Major_Approaches_to_Clinical_Psychology

Major Approaches to Clinical Psychology: Obsessive-Compulsive Disorder Speaker Notes Elements of Clinical Psychology PSY 480 August 27, 2012 Kristi Collins-Johns, Psy. D. Major Approaches to Clinical Psychology: Obsessive-Compulsive Disorder Speaker Notes Slide 1: Title Page Only Slide 2:  Several approaches of treatment for obsessive-compulsive disorder (OCD) exist. Four major theoretical approaches include psychodynamic, cognitive-behavioral, humanistic, and family systems (Plante, 2011). Each approach perceives OCD as an intrusive condition possessing characteristics of unwanted thoughts, producing anxiety with the accompaniment of compulsive acts, or ritualistic behavior the individual believes will protect him or her from the anxiety (Hansell & Damour, 2008). The individual has no control of the obsessive impulses or thoughts and is driven to relieve the anxiety-producing obsessions through compulsive ritualistic behaviors (Hansell & Damour, 2008). OCD has similar biological components as other anxiety disorders (Hansell & Damour, 2008). Through the biological perspective the anxiety-producing obsessions cause an affective, physical reaction in the individual revealing deficiencies or excesses with the stimulation of the nervous system (National Institute of Health, 2012). In addition, genetic predisposition is a possibility, including hormonal or neuro-chemical malfunctions (Schimelpfening, 2011). OCD also possesses underlying emotional components of unresolved experiences or concerns (Hansell & Damour, 2008). The psychodynamic perspective suggests that sadness and pain result from early childhood, and the parent-child relationships (Hansell & Damour, 2008). Wide acceptance revolves around underlying conditions as a precursor to OCD (Hansell & Damour, 2008). Through the cognitive-behavioral perspective individuals with OCD possess cognitive distortions of the self and his or her environment (Hansell & Damour, 2008). The maladaptive thought processes as well as dysfunctional thought patterns produce anxiety (Hansell & Damour, 2008). Additional contributors to the disorder can include situational misinterpretations as well as underestimating one’s emotional ability (Hansell & Damour, 2008). Each intervention possesses distinct perceptions and treatment methods for the intrusive and obsessive thoughts as well as the compulsive and ritualistic behavior (Hansell & Damour, 2008). Slide 3: Freud’s perspective of OCD symptoms rely upon his theory of defense mechanisms; isolation of affect and undoing (Hansell & Damour, 2008). The individual copes with the symptoms of OCD through defense mechanisms in this theory (Hansell & Damour, 2008). Isolation of affect allows the individual to disconnect the intrusive thoughts or obsessions from other emotions and experiences; perceiving them as intrusive annoyances (Hansell & Damour, 2008). Undoing allows the individual to proceed in some form of ritualistic behavior that acts as a magical cure for the intrusive obsession (Hansell & Damour, 2008). Freud’s perspective continues with theories of rigid toilet-training methods, misunderstood childhood punishments, and sexual issues causing internalization of unresolved conflicts resulting in OCD symptoms (Hansell & Damour, 2008). In addition to childhood punishment and parenting styles, other psychodynamic perspectives view the symptoms of OCD as a result of cultural demands on neatness or cleanliness (Hansell & Damour, 2008). Fraum (2012), perceives "the fundamental issues that drive these symptoms include fear of rejection or abandonment, as well as interpersonal issues regarding intimacy, sex, control, power or other problems in their relationship" (para. 12). Through the psychodynamic intervention goals for the individuals will include understanding the underlying cause for the symptoms, creating a sense of self-acceptance, and learning to cope with emotional conflicts without the need for ritualistic behaviors (Hansell & Damour, 2008). Through learning to cope with emotional conflicts the individual will reduce anxiety, and remove the necessity for defense mechanisms (Hansell & Damour, 2008). Slide 4: Psychodynamic therapy places its focus on the assumption that pathological anxiety rises from unconscious emotional conflicts (Plante, 2011). Psychologists will use basic psychodynamic techniques to address most anxiety disorders, including OCD (Abend, 1996). Establishing and maintaining the patient-therapist bond allows the individual to speak freely through free association, recall dreams, and supply vital information for the therapist to interpret; revealing the underlying unconscious directives for the anxiety (Abend, 1996). Psychodynamic therapy can also include guided movement and imagery to assist the patient in understanding the symptoms as a defense mechanistic reaction to past and present conflicts (Abend, 1996). Psychodynamic intervention is effective in revealing the underlying issues causing the symptoms, and successful in developing treatment goals in individual or group treatment (Wells, Glickauf-Hughes, & Buzzell, 1990). Group therapy allows the individual to evolve through autonomous functions as well as through relationships with other individuals (Wells, et. al., 1990). With severe cases of OCD efficacy largely increases through adding cognitive-behavioral techniques to assist in the treatment plan (Bram & Björgvinsson, 2004). Slide 5:  The cognitive behavioral perspective views OCD as an association between an anxiety-reducing compulsive ritual and an intrusive thought or obsession (Hansell & Damour, 2008). Through this perspective the effect of reducing the anxiety negatively reinforces the ritualistic behaviors (Hansell & Damour, 2008). The cognitive-behavioral perspective perceives behavior as the result of one’s environment with conditioning through positive or negative reinforcement, or positive or negative punishment (Plante, 2011). Through this perspective an individual learns to adjust behavior as a response to the environment (Plante, 2011). The goal in cognitive-behavioral intervention is to alter the individual’s response to the environmental stimuli, resulting in a response change to the intrusive obsessions or thoughts (Hansell & Damour, 2008). This goal includes the individual experiencing the intrusive thoughts and obsessions without engaging in the ritualistic behaviors (Hansell & Damour, 2008). Interrupting the pairing of intrusive thoughts or obsessions with the ritualistic behaviors will provide negative reinforcement to the anxiety, and condition a new response (Hansell & Damour, 2008). Learning new strategies and perspectives to life’s challenges, individuals will gain a sense of self-efficacy through cognitive-behavioral intervention (Phillipson, 2012). In addition to the ability to aid in experience, knowledge, and training a therapist must also possess compassion, warmth, and understanding (Phillipson, 2012). Slide 6: Cognitive-behavioral intervention for anxiety disorders is most often highly structured and goal-oriented (Plante, 2011). Cognitive-behavioral therapists proceed with an active and direct approach toward the individual’s problems (Beck, Emery, & Greenberg, 2005). The therapist aids in identifying the compulsive responses to the intrusive obsessions as well as the negativity in association to the obsessions (Beck, et. al., 2005). Through discussing the logical or illogical aspects of the thought processes, the therapist can aid in the identification of distortions (Beck, et. al., 2005). In addition, the therapist will teach the individual how to challenge his or her thought processes to avoid distorted views (Beck, et. al., 2005). The cognitive-behavioral intervention is foundational upon the assumption that individuals learn through environmental reinforcement (Plante, 2011). Strategies for therapeutic intervention place emphasis upon altering environmental reinforcement patterns (Phillipson, 2012). If an individual’s response causes the dysfunctional patterns, conditioning a new response is necessary (Phillipson, 2012). The cognitive-behavioral approach assumes that learning takes place through an individual’s adaptability to the changing environment; conditioning a new response establishes new patterns and alleviates the OCD symptoms (Phillipson, 2012). The research of Clark, Ehlers, McManus, Hackmann, Fennell, Campbell, Flower, Davenport, and Louis (2003) concludes that cognitive-behavioral (CB) therapy is effective in treating anxiety disorders. In addition, CB therapy provides the individual with effective tools necessary in the management of anxiety as well as challenging the internalized thought processes (Phillipson, 2012). In contrast to the extensive patient-therapist relationship of psychotherapy, individuals can place the tools of CB therapy immediately to use; learning to manage obsessions and conditioning a response without compulsive rituals (Phillipson, 2012). Cognitive-behavior intervention is highly effective and is useful for increasing efficacy in combination with other interventions (Nathan & Gorman, 2002). Slide7:  The humanistic approach relies upon philosophy, existentialism, and the assumption that human motivation is driven through the need for growth potential (Plante, 2011). Humanism places emphasis on the human ability to experience freedom, possess self-determination, and to reflect consciously upon the environment (Plante, 2011). With strong philosophical influences, and an existential approach to psychotherapy, humanism embraces the characteristic need to embrace life’s meaning (Plante, 2011). The individual has an active and cognitive role in therapy as a responsible and participating party to the maintenance of his or her own mental and emotional states (Plante, 2011). This provides the individual control and the choice to alter his or her own mental state in an appropriate environment (Dombeck, 2006). In contrast to Freud’s assumptions that humans are dysfunctional and bad by nature, humanism assumes people are essentially good (Plante, 2011). The humanistic intervention for OCD has a goal to provide an appropriate environment in which the individual can develop, evolve, and mature; continuing toward healthy development (Dombeck, 2006). According to humanism, dysfunction occurs through a developmental interruption because of emotional and social immaturity (Dombeck, 2006). Through the process of natural development in an appropriate environment an individual can regain health (Dombeck, 2006). Maintaining this natural development allows continuance for the individual to grow in his or her personal path in life as well as meeting psychological needs (Dombeck, 2006). Slide 8:  Humanism views the individual as an active and cognitive participant with the inherent power in determining the course of his or her life as well as mental dysfunctions (Dombeck, 2006). This places the individual at the center of the therapy known as patient-centered therapy (Dombeck, 2006). Techniques in the Rogerian approach places focus on therapy that gently guides the individual toward his or her own determination of emotions on specific topics (Dombeck, 2006). Conversely, the Gestalt approach is more direct allowing the individual to experience bodily emotion rather than limiting the emotion to a cognitive experience (Dombeck, 2006). One Gestalt approach is the empty chair technique; a visualization technique (Dombeck, 2006). The individual is to imagine a person sitting in the empty chair and start a conversation with the empty-chair person; resolving conflicts more readily (Dombeck, 2006). This allows the individual to face the emotions and fears encompassing an issue, or person until this fear resolves (Dombeck, 2006). Removing the fear allows the individual to discontinue avoidance, and alleviate anxiety (Dombeck, 2006). The depth of the experience in psychotherapy possesses positive correlation to the outcome of therapy (Whelton, 2004). With humanistic intervention this depth of experience is an expectation of therapy (Whelton, 2004).This provides the indication of emotional processing, the formation of appropriate meanings, and the discovery of solutions for fear and avoidance issues as well as other life derailments that hinder growth (Whelton, 2004). Although the humanistic intervention can reduce anxiety minimally, no empirical research provides evidence of effectively treating symptoms of OCD (Whelton, 2004). Slide 9:  "Prior to the 1950s most psychological treatment focused on the identified patient defined as the person regarded within the family as manifesting problematic symptoms, behaviors, or attitudes" (Plante, 2011, p. 59). Family members did not participate in the individual’s therapy, and therapists did not perceive the family members as contributors to the dysfunction (Plante, 2011). Throughout the next three decades the family systems approach grew in popularity for the mental health domain (Plante, 2011). The family systems approach differs from other major approaches because the entire family possesses consideration in the recognition and treatment of dysfunction (Plante, 2011). This psychological insight supports the family as an interrelated system creating a new intervention; family therapy (Plante, 2011). Family therapy differs from group therapy because members are not random with unrelated experiences (Plante, 2011). This relatively new intervention views each family member’s problems as a product of the dysfunction residing within the family itself (Plante, 2011). The goals of the family systems intervention revolve around treating the entire family, and reducing dysfunction affecting each member, especially the dysfunction of any indentified member of he family unit (Plante, 2011). Each issue is identified and addressed through the family as a unit that the identified family member presents (Plante, 2011). This process allows the identified individual to grow, and other members of the family unit to develop as independent, and autonomous while reestablishing solidarity within the family unit (Plante, 2011). This approach provides a balance between group function and the performance of each individual (Plante, 2011). Slide 10:  Through defining goals and assessing needs, a family systems therapist guides the family away from dysfunction (Plante, 2011). Different techniques within this approach will assist in reaching this goal by improving communication (Plante, 2011). The therapist assists the family in changing perceptions within the group, reframing the family unit, defining the symptoms, and alleviating the resistance to the intervention (Plante, 2011). A requirement of a family therapist is the ability to develop a rapport with the group to view the inner workings and mechanisms that provide a cause for the symptoms of OCD (Plante, 2011). This rapport provides the therapist a closer look into the family unit to identify specific relationships possibly causing anxiety or psychological problems in addition to members coping to the situation with defense mechanisms (Plante, 2011). These defense mechanisms can include disengagement, distorted thought processes, and compulsive behaviors (Plante, 2011). This form of intervention provides the therapist with a more complete view of psychological and anxiety-producing pressures the identified individual is experiencing (Plante, 2011). This vital information assists the family in reestablishing solidarity, reducing anxiety-producing pressures, and alleviating the symptoms of OCD in the identified individual (Plante, 2011). The communications approach provides a means by which healthy communication reestablishes within the family (Plante, 2011). The dysfunctional communication can come about through inappropriate rules, unreasonable expectations, and misguided assumptions between members; increasing anxiety and promoting symptoms of the OCD in the identified individual (Plante, 2011). Reestablishing healthy communication can reduce the dysfunctions as well as alleviate the symptoms (Plante, 2011). The structural approach provides a means to balance the relationships within the family as well as reestablish healthy, functioning patterns within the family (Plante, 2011). The Milan approach, similar to the communications approach seeks to place the therapist close within the family unit (Plante, 2011). This provides a neutral person who each member of the family can respect in the therapy process (Plante, 2011). At the core of each approach the assumption is that the family unit possesses dysfunctions that contribute to the OCD symptoms of the identified individual (Plante, 2011). Differing from other types of intervention, family systems does not provide sole treatment for the identified individual but rather addresses the family dysfunctions and inadequacies as an interrelated problem within the unit (Plante, 2011). Although this type of intervention addresses the relational issues within the group and provides a healthier family unit, little evidence supports efficacy of the family systems in alleviating symptoms of OCD as the exclusive treatment (Carr, 2000). Family therapy provides effective treatment as a sole intervention or in combination with other interventions in the treatment of conduct problems, child abuse or neglect, psychosomatic problems, or emotional problems (Carr, 2000). However with cases of OCD, especially those with severe symptoms the additional interventions are necessary (Carr, 2000). Slide 11:  The four major approaches to clinical psychology place foundations on philosophical assumptions in regard to human behavior. These approaches provide psychologists with the tools necessary to perceive, conceptualize, and understand the nature of mental illness, dysfunction, and disorder. Although each approach differs in perspective, they provide consistency in assessment, plans of action, and treatment in different situations according to the individual’s needs. The psychodynamic perspective places emphasis upon the unconscious mind as the influence of health or dysfunction in an individual’s life. The cognitive-behavioral approach places emphasis upon the environment conditioning an individual’s observable, measurable, and responsive behavior. The humanistic approach places emphasis upon the individual as possessing an innate ability to grow and evolve, and the family systems approach views the problems of an individual as an interrelated dysfunction of the family unit. Each approach possesses strengths and weaknesses in treating specific problems. Through integration, psychologists can provide the necessary care to individuals in need. This integration allows the psychologist to use the strength of each theoretical perspective to provide the broadest spectrum of care for specific problems the individual presents. Additionally, as the psychological discipline reveals new information regarding new information, the adaptation of new approaches or further integration is necessary to continue providing the best care for those in need. References Abend, S. M. (1996). Psychoanalytic psychotherapy. In Lindemann, C. G., Handbook of the treatment of anxiety disorders (p. 401–410). Northvale, NJ: Jason Aronson, Inc.   Beck, A. T., Emery, G., & Greenberg, R. L. (2005). Anxiety disorders and phobias: A cognitive perspective. Cambridge, MA: Basic Books.   Bram, A., & Björgvinsson, T. (2004). A psychodynamic clinician's foray into cognitive- behavioral therapy utilizing exposure-response prevention for obsessive-compulsive disorder. American Journal of Psychotherapy, 58(3), 304-320. Carr, A. (2000). Evidence-based practice in family therapy and systemic consultation Child- focused problems. Journal of Family Therapy, 22(1), 29-60. doi: 10.1111/1467- 6427.00137 Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., Flower, T., Davenport, C., & Louis, B. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: A randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71(6), 1058-1067. doi: 10.1037/0022-006X.71.6.1058 Dombeck, M. (2006). Humanistic Psychotherapy. Retrieved August 23, 2012, from http://www.mentalhelp.net/poc/view_doc.php'type=doc&id=10441 Fraum, R. M. (2012). Psychology and counseling for obsessive-compulsive disorder (OCD). Retrieved August 23, 2012 from http://www.psychologistcounselorpsychotherapist.com/obsessive-compulsive-disorder- ocd-nyc-westchester.aspx Hansell, J., & Damour, L. (2008). Abnormal psychology. Hoboken, NJ: Wiley. Nathan, P. E., & Gorman, J. M. (2002). A guide to treatments that work (2nd ed.). New York: Oxford University Press. National Institutes of Health. (2012). Anxiety disorders. Retrieved August 23, 2012, from http://www.nlm.nih.gov/medlineplus/phobias.html  Phillipson, S. (2012). When seeing is not believing: A cognitive therapeutic differentiation between conceptualizing and managing OCD. Retrieved August 23, 2012, from http://www.ocdonline.com/definecbt.php Plante, T. G. (2011). Contemporary clinical psychology (3rd ed.). Hoboken, NJ: John Wiley & Sons. Schimelpfening, N. (2011). Major depressive disorder. Retrieved August 23, 2012, from http://depression.about.com/cs/diagnosis/a/mdd.htm Wells, M. C., Glickauf-Hughes, C., & Buzzell, V. (1990). Treating obsessive-compulsive personalities in psychodynamic/interpersonal group therapy. Psychotherapy: Theory, Research, Practice, Training, 27(3), 366-379. doi: 10.1037/0033-3204.27.3.366 Whelton, W. J. (2004). Emotional processes in psychotherapy: Evidence across therapeutic modalities. Clinical Psychology & Psychotherapy, 11(1), 58-71. doi: 10.1002/cpp.392