Mechanism of Changes and Techniques of Psychotherapies

Zsolt Unoka, M.D., PhD.
[email protected]
Department of Psychiatry and Psychotherapy
Semmelweis University
Psychotherapy is an effective treatment
many meta-analyses and even meta-meta-analysis
show an effect size of approximately 0.8
0.8 a ‘strong’ effect size in the social sciences
this makes psychotherapy more potent than many
well established EBM procedures includ-ing (for
example) almost all interventions in asthma,
geriatric medicine and cardiology (Wampold,
Factors Influencing Psychotherapy
Outcome (Lambert & Barley, 2002)
Common Factors (30%)
Expectancy Effects (15%)
Placebo effects
The Dodo bird hypothesis
Specific therapy techniques (15%)
Relationship with therapist
Systematic desensitisation, dream analysis, role play, etc.
Extratherapeutic factors (40%)
Spontaneous recovery or remission
Fortunate events
Social support
Common factors or non-specific
curative factors in psychotherapy
“…decades of research consistently demonstrate that
relationship factors correlate more highly with client
outcome than do specialized treatment techniques…
therapists need to remember that the development and
maintenance of the therapeutic relationship is a primary
curative component of therapy and that the relationship
provides the context in which the specific techniques exert
their influence.”
- Lambert & Barley (2001)
Psychotherapy, 38(4):357-361
Common factors or non-specific
curative factors in psychotherapy
Working alliance:
 Goals:
Objectives of therapy that both client and
therapist endorse
 Tasks: Behaviors and processes within the therapy
session that leads to the goal
 Bonds: The positive interpersonal attachment between
therapist and client of mutual trust, confidence, and
Patient rated alliance is the best predictor of
effectiveness and drop-out.
Client-centered therapy is a common
factor therapy
It’s specific factors are the common factors of
Congruence - the willingness to transparently relate
to clients without hiding behind a professional or
personal facade.
Unconditional Positive Regard - the therapist
offers an acceptance and prizing for their client for
who he or she is without conveying disapproving
feelings, actions or characteristics and
demonstrating a willingness to attentively listen
without interruption, judgement or giving advice.
Empathy - the therapist communicates their desire
to understand and appreciate their clients
The goal:
 Since psychological problems originate from
childhood repressed impulses and conflicts, the aim
of psychoanalysis is to bring repressed feelings into
conscious awareness where the patient can deal with
Focus on expression of emotion
Exploration of distressing experience
Identification of recurring themes
Discussion of development
Focus on interpersonal relations
Focus on the therapy relationship
Exploration of fantasy life (Shedler, 2010).
Behaviour therapy
Assumptions of psychopathology:
 People learn their problems
 Problems occur naturally through a learning process
Classical conditioning (Pavlov)
Operant conditioning (Skinner)
e.g., phobias
e.g., Substance abuse, Personality disorders, depression
Modell learning (Bandura)
Problems are sustained largely through
escape and avoidance of aversive events
Behaviour therapy
Assumptions of curative factors
 If problems are learned, new and more effective behaviors can be learned as well
 Mechanism:
classical and operant conditioning modell learning
 Techniques
Systematic desensitization (Wolpe)
Graduated exposure treatments
Cognitive therapy
Albert Ellis and Aaron T. Beck
Assumptions of psychopathology
 Thoughts
are the cause of our problems
 Way we think about the world dictates how we feel
about ourselves, others, and the future
 This is a cognitive triad
 Depressed people have a negative cognitive triad
 Combined with logical errors
get depressed
Cognitive therapy
Assumptions of curative factors
 Need to identify dysfunctional core schema and
replace with more accurate and effective schema
 Need to challenge the cognitive distortions or false
beliefs with evidence and look for more accurate
 Techniques
Identify irrational beliefs, maladaptive interpretations of
 Challenge beliefs directly
 Encourage more rational beliefs and interpretations
Family therapy
Assumptions of psychopathology:
 Dysfunctional family system
Assumption of curative factors:
 Family therapy treats the family as a system.
 Therapy guides family members toward positive
relationships and improved communication.
Curative factors in group
therapy(Yalom, 2005)
The recognition of shared experiences and feelings among group members and that these may be widespread or
universal human concerns, serves to remove a group member's sense of isolation, validate their experiences, and
raise self-esteem
The group is a place where members can help each other, and the experience of being able to give something to
another person can lift the member's self esteem and help develop more adaptive coping styles and interpersonal
Instillation of hope
In a mixed group that has members at various stages of development or recovery, a member can be inspired and
encouraged by another member who has overcome the problems with which they are still struggling.
Imparting information
While this is not strictly speaking a psychotherapeutic process, members often report that it has been very helpful to
learn factual information from other members in the group. For example, about their treatment or about access to
Corrective recapitulation of the primary family experience
Members often unconsciously identify the group therapist and other group members with their own parents and
siblings in a process that is a form of transference specific to group psychotherapy. The therapist's interpretations
can help group members gain understanding of the impact of childhood experiences on their personality, and they
may learn to avoid unconsciously repeating unhelpful past interactive patterns in present-day relationships.
Development of socializing techniques
The group setting provides a safe and supportive environment for members to take risks by extending their
repertoire of interpersonal behaviour and improving their social skills
Curative factors in group
therapy (Yalom, 2005)
Imitative behaviour
One way in which group members can develop social skills is through a modeling process, observing and imitating
the therapist and other group members. For example, sharing personal feelings, showing concern, and supporting
It has been suggested[3] that this is the primary therapeutic factor from which all others flow. Humans are herd
animals with an instinctive need to belong to groups, and personal development can only take place in an
interpersonal context. A cohesive group is one in which all members feel a sense of belonging, acceptance, and
Existential factors
Learning that one has to take responsibility for one's own life and the consequences of one's decisions.
Catharsis is the experience of relief from emotional distress through the free and uninhibited expression of emotion.
When members tell their story to a supportive audience, they can obtain relief from chronic feelings of shame and
Interpersonal learning
Group members achieve a greater level of self-awareness through the process of interacting with others in the
group, who give feedback on the member's behaviour and impact on others.
This factor overlaps with interpersonal learning but refers to the achievement of greater levels of insight into the
genesis of one's problems and the unconscious motivations that underlie one's behaviour.
Principles of interventions
Long term goals
Tasks of the session
Moment to moment
Yeomans, Clarkin, Kernberg 2002. alapján

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