PSYCHOLOGICAL INTERVENTIONS AND THEIR GOALS:THE EXPERT ROLE

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Clinical Psychology (PSY401)

LESSON 25

PSYCHOLOGICAL INTERVENTIONS AND THEIR GOALS

DEFINING THE INTERVENTION

In a most general way, psychological intervention is a method of inducing changes in a person's

behavior, thoughts, or feelings.

Although the same might also be said for a TV commercial or the efforts of teachers and close

friends, psychotherapy involves intervention in the context of a professional relationship-a

relationship sought by the client or the client's guardians. In some cases, therapy is undertaken to

solve a specific problem or to improve the individual's capacity to deal with existing behaviors,

feelings, or thoughts that are debilitating. In other cases, the focus may be more on the prevention

of problems than on remedying an existing condition. In still other instances, the focus is lesson

solving or preventing problems than it is on increasing the person's ability to take pleasure in life or

to achieve some latent potential.

Psychologists are involved in intervention whenever they purposefully try to produce change in the lives

of others. We will consider three typesof interventions that are intended to produce change in people's

lives.

First, there has been a recent emphasis in clinical psychology (and, indeed, in psychology in general) on

"positive psychology," including the promotion of health and positive behaviors. This approach typically

targets broad populations and is exemplified by programs that teach for example, stress management,

exercise and healthy eating, and social competence skills.

Second, programs designed to prevent psy chopathology and diseases have a longer history. These

programs typically target groups who are at elevated risk for developing disorder (e.g., low

weight infants, children of depressed mothers, victims of assault) and are designed to reduce the

probability of adverse outcomes in these samples.

Third, the most common form of intervention in clinical psychology is psychotherapy. The process used to

treat various types of disorders once they have occurred. Many different forms of psychotherapy have

been developed to treat depression, anxiety, personality disorders, and other psychological problems.

GOALS OF PSYCHOLOGICAL INTERVENTION

Interventions carried out by clinical psychologists have a remarkably wide range of goals and take a

variety of different forms. Psychological interventions have been developed to change behaviors in

order to reduce the risk for AIDS, prevent violent behavior. Promote healthy patterns of diet and

exercise, improve children's learning and performance in school, control alcohol abuse, treat the

victims of trauma, manage problems of inattention and aggression in children, alleviate major

depression, and prolong the lives of patients with serious illness. These are only a few examples of

the wide range of psychological interventions that have been developed within the realm of clinical

psychology and other mental health professions.

WHAT ARE WE TRYING TO CHANGE?

Psychological interventions differ in the aspects of human functioning that they are designed to change.

Just as psychologists can choose to assess and measure thoughts, feelings, behavior, biology, or the

environment, so too can psychologists help people change in one or more of these various levels of

functioning (Kanfer & Goldstein, 1991). Some interventions are intended to change what people do,

to change particular problem behaviors. For example, an intervention may be designed to reduce-the

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amount and frequency of the consumption of alcohol or cigarette smoking. Other interventions are

designed to change emotions by decreasing emotional distress and increasing emotional comfort, as

when an intervention is used to reduce feelings of anxiety and worry. Still other interventions are in-

tended to change the ways that people think; for example, to stop persistent thoughts about a traumatic

experience or to help individuals develop more positive and optimistic beliefs about the future.

Psychological interventions also may be designed to change underlying biological processes. Examples

include the use of psychological techniques to reduce blood pressure, lower resting heart rate, or decrease

headache pain. Finally, interventions can be designed to change the environment rather than the person,

such as changing the structure and resources of a junior high or middle school to ease the often stressful

transition of students from the primary grades. Most interventions are, in fact, designed to produce

change in more than one of these levels of functioning.

Much of the work carried out by clinical psychologists is concerned with the prevention or treatment of

specific forms of psychopathology as defined in the DSM-IV but clinical psychological interventions

are also concerned with broader social problems and problems in living that are not included as specific

diagnostic categories in the DSM-IV (Adelman, 1995). These include problems in learning and

development, difficulties in daily living, and problems in interpersonal relationships. Furthermore,

advances in clinical health psychology and behavioral medicine have expanded the focus of

interventions in clinical psychology to include a number of physical disorders and diseases-

psychologists contribute directly to the prevention and treatment of, among other diseases, cancer,

diabetes, hypertension, and AIDS.

The goals of an intervention may not be the same for all parties involved. For example, the parents and

the teachers of an adolescent boy who is referred for treatment of disruptive behavior and conduct

problems may not share the same goals for improving his behavior. The adolescent may have radically

different goals than either his parents or his teachers, or he may not, wish to change at all. Similarly, a

client may, have different goals from those that are formulated by a psychologist. A framework for

understanding differences in goals for intervention been outlined by psychologist Hans Strupp.strupp's

tripartite model distinguishes among the criteria for successful interventions that are held by

clients,societry,and mental health professionals. Clients are typically concerned with achieving change

in their subjective sense of distress.Alternativel,society is most often concerned with interceptions that

bring change in disruptive or harmful behavior.finally,mental health professionals are concerned with

change that can be evaluated according to criteria that are specified as part of a model of personality or

psychopathalogy. Therefore,the goals of interventions and the evaluation of success is achieving these

goals involve the measurement of different perspectives and frequently use different criteria of success.

INTERVENTION AND PSYCHOTHERAPY

As often as not, the terms intervention and psychotherapy hive been used interchangeably. A rather

typical general definition of psychotherapy was provided years ago by Wolberg (1967):

"Psychotherapy is a form of treatment for problems of an emotional nature in 88which a trained

person deliberately establishes a professional relationship with a patient with the object of removing,

modifying or retarding existing symptoms, of mediating disturbed patterns of behavior, and of

promoting positive personality growth and development.'

Wolberg's definition includes such words as symptoms and treatment, and his subsequent elaboration of

the definition gives it a distinctly medical flavor. Yet, overall, the definition is not much different from

one offered by a more psy¬chologically oriented clinician (Rotter, 1971)

"Psychotherapy ... is planned activity of the psychologist, the purpose of which is to ac¬complish

changes in the individual that make his [sic] life adjustment potentially happier, more constructive, or

both."

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J. D. Frank (1982) elaborates this general theme as follows:

Before we describe in more detail the goals and features of psychotherapy, a general question

needs to be addressed. Does psychotherapy work? Both advocates (for example, Lambert & Bergin,

1994) and critics (for example, Dawes, 1994) agree that empirical evidence supports the efficacy of

psychotherapy. Of course, this does not mean that everyone benefits from psychotherapy. Rather, on

average, individuals who seek out and receive psychotherapy achieve some degree of relief. For

example, a frequently cited meta-analytic review of more than 475 psychotherapy outcome studies

reported that the average person receiving psychological treatment is functioning better than 80% of

those not receiving treatment (Smith, Glass, & Miller, 1980). At this point, a recent large-scale survey on

the benefits of psychotherapy deserves mention. The November 1995 issue of Consumer Reports ("Mental

Health," 1995) summarized the results of a survey of 4,000 readers who had sought treatment for a

psychological problem from a mental health professional, family doctor, or self-help group during the

year's 1991-1994. Most of the respondents were well educated, their median age was 46 years, and about

half were women. Of this sample, 43% described their emotional state at the time that treatment was sought

as "very poor" ("I barely managed to deal with things") or "fairly poor" ("Life was usually pretty tough").

The 4,000 respondents presented for treatment of a wide range of problems, including depression,

anxiety, panic, phobias, marital or sexual problems, alcohol or drug problems, and problems with children.

The major findings were as follows:

1. Psychotherapy resulted in some improvement for the majority of respondents. Those who

felt the worst before treatment began reported the most improvement.

As for which types of mental health professionals were most helpful, psychiatrists, psychologists,

and social workers all received high marks. All appeared to be equally effective even after

controlling for severity and type of psychological problem.

3. Respondents who received psychotherapy alone improved as much as those who received

psychotherapy plus medication as part of their treatment.

4. In this survey, longer treatment (more sessions) was related to more improvement.

These findings are both interesting and provocative. This survey, however, is limited in a number of

respects such that we must be cautious in our generalizations. For example, few respondents

reported severe psychopathology (such as schizophrenia), and reports were both retrospective and

based solely on the clients' self-reports. In addition, the percentage of potential respondents who

returned the survey was relatively low, raising the possibility of an unrepresentative sample. Further,

readers of this publication may not be particularly representative of the general U.S. population.

Despite these limitations, the Consumer Reports survey provides some support for the contention that

psychotherapy works. Further, it represents th e largest st udy to date that has assessed "the

effectiveness of psychotherapy as it is actually performed in the field with the population that

actually seeks it, and it is the most extensive, carefully done study to do this.

FEATURES COMMON TO MANY THERAPIES

The apparent diversity among psychotherapies can sometimes lead us to overlook the marked

similarities among them. One reason is that the purveyor of a new brand of psychotherapy must emphasize

the special features of the new product. Bringing forth a minor variation of an old therapeutic theme

would be unlikely to capture anyone's interest. Yet most psychotherapy has a great deal in common-a

commonality that in many respects outweighs the diversity.

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Hundreds of "brands" of psychotherapy have been identified. Some are effective, whereas others probably

are not. Unfortunately, not all of these forms of psychological intervention have been subjected to

empirical scrutiny. Of those that have received research attention, however, there is only limited evidence

that one approach or technique is more effective than others. As Lambert and Bergin (1994) note, one

implication of therapeutic equivalence is that the positive changes effected by psychological treatment may

actually be the result of a set of common factors that cuts across various theoretical and therapeutic

boundaries. Lambert and Bergin (1994) provide a list of common factors categorized according to a

sequential process that they believe is associated with positive outcome.

Briefly, they propose that supportive factors (for example, positive relationship, trust) lay the groundwork

for changes in clients' beliefs and attitudes (learning factors-for example, cognitive learning, insight),

which then lead to behavioral change (action factors-for example, mastery, taking risks). Some of the

factors are discussed below.

THE EXPERT ROLE

It is assumed that the therapist brings to the therapy situation something more than acceptance, warmth,

respect, and interest. These personal qualities are not sufficient for certification as a clinical psychologist.

Conventional wisdom seems to suggest that all one needs in order to conduct psychotherapy is an

unflagging interest in others. In fact, however, this is not enough.

In all forms of psychotherapy, patients have a right to expect that they are seeing not only a warm human

being but a competent one as well. Competence can only come from a long, arduous period of training.

Some may be quick to reply that the assumption of an expert role introduces an authoritarian element

into the relationship, implying that the patient and the therapist are not equal, and thus destroying the

mutual respect that should exist between them. However, mutual understanding and mutual acceptance of

the different roles to be played would seem sufficient to guarantee the maintenance of mutual respect.

Therapists are, of course, no better than patients, and they cannot lay claim to any superior consideration in

the cosmic scheme of things. However, this kind of equality need not deny the importance of training,

knowledge, and experience that will assist therapists in their efforts to resolve the patient's problems.

THE RELEASE OF EMOTIONS/CATHARSIS

Some have stated that psychotherapy without anger, anxiety, or tears is no psychotherapy at all. Psycho-

therapy is an emotional experience. The conviction of most psychotherapists is so strong on this point

that they would seriously question whether a patient who, session after session, maintains a calm,

cool, detached or intellectual demeanor is really benefiting. The problems that bring a person to

psychotherapy are typically important ones. Consequently, they are likely to have important

antecedents.

The release of emotions, or catharsis as it is sometimes termed, is a vital part of most psychotherapies. Its

depth and intensity will vary, depending on the nature and severity of the problem and on the particular

stage in therapy. But the psychotherapist must be prepared to deal with emotional expression and to use

it to bring about change. Although some forms of psychotherapy certainly place more reliance on emo-

tional expression than do others, a new brand of therapy is likely to be criticized if it seems to neglect this

important facet. On the other hand, there are clearly some forms of psychotherapy (su ch as an g er

man ag emen t ) i n wh i ch cat h arsi s are not likely to be a desirable goal. In these cases, the goal may be to

gain better control over the expression of one's emotions.

RELATIONSHIP/THERAPEUTIC ALLIANCE

For some, the nature of the relationship or, therapeutic alliance between patient and therapist is the

single element most responsible for the success of psychotherapy. Although not all therapists would el-

evate the relationship to the status of the primary, " curative" agent, almost all therapists would at-

test to the unique importance of the relationship. Where else can patients find an accepting, non-

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judgmental atmosphere in which to discuss their innermost urges, secrets, and disappointments?

Discussions of this kind with a friend or relative always seem to contain an implicit aura of evaluation and

often lead to unforeseen complications because the other person has a personal stake in the matters

discussed. Friends can easily be threatened by such discussions because the content of the discussions

has the potential to disturb the basis for the relationship. Can a husband discuss his dependency

anxieties with his wife, whose perception of her role may be disturbed by such revelations? Can a son

reveal his fear of failure to a father who has been boastful of the son's achievements? Can a daughter tell

her mother that she wants to give up her role as housewife in favor of a career without seeming to question

her mother's values?

In psychotherapy, all of this is possible. The effective therapist is someone who can be accepting,

nonjudgmental, objective, insightful, and professional all at the same time. These lavish adjectives scarcely

fit all therapists all of the time. Nevertheless, the general ability of therapists to rise above their personal

needs and to respond with professional skill in a nonjudgmental atmosphere of confidentiality,

understanding, and warmth is probably a major reason for the success and persistence of psychotherapy

in our society.

ANXIETY REDUCTION/RELEASE OF TENSION

Initially, it is important that the anxiety accompanying the patient's problems in living be reduced

enough to permit examination of the factors responsible for the problems. The essential conditions of

psychotherapy-including the nature of the relationship, the qualifications of the therapist,

confidentiality, and privacy-combine to provide a reassurance and a sense of security that can

lower the patient's anxiety and permit the patient to contemplate his or her experiences systematically.

In instances in which the anxiety level is extremely high, some patients may require, on medical

advice, antianxiety medications to help deal with the situation. However, it is important that such

medications be regarded as a temporary tool rather than a permanent solution. Some clients may

experience side effects to medications, and medications may actually interfere with some forms of

psychological treatment (such as exposure-based therapies) in which the goal is to increase anxiety

levels in the face of certain stimuli so that habituation will occur.

INTERPRETATION/INSIGHT

Many nonprofessionals erroneously view psychotherapy as a rather straightforward process in which

a person presents a problem, the therapist asks the person to describe his or her childhood experiences,

the therapist offers a series of interpretations as to the real meaning of those childhood experiences,

and the person then achieves insight. With the sudden, explosive force of revelation, this insight

strikes home. A brief period of wonderment follows, as the problem falls away like melting snow.

In conclusion, the patient walks away from the consulting room, framed in the light from the setting sun,

assured that relief and everlasting joy have been attained. This, of course, is a scenario from a bad movie

or from the fantasies of a beginning therapist.

There is, however, an element of-reality in the foregoing scenario. A broad band of psychotherapies does

attach importance to patients' childhood experiences, though such psycho--therapies vary in the

degree of importance they attach to them, the amount of related information they seek, and their view

of the effects generated by the experiences. Similarly, interpretation is a very common component of

psychotherapy. But again, the extent of its use, the kinds and the timing of the interpretations, and

the importance attributed to those interpretations vary with the school of psychotherapy. But

regardless of terminology, an important element in many forms of psychotherapy is the attempt to get the

patient to view past experience in a different light.

The importance attached to insight has eroded over the years. Once it was naively thought that

insight into the nature and origin of one's problems would somehow automatically propel the patient into a

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higher level of adjustment. Most psychotherapists no longer cling to this simple belief. Insight is still

viewed as important, but it is recognized that significant behavioral change can be brought about by

other means. Insight may be seen as a facilitator of psychological growth and improvement, but not as

something that by it will inevitably bring about such changes. Indeed, waiting for insight to free one from

problems can be a delaying tactic used by some patients to avoid taking the responsibility for initiating

changes in their lives.

BUILDING COMPETENCE/MASTERY

In one sense, a goal of most therapies is to make the client a more competent and effective human

being. All of the foregoing features of psychotherapy will facilitate the achievement of greater effective-

ness and satisfaction. But beyond such elements as the therapeutic relationship and anxiety reduction,

some forms of therapy have other feat u r e s t h a t a r e a l s o a p p l i c a b l e h er e . F o r ex a mp l e , therapy

can be a setting in which the client learns new things and corrects faulty ways of thinking. At times,

some forms of therapy will take on distinct teaching overtones. The client may be "tutored" on more

effective ways to find a job, or sexual information may be provided to help alleviate past sexual

difficulties and promote a better sexual adjustment in the future. Therapy, then, can be more than just

exorcising old psychological demons; it can also be a learning experience in the direct sense of the word.

Bandura (1989) has emphasized the importance of feelings of self-efficacy in promoting a higher

performance level in the individual. In short, those persons who experience a sense of mastery-who

feel confident, expect to do well or just feel good about themselves-are more likely to function in

an effective fashion.

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