BAHAR BAŞTUĞAssist. Prof. Dr.

Psychotherapeutic Issues

Lecture PreviewDoes Psychotherapy Work?Long-Term Therapy versus Short-Term TreatmentWho 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

OutcomeWhy Is Change Difficult?Must Someone Be a Professional to Be an Effective

Therapist?Does Psychotherapy Help Reduce Medical Costs?Can Psychotherapy Be Harmful?

1.Does Psychotherapy Work?the usefulness of psychotherapy.

This such question is difficult to answer and varies from individual to individual and treatment to treatment.

Psychotherapy is one of the most common activities conducted by clinical psychologists. Each patient, each psychologist, and each psychotherapy experience are unique.

Psychotherapy is a highly personalized experience. It is impacted by the skills, interest, training, motivation, and personality of the psychotherapist 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 interaction plays a significant role in treatment outcome. Also, some factors such as beliefs, attitudes, and expectations play a significant role in treatment outcome.

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 associated with the passage of time (i.e., “time heals all wounds”).

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.

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 experiencing psychological distress would improve without treatment.

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.

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 therapies were more effective than verbal therapies.

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 psychotherapy outcome studies and concluded that a patient receiving psychotherapy was better off than untreated control subjects and that relapse rates were small.

1.Does Psychotherapy Work?An extensive review of all the research studies concludes that psychotherapy does indeed work. Both researchers and clinicians have been trying to answer many follow-up questions such as: How does psychotherapy work and what types of treatment and therapists are effective for what types of problems and patients?Recent efforts by the APA have attempted to identify specific treatment approaches for specific problem areas.

Seligman (1994) states that the depth of a problem predicts if the problem can be altered through psychotherapy. Problems that are biologically oriented and pervade all aspects of life are less appropriate for psychotherapy than problems that are learned and are less pervasive. He suggests that problems such as panic and phobia are much more responsive to therapy than obesity and alcoholism.

2.Is Long-Term Therapy Better than Short-Term Treatment?

Psychotherapy can last for one session or for hundreds of sessions in many years.

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 a crisis and wish to obtain relief asap. They want relief symptoms within 12 weeks.

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.

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.

Research has found that even a single session is associated with positive outcomes such as a decrease in medical office visits.

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.

3. Who Stays In and Who Drops Out of Psychotherapy?

About a third ofpsychotherapy patientsdo not attend a secondsession.

What factors might predictpsychotherapy dropout?

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 the therapist 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.

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 therapist and patient may not “click” during the first session as well. Patients who do not like their therapist are less likely to attend next sessions.

4. Is One Type of Therapy Better than Another?

Is psychodynamic psychotherapy better than CBT?Is individual psychotherapy better than family systems approaches? Is any one type of psychotherapy superior to another?

Many research have been conducted to determine if one type of psychotherapy is superior to others.

4. Is One Type of Therapy Better than Another?

To ensure that these studies use pure forms of 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 use treatment manuals in actual practice. They use integrative approach, that’s mix and match techniques and approaches from different theories.

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.

Since the mid-1970s, some researchers have referred to the equality of different types of psychotherapy as 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.

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.

4. Is One Type of Therapy Better than Another?

Although no one type of therapy is superior to another, several specific disorders tend 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 depr and

marital discord.

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.

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 studies treating anxiety and found that anxiety reduction lasted up to 1 year after treatment when compared with controls.Feske and Chambless examined 21 research using CBT for social anxiety and found improvements lasting up to 1 year after treatment relative to controls.

5. Do the Effects of Psychotherapy Last after Therapy Ends?

Similar findings have 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.

6. What Common Factors Are Associated with Positive Psychotherapy Outcome?

In sum, psychotherapy is effective in treating numerous problems compared with receiving no treatment. No one type of psychotherapy is superior to 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.

6. What Common Factors Are Associated with Positive Psychotherapy Outcome?

The search for common factors is 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.

6. What Common Factors Are Associated with Positive Psychotherapy Outcome?

According to Frank a professional office associated with being

helped; a trained professional who is supportive; enhanced hope that thoughts, feelings, and

behaviors can change;

fees associated with service;the avoidance of dual relationships.

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 the patient perceives as helpful and accepting is a powerful common factor in all types of psychotherapy.

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 writing or talking about a problem alone without a therapist results in improvement. Working on problems are powerful common factors.

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»

In another study, getting advice and talking with someone who understands and is interested in their 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.

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.

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.

His theory includes five stages of change precontemplation, contemplation, preparation, action, and maintenance. The desire to change is likely to be a very important factor in explaining behavioral change.

Kleinkeoutlined 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.

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 of the patient with agoraphobia may feel important and needed by the patient. Increased independence may be experienced by the spouse as a threat to his or her power.

As a result, many people resist change when they feel that their freedom is threatened.

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.

8. Must Someone Be a Professional to Be an Effective Therapist?

Level of training for psychotherapists?? Does someone really need to have a PhD or other advanced degree to be an effective psychotherapist? Aren’t a lot of friends, colleagues, neighbours, and grandparents excellent “therapists”?

Research indicates that the therapist’s psychological health, skill and a sincere interest in helping others are necessary qualities for being an effective psychotherapist.

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 paraprofessionalsresults in superior outcomes relative to professionals, but they have been criticized for using poor quality research.

8. Must Someone Be a Professional to Be an Effective Therapist?

Another study found that psychology interns under supervision have better treatment outcomes than professional therapists.

But, there are a lot of studies demonstrating that the experience and training of the therapist is important for positive outcomes.

8. Must Someone Be a Professional to Be an Effective Therapist?

As a result, both well-trained and poorly trained therapists can provide poor service and do harm. Poorly trained therapists are more likely to provide a very narrow range of treatment options. Well-trained professionals are more likely to have a wide range of treatment options and use integrative approaches based on scientific support.

Psychiatrist analysing Freud.

9. Does Psychotherapy Help to Reduce Medical Costs?

Because of biopsychosocial perspective, a more healthy emotional life may result in a healthier physical life as well. 50% of all deaths are due to behavioral and lifestyle factors such as eating high-fat foods, being sedentary, and misusing alcohol.

Changing health care behavior and attitudes by psychotherapy may lead to healthier living and fewer illnesses.

An important question for government agencies and insurance companies is the association between psychotherapy and health care costs.

9. Does Psychotherapy Help to Reduce Medical Costs?

A person experiencing psychotherapy is less likely to need or seek out medical attention. Psychotherapy appears to reduce medical costs.

50% to 70% of patients who seek medical treatment have no medical problems. Their symptoms are primarily due to psychological factors such as anx, stress, and depr.

9. Does Psychotherapy Help to Reduce Medical Costs?

Emotional problems are associated with many medical problems such as heart disease, diabetes, and cancer. They are associated with psychophysiological diseases such as dermatitis, irritable bowel syndrome, chronic headaches, and asthma.

Treatment of psychological factors by psychotherapy assists in the treatment of many of these medical problems and symptoms.

9. Does Psychotherapy Help to Reduce Medical Costs?

Those who experience a mental illness tend to use medical services a lot. For example, about one-third of depressed patients experience somatic complaints.

Psychotherapy increases psychological functioning and well-being, also improves medical symptoms and reduces health care costs.

10. Can Psychotherapy Be Harmful?

Psychotherapy is helpful for people. Therapy, unlike a medical procedure such as surgery, does not seem to have life-and-death consequences.

Psychotherapy may not be appropriate or useful for everyone. Some people may get worse in functioning during or after psychotherapy.

Freud’s most famous case example of Anna O. was a treatment failure. She had more severe symptoms after she began treatment with Freud.

10. Can Psychotherapy Be Harmful?

Many factors associated with treatment failure may or may not be directly associated with the psychotherapy experience. These factors include stressful life events such as divorce, loss of job, development of physical illness, and death of a loved one. A number of both patient and therapist variables (e.g., patient diagnosis, therapist personality and technique) have been found to be associated with negative treatment outcome. Poorly trained therapists have been found to be damaging when they offer inappropriate therapies.

10. Can Psychotherapy Be Harmful?Research has shown that many variables are associated with poor treatment outcome such as characteristics of the patient and the therapist, and the interaction between patient and therapist.

Patient diagnosis, severity of symptoms, and some psychotherapy approaches are associated with poor outcome among certain patients.

10. Can Psychotherapy Be Harmful?

Patient characteristics have been associated with poor outcome:

with SCH, borderline personality disorder and OCD

have little motivation for change, low tolerance for anxiety, a history of inability to maintain satisfying

interpersonal relationships. highly suspicious and hostile.

10. Can Psychotherapy Be Harmful?In addition to patient variables, therapist

characteristics have been associated with poor outcome:

lack empathy impatient and authoritarian fail to focus the session, fail to deal with negative feelings of the patient

toward the therapist or treatment, inappropriately use techniques unethical and incompetent therapists can certainly

do a great deal of harm to their patients.

Sexual relationships between therapist and patient can be harmful.

Psychotherapy can be harmful if these factors are not examined.