Assessment and Therapy

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 ones 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 of logical 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
Types of Logical Errors

• 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

20
Which Logical Error?
Emotional Consequence
Activating event
Belief or thought
Hes useless
Referee awards Penalty
Anger
- Must or Should Emotional Reasoning
- Invalid allocation of responsibility
- Overgeneralisation - Biased Weighting
21
Which Logical Error?
Emotional Consequence
Activating event
Belief or thought
My career is over, this is the end
Bike Smash
Depression

• Catastrophisation
• More dire than justified
• Unjustified negative prediction
• - Overgeneralisation
• (External attribution)

22
Which Logical Error?
Emotional Consequence
Activating event
Belief or thought
Ill 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
Hes useless
Referee awards Penalty
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
My career is over, this is the end
Bike Smash
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
Ill 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 Perls 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, its
  beautiful
• If not, it cant 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
(OHanlon Weiner-Davis (1989)

• Clients have resources and strengths to solve
  complaints
• Change is constant
• The SF therapists 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 isnt 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
• Im 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 dont 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) dont tell them what it is, (Partner or
  parents) job is to find out what it is. Dont
  compare notes, we will do that at next session

51

• Write, read and burn
• Write about a problem on even numbered days for
  specific time periods and odd numbered days read
  notes and burn them.
• Structured fight
• Changing the pattern
• Flip a coin to decide who goes first then winner
  has 10 minutes uninterrupted time to bitch. The
  other then gets 10 minutes. There must be 10
  minutes of silence before flipping the coin
  again.
• Do something different
• Aim to disrupt the more of the same routine