psy3333-last lecture slides

Chapter 15
Group Therapy, Family Therapy, and
Couples Therapy
Family Therapy: Origins
• Origins can be traced back to the 19th century social work
• Dominance of psychoanalysis prevented its ability to gain
prominence until the mid-20th century
• Early family systems theory was applied to severe mental
disturbances, such as schizophrenia
– Bateson: the “double-bind”
– Lidz: pathological alliance from one parent toward the child
– Bowen: entire family is pathogenic
• Gave direction to the family therapy movement
Family Therapy: Communication
• The concept of communication is a primary emphasis
• Pathology = failure of communication of family members
• General systems theory: family therapy deals with the
relationship between the individual family member and
the family system, seeks to change the system in some
• Primary goals of family therapy:
– To improve communication within the family
– To de-emphasize the problems of the individual in favor of
treating the problems of the family as a whole
Family Therapy: Some Considerations...
• Family members have a shared
– Frame of reference
– History
– Language
• Therapist must learn the family roles, the idiosyncratic subculture
of the family
• Therapist must maintain some detachment, avoid becoming overly
identified with one faction over another
• History and assessment process is a typical part of therapy
– Extends the context and leads to increased understanding, empathy, tolerance
– Promotes a shared frame of reference not possible earlier
Family Therapy
• Conjoint family therapy: all family members are seen together
at the same time by one therapist
• Satir: regarded the family therapist as a resource person who
observes the family process in action and then becomes a model
of effective communication
• Five basic modes of communication (Satir, 1975)
– Placating
– Blaming
– Super-reasonable
– Irrelevant
– Congruent
Family Therapy
• Concurrent family therapy: one therapist sees all family members, but
in individual sessions
• Collaborative family therapy: each family member sees a different
• Behavioral approaches to family therapy:
– Behavioral family therapy: a process of inducing family members
to dispense the appropriate reinforcements to one another for the
desired behaviors
– Cognitive-behavioral family therapy: a process of teaching
individual family members to:
• Self-monitor problematic behaviors and patterns of thinking
• Develop new skills (negotiation, problem-solving, communication, etc.)
• Challenge interpretations of family events and reframe if necessary
Family-of-Origin Therapy
• Developed by Bowen
• Focuses primarily on past family dynamics
• Dysfunction = when individuals are enmeshed in their families of origin
and thus unable to assert their feelings and thoughts effectively
• Differentiation of self: the degree to which individuals differentiate
between emotional/intellectual functioning of themselves and other
family members
• Well-differentiated individuals are neither overly invested in the
emotional climate of their family of origin nor totally withdrawn from
them and negating their importance (emotionally cut off)
• Family genogram: map of the process and structure of 3 gen.
Couples Therapy
• Background
– Form of family therapy
– Wide range of theoretical approaches
– High rate of growth since 1960s
Couples Therapy
• Behavioral Marital Therapy (BMT)
– Application of reinforcement principles
– Contingency contracting
– Support-understanding technique
– Problem-solving techniques
Couples Therapy
• Emotionally Focused Therapy (EFT)
– Brief treatment
– Changes negative emotional interactional styles
– Establish more secure attachment
– 9 step process
Emotionally Focused Couples Therapy
Mental Health and
Children and Adolescents
• Est. 14 million children and adolescents have psychiatric disorders
and need mental health services
• Recent studies: established that 1 in 5 have a dx-able mental d/o
• For years, the mental health needs of children and adolescents have
not been adequately met, and this trend is likely to continue
• Large gap exists between needs and available services
• Families face difficulties in accessing appropriate services
• Mental health care for children and adolescents is focused mostly
on those with the most severe needs and least on prevention for atrisk groups and promotion of positive mental health
Clinical Child and Adolescent
Clinical psychologists have worked with children
since the inception of the field
First clinic (Lightner Witmer, late 1800s) was designed for
Clinical child psychology is now a popular specialty
Pediatric psychology—a sub-specialty focusing on
the mental and physical health of children with
medical conditions
A Developmental Perspective
• Psychological problems in childhood and adolescence result from
some deviation in one or more areas of development when
compared to same age peers
– Cognitive
– Physical
– Emotional
– Behavioral
– Social
• Development is an active dynamic process best assessed over time
• Similar developmental problems  different outcomes
• Different developmental problems  similar outcomes
• Developmental processes and the environment are interdependent
Pathways to Development
The Concept of Resilience
• Resilience: The qualities in individuals that are associated with
their ability to overcome adversity and achieve good developmental
• Such factors are not necessarily causal but are simply associated
with resilient outcome
• Individuals seem to be buffered in part by:
– Factors which promote strong parent-child attachments
– Factors which indicate a capacity for good problem-solving skills
• Resilience studies can help guide interventions towards preventing
risk factors, building on resources, and enhancing relationships or
processes such as self-efficacy and self-regulation
Risk and Resilience
Positive outcome in the face of risk
Trio of protective factors:
Good IQ
Appealing, sociable
Easy temperament
Self-efficacy and self-confidence
Risk and Resilience
Resilience, continued
Close to parent or caregiver
Authoritative parenting
Socioeconomic advantages
Connections to support
Bonds to positive adult role models
Connections to organizations
Good schooling
Psychological Issues of
Childhood (cont.)
Externalizing disorders
Child “acts out” and becomes disruptive
ADHD, conduct disorder, ODD
Internalizing disorders
Maladaptive thoughts and feelings
Mood disorders, anxiety disorders
Assessment of Children and Adolescents
• Information should come from multiple sources
• Information may not always be consistent across sources
• Information should come from multiple assessment methods:
– Interviews
– Observation
– Formal testing
– Behavior checklists
– Intelligence testing
– Testing of other abilities
– Psychological testing
Assessment: Behavioral Observations
• Behavior observations are crucial to any assessment
• Observations may occur during interview, testing, etc. in
the clinic setting
• Observations may also occur in a more naturalistic setting
(e.g., home, school)
Assessment: Psychological Tests
• Projective measures:
• Rorschach Inkblot Test???
• Thematic Apperception Test (TAT)
• Incomplete Sentences Blank
• Draw-A-Person
• Other projective drawings
• Non-projective measures:
Assessment: Behavior Checklists
• Child Behavior Checklist (CBCL) (Achenbach, 1994)
– Overall problem score
– Eight syndrome scores (internalizing and externalizing)
– Overall Internalizing Problem score
– Overall Externalizing Problem score
• Behavior Assessment System for Children-3rd Ed.
– Caution Indexes help with questions of validity
– Clinical Scales (Externalizing, Internalizing, School Problems)
– Adaptive Scales (Adaptability, Social Skills, Leadership, Study
Interventions with Children and Adolescents
• Psychoanalytically oriented therapy
• Play therapy
• Behavior therapy
• Behavioral pediatrics
• Cognitive-behavioral therapy
• Group therapy
• Family therapy
• Biofeedback
Why Health Psychology
and Behavioral Medicine?
• Most health problems in the U.S. are related to chronic diseases
(e.g., heart disease, cancer, stroke, etc.)
• These diseases are often associated with behavior or lifestyle
choices of individuals
• Over the last five decades, the cost skyrocketed to more than
16% of the gross domestic product in the U.S.
• Psychology, as a science of behavior, has much to contribute to
the field of health
• Health psychology has become a fast-growing specialty in
clinical psychology
Behavioral Medicine
• The integration of the behavioral sciences with
the practice and science of medicine
• Matarazzo (1980): The broad interdisciplinary
field of scientific investigation, education, and
practice that is concerned with…
– Health
– Illness
– Related physiological dysfunctions
Health Psychology
• A specialty area within clinical psychology
• A more discipline-specific term, referring to
psychology’s primary role as a science and profession
in behavioral medicine
• “The aggregate of the specific educational, scientific,
and professional contributions of psychology to:
– The promotion and maintenance of health
– The prevention and treatment of illness
– The identification of etiologic and diagnostic correlates of
health, illness, and related dysfunction” (Matarazzo, 1980)
Health Psychology (cont’d.)
According to Brannon and Feist (2010), health
psychology “includes psychology’s
contributions to:
• The enhancement of health
• The prevention and treatment of disease
• The identification of health risk factors
• The improvement of the health care system
• The shaping of public opinion with regard to health”
(p. 13)
• Two major perspectives
– Biomedical tradition
• Understand and discover
• Purely biologically focused
• Mind-body duality
– Psychosocial perspectives
• Illness and disease caused by psychological factors
• Psychosomatic diseases
• 1960s
– Focus on cardiovascular disease and cancer
• Associated behaviors responsible: overeating, smoking,
• Stress/ life factors seen to contribute to disease
• Gives rise to biopsychosocial model: both psychological
and social factors influence illness and health
The Biopsychosocial Model
• Biological influences:
– Genetic predispositions
– Nutritional deficiencies
– Biochemical imbalances
• Psychological influences:
– Behaviors
– Emotions
– Cognitions
• Social influences
– Social support network
– Home environment
– Life events
Stress and Health
Stress is a process that involves
• An environmental event (a stressor)
• Its appraisal by the individual (is it challenging or threatening?)
• The various responses by the organism
– Physiological
– Emotional
– Cognitive
– Behavioral
• The re-evaluations that occur as a result of these responses and
changes in the stressor
Stress can directly affect hormonal, autonomic, and immune
Stress and Health
• Perception of stress causes the sympathetic nervous system to
stimulate the adrenal glands
• Leads to the production of catecholamines (epinephrine,
• Results in increased heart rate, blood flow, respiration, and
muscle strength
• Stress also causes the pituitary gland to release
adrenocorticotropic hormone (ACTH)
• Stimulates the release of glucocorticoids
• Cortisol is a glucocorticoid which mobilizes the body’s
resources by increasing energy level and reducing inflammation
Stress and Physical
Stress can play a role in many physical disorders:
Migraine headaches
Back pain
Cardiovascular disease
Fertility problems
High cholesterol
Many others
Behavior and Health
• Behaviors, habits, and lifestyles can affect both health and disease
• Smoking, excessive drinking, poor diet, lack of exercise, poor
hygiene, etc.
• Such behaviors may be deeply rooted in cultural values or personal
needs and expectations and are thus often hard to change
• Cognitive variables may influence our decisions about adopting
healthy or unhealthy behaviors
• Self-efficacy: “people’s beliefs about their capabilities to exercise
control over events that affect their lives” (Bandura, 1989)
• Protection motivation theory (PMT): behavior is a function of
threat appraisal and coping appraisal
Personality Factors
• …may result from disease processes
• …may lead to unhealthy behaviors
• …may directly affect disease through
physiological mechanisms
• A third, underlying biological variable may relate
to both personality and disease
• Several causes and feedback loops may affect the
relationship between personality and disease
Personality Factors
• A widely studied association between a personality
trait/behavior pattern and illness is the link between
Type A behavior and coronary heart disease
• Type A individuals are at relatively greater risk for
• Recent studies suggest that the anger/hostility
component of the Type A pattern more strongly
predicts CHD than does the more global Type A
Behavior and Health
• 4 models for link between Type A and CHD
– Psychophysiological reactivity: hostile individuals
experience increased physiological responses
– Psychosocial vulnerability: high level of mistrust
leads people to have more stressful environments
– Transactional model of stress: hostile people
create stressful environments
– Health behavior: hostile individuals engage in poor
health habits
Social Support and Health
• Social support refers to the quantity and quality of an
individual’s social relationships
• Interpersonal relationships can actually promote health
• Increased social support can help:
– Insulate an individual from harm when he/she encounters stress
– Decrease an individual’s susceptibility to illness
– Encourage treatment compliance
• The relationships among social support, health, and
disease may depend on other factors, such as race, gender,
and culture
Range of Applications of Health Ψ
• Smoking
• Anorexia nervosa
• Alcohol abuse
• Chronic vomiting
• Obesity
• Encopresis
• Type A personality
• Ulcers
• Hypertension
• Irritable bowel syndrome
• Cardiac arrhythmia
• Tics
• Sexual dysfunction
• Cerebral palsy
• Alzheimer’s disease
• Epilepsy
• Cerebrovascular accidents
• Cystic fibrosis
• Diabetes
Methods of Intervention:
Respondent Methods
• Extinction: a conditioned emotional reaction is eliminated by
creating a situation in which the conditioned stimuli are no longer
associated with the environmental stimuli that generated the
• Systematic desensitization
• Relaxation and/or imagery appear to be effective in treating
– Hypertension
– Tension headaches
– Anxiety
– Burn pain
– Nausea and anxiety associated with chemotherapy
Methods of Intervention:
Operant Methods
• Learned responses can be either maintained or eliminated
through the consequences they bring about
• Operant conditioning can be used in health psychology
and behavioral medicine to either increase behaviors
which lead toward health or decrease those that contribute
to illness
• Contingency contracting:
– Patient and therapist draw up a contract specifying behaviors
and their consequences
Methods of Intervention:
Cognitive-Behavioral Methods
• Emphasize the role of thinking in the etiology and
maintenance of health problems
• Seek to change or modify cognitions and perceptions that
are believed to be related to a patient’s problem
• Stress inoculation training has been used to help patients
cope with various stressors
• Other cognitive-behavioral therapies have been shown to
be effective in treating chronic pain, headache, smoking
cessation, and bulimia
Methods of Intervention:
• Under certain conditions, patients can learn to modify or control
physiological processes, such as heart rate, blood pressure, and
brain wave activity
• Some aspect of the patient’s physiological functioning is monitored
by an apparatus that feeds the information back to the patient
• The patient then learns to modify the signal by changing the
physiological function
• Has been shown to be efficacious in the treatment of headache pain,
hypertension, and low back pain
• Effects are not necessarily superior to those of relaxation
• Hard to separate the effects of biofeedback and relaxation
• Other applications
– Coping with Medical exams and procedures
• Procedural information: what will occur
• Sensory information: sensations patient will feel
• Behavioral interventions: attentional distraction,
breathing techniques, positive reinforcement, coaching
– Surgery preparation
Procedural and sensory information
Cognitive coping skills
Coping model: give patient example of someone else
successfully coping with the surgery
• Other applications
– Regimental compliance
• Four categories of compliance predictors
Disease characteristics
Personal characteristics
Environmental factors
Practitioner-patient interactions
• Strategies
– Prompts as reminders
– Tailoring regimen to patient’s lifestyle
– Using written contracts that promise reward for compliance