Assessment and
Therapy
Major methods of clinical assessment
 Therapeutic approaches
1. Psychoanalysis
2. Cognitive Behavioural Therapy
3. Gestalt Therapy
4. Solution-focussed Therapy
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Major methods of clinical
assessment
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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, selfesteem 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.)
Major Research Methods
Case Studies
 Epidemiological Research
 Correlational Studies
 Experimental studies: vary with regard
the amount of control and
randomisation
 Single-case experimental design
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Psychoanalysis (Freud &
others)
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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.
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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 one’s own conscience (built on the
standards of parents or society).
Defence Mechanisms:
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Repression
Denial
Reaction Formation
Projection
Displacement
Sublimation
Rationalisation
Regression
Identification
Intellectualisation
Assessment: Projective
techniques
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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
Goals of Therapy:
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Make the unconscious, conscious
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Awareness of past experiences
Acknowledgment of anxiety and threat
Gain insight into patterns of behaviour
Strengthen the ego
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Behaviour in tune with reality
Able to withstand impulses of ID & Superego
No need for reliance on defence
mechanisms
Therapeutic Process
Goals are achieved through analysis of
childhood experiences. These experiences are:
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Reconstructed
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Interpreted
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Analysed
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
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Transference
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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
Techniques and Procedures
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Free association: relate everything they are aware
and this allows for unconscious material to arise
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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
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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
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Encouragement of Regression:
• Returning to an earlier way of reducing threat,
anxiety or pain
Cognitive Therapy
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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
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
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Self
 World
 Future
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Automatic Thoughts
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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
Schemas
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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)
STREAM OF CONSCIOUSNESS
(Includes awareness of
sensations)
AUTOMATIC
THOUGHTS
ACTIVATING
EVENT
Emotional
Response
SCHEMAS
Behavioural
Response
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
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Types of Logical Errors
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Catastrophisation
 More dire than justified
 Unjustified negative
prediction
Overgeneralisation
Personalisation
 Invalid assumption of
responsibility
 Mindreading
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Selective Abstraction
 Biased weighting
 Not considering all the
facts
 Black & White thinking
 False Absolutes
Arbitrary Thinking
 (Shoulds)
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Emotional Reasoning
Which Logical Error?
Activating event
Belief or thought
Referee
awards
Penalty
He’s
useless
- Invalid allocation of
responsibility
- Overgeneralisation
- Biased Weighting
Emotional
onsequence
C
Anger
- Must or Should
Emotional Reasoning
Which Logical Error?
Emotional
onsequence
Activating event
Belief or thought
C
Bike
Smash
My career is
over, this is
the end
Depression
Catastrophisation
- More dire than justified
- Unjustified negative
prediction
- Overgeneralisation
(External attribution)
Which Logical Error?
Activating event
Going
to a
party
Belief or thought
I’ll
probably
embarrass
myself
Catastrophisation
- Biased Weighting
- More dire than justified
- Unjustified Negative Prediction
Emotional
onsequence
C
Anxious
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
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Which Schema Theme?
Activating event
Belief or thought
Referee
awards
Penalty
He’s
useless
Emotional
onsequence
C
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
Anger
Which Schema Theme?
Emotional
onsequence
Activating event
Belief or thought
C
Bike
Smash
My career is
over, this is
the end
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
Which Schema Theme?
Activating event
Going
to a
party
Belief or thought
I’ll
probably
embarrass
myself
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
Emotional
onsequence
C
Anxious
What goes Wrong?
We make logical errors in our childhood
 We develop Early Maladaptive
Schemas
 We make logical errors after Activating
(Critical) Events
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Activate negative emotion from an EMS
 Have frequent negative automatic
thoughts
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We believe in and use dysfunctional
strategies
Which counterproductive
strategy?
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Avoidance?
Surrender?
Overcompensation?
Cognitive Behavioural Therapy:
adds a behavioural or ‘change
to strategy’ element
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
Therapeutic process
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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
Funnelling
BROAD
your
Psychoeducation
questions
Investigation
leads to
automatic
Experiment
thoughts
SPECIFIC
Gestalt Therapy
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Gestalt - German word meaning “pattern”
or “whole”
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Fritz Perl’s 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, it’s beautiful
If not, it can’t be helped.
(Source: Fritz Perls, as quoted in Shepard, 1975, p.3.)
Personality - Five Layers
Cliché layer
(Phony)
Implosive
layer
Role playing
layer (Phobic)
Impasse
layer
Explosive layer
Genuine
personality
Key concepts
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Gestalt - exists through the inter relation of parts.
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Healthy functioning: parts form a meaningful whole
Awareness: contact within self and with others.
Ability to focus on what exists in the now.
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Becoming aware of :
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Sensations - senses: seeing, hearing, touching etc..
Feelings - emotional and physical
Future events - wants and desires
Values - social, spiritual, and relationship issues
Key concepts cont...
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Unfinished business- unexpressed
feelings from the past
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The Now- present focus- incorporating
bodily and sensing systems
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Responsibility- core of Gestalt Therapy.
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Holism
Assessment
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Focus is on “moments in therapy”
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Gestalt contact style questionnaire
(how the “I” comes into contact with
others and the world in terms of body,
values, emotional expression etc.)
Goals of Therapy
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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
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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
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Gestalt Techniques
The dialogue exercise
 Playing the projection
 I take responsibility for
 May I feed you a sentence
 The rehearsal exercise
 Experiments
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Solution Focussed Therapy
Overview of Philosophical Approach
Serious optimism
 Client as expert
 Collaborative
 Customers and complaints
 Power of language
 No absolute truths
 Constructivist
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Assumptions of solution
focussed therapies
(O’Hanlon & Weiner-
Davis (1989)
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Clients have resources and strengths to solve complaints
Change is constant
The SF therapist’s 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
Central constructs
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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”
Therapy
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Roles
Client is expert on the problem
 Therapist expert on change and
solutions
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Assessment
Traditional assessment belongs in the
medical, problem focused models
 Focus is on interviewing for solutions
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• How were you hoping I could help you?
• Have you tried anything to solve this?
• What do you notice when it isn’t happening?
Therapy continued…
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Goals
Need to be specific, attainable,
observable and concrete
 Good goals:
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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
Therapeutic techniques
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Questions
Heavily relied upon
 Special tactic: The pre
suppositional question
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• When the problem is not present, how are
things different?
• Assumes that success already occurs
Some solution focused
questions
(Hudson, OHanlon & Weinrer-Davis, 1989)
1.
2.
3.
4.
5.
6.
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?
Techniques continued…
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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
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Normalising the problem
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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
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The miracle question
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Help identify goals without focusing on
problems and causes
The Miracle question
Set the scene:
I’m 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 don’t 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?
Techniques continued….
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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?”
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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
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Surprise task
 Do one or two things that will surprise
(partner, parents) don’t tell them what it is,
(Partner or parents) job is to find out what
it is. Don’t compare notes, we will do that
at next session
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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.
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Do something different
 Aim to disrupt the more of the same
routine