false reassurance usually knows this, and so does the person who receives it Arab communication: • When two Arabs meet
    33. 33. self-fulfilling prophesy: • A false definition of the situation that evokes a new behavior that makes the original conception become true, • For example, labelling behavior as delinquent may cause more delinquent behaviour
    34. 34. Copyright 2004 - Prentice Hall 15-35 How We View Our Patient Attribution: • involves deciding why certain events occurred and why certain people behaved as they did. • Internal vs. external attribution • With internal attributions, behavior is seen as being caused by factors residing within a person (internalization) • With external attributions, the causes of behavior are viewed as residing outside an individual. • The attribution error occurs when internal factors are emphasized to the exclusion of external or situational factors. • Did You Offer Sympathy for Her?
    35. 35. Copyright 2004 - Prentice Hall 15-36 How We View Our Patients Attitudes: • Attitudes are evaluative judgments (negative, positive, or neutral) that are formed about people, places, and things. • Affect, cognition, and behavior are the three components of an attitude. • Discrimination consists of behaviors directed at members of a particular group that affect them adversely. • Racism • Modern discrimination (behavior) • Bias Prejudice (feeling; (medial prefrontal cortex)  MPF cortex is activated when looking to ordinary persons  MPF is silent when looking to social outcasts; drug addicts medial prefrontal
    36. 36. Evaluating a bad Therapist: Danger Signals Therapist Who • makes sexual advances • Repeated verbal threats or is physically aggressive • Excessively hostile, controlling, blaming, or belittling • Talks repeatedly about his/her own problems • Encourages prolonged dependence on patient • Demands absolute trust or tells client not to discuss therapy with anyone else • Discussing therapy issues with other is a step toward full awareness and readiness to do activities • Confidentiality and privacy
    37. 37. Too Far
    38. 38. Too close
    39. 39. Hands crossed
    40. 40. Legs crossed: arrogance
    41. 41. Too high
    42. 42. Too High Turkish ambassador Was humiliated by Israeli officials due to anti Israeli TV show
    43. 43. Unavailable: Invisible
    44. 44. Equal Height (correct)
    45. 45. Therapeutic Relationship and Alliance The conclusion for therapists: No matter what therapeuticNo matter what therapeutic technique or model is used,technique or model is used, it is not likely to be effectiveit is not likely to be effective if there is not a strong client-if there is not a strong client- therapist relationshiptherapist relationship..
    46. 46. Therapeutic Alliance: Outcome by Type of Factor
    47. 47. Successful Therapy • Psychotherapy outcome depends not only on method of therapy. • Qualities of client and therapist, and their alliance, also determine success.
    48. 48. Acknowledgement: • Many thanks to Ms. Abeer Al Abdulaziz who has generously contributed to this lecture by taking the snapshots • Many thanks to Dr. Mohamed Al-Qahtani (senior psychiatric resident) for his role-play of a patient
    49. 49. Professor Kurt Haas (1988) State University of New York – New Paltz Don’t Do Harm
    50. 50. Thank you!