Comps 2020 Intervention
Cabral and Smith, 2011
Ethnic client-therapist matching provides almost no benefit
Beutler et al's (2004) Observable States
1. Professional Discipline and Amount of Training: § does not appear related to therapeutic success, although this is confounded by the content of the training and the program of study. § Psychologists do slightly better than M.D.s 2. Professional Experience: § The effect sizes were variable across studies are typically small. § It is possible that just having more general clinical experience (seeing more patients, being a clinician for a long time) helps reduce patient panic and anxiety. 3. Interpersonal Psychotherapy Style (complementary and positive) § Reciprocal Interactive Styles: · Friendly behaviors on the part of the therapist in conjunction with compatible dominance-submission styles were associated with positive outcomes. § Verbal Patterns of interacting: agreement was associated with continuance in therapy § Non-verbal Communication: Discrepancies between verbal and non-verbal bad. Voice tone and posture leak information. 4. Therapist methods (manual vs. no manual) § Although adherence to manuals is generally associated with better outcomes, the most effective therapists tend to depart from treatment manuals to build the therapeutic relationship. § Therapists with least training benefit most from manuals. 5. Supervision § Therapists-supervisor orientation match best outcomes. Supervisor empathy and skills training à client benefits 6. Therapists skill § Increase client compliance with homework à better outcomes. 7. Therapist and Client Factors § Client moderators of whether they prefer directive therapy influences outcome, but generally directive interventions were slightly preferred (e.g., CBT and other action-oriented therapies). 8. Insight vs. symptom orientation § Match to client diagnosis and cognitive style 9. Emotive vs. supportive § depends on alliance and relationship strength 10. High intensity vs. low intensity (dose) § Only matters for high stress clients 11. Self-Disclosure § Decreases distress in client and positive effect on depression 12. Dominance § Generally low dominance à better outcomes. But, can use more dominance when ethnic match. 13. Therapist confidence § Increase confidence à increase client outcomes
Plan Formulation Method
Gazzilo, Dimaggio & Curtis, 2019 A bottom-up method of treatment planning not bound to assumptions of any specific theory. Includes: Goals Obstructions Traumas Tests Insights Integration
· Models to Integrate Cultural Considerations
Huey, Tiley, Jones, & Smith, 2014 Skills-based model Adaptation model Process-oriented models
Process-oriented models
Huey, Tiley, Jones, & Smith, 2014 address the dynamic mechanisms underlying the therapist-client interaction, and how cultural meaning is ascribed to specific behavior and treatment contexts. Considered the best model for capturing nuances of culture
Common Factors vs. Technique
Lambert, 2013 o Lambert's pie chart indicates that common factors are more important than techniques (30% therapeutic alliance compared to 15% techniques; 15% placebo & 40% extratherapeutic factors) o However, you need techniques as the vehicle for improvement so that the client buys into therapy. Focus on technique because it can be controlled.
Client Characteristics Related to Treatment Outcomes
Norcross and Wampold, 2011 Reactance Stage of change Client preferences Culturally-adapted interventions Coping Style Religion Expectations Attachment style
Client Preferences
Norcross and Wampold, 2011 those who received their preferences in therapy method, treatment format, relationship style, therapist characteristic, or treatment length do significantly better and are less likely to drop out of psychotherapy prematurely. Implications for culturally-adapted treatments.
Feminist Therapy Code of Ethics
Rave & Larson, 1995 · Suggests that a psychologist must consider the impact of society on problems brought into therapy. Additive to APA code
Alliance with youth and adolescents
Shirk & Karver, 2011 · r=.19 (slightly lower than with adults; may be higher with behavioral treatment) · Must attend to the alliance with not only the child, but with their parents, as they are the ones bringing the child for treatment. o Parents and children often disagree, so it is important not to take sides
More Therapist Variables (Beutler et al., 2004)
Two intersecting dimensions of therapist variables 1. Traits and Sates of the therapist 2. Observable (sex/age) and Inferred (religion/political affiliation) Qualities
Disabled - Considerations
(Berman & Shopland, 2005) o In treatment: Avoid errors of omission (assuming something is not relevant, like sexuality) and commission (assuming something is important to a person with a disability). Self-advocacy skills and positive framing of problems is useful
Gender - Considerations
(Berman & Shopland, 2005) o Men are discouraged from expressing emotions except for anger, help-seeking behavior is discouraged, maintain masculinity/dominance/self-reliance/stoic/financially support family o Women are encouraged to be submissive, passive, nurturing, emotionally attuned to relationships, dependent on others/ domestic responsibilities
Violating the Ethics Code
APA, 2003 possibility of losing APA membership or other psychological services. License too.
Attending behavior
Berman and Shopland, 2005 verbal and nonverbal behavior that helps the client understand that the therapist is listening carefully and trying to fully understand what is being said a. Verbal attending behaviors include the rate of speech, intonations, sighs, and "mmhmms". b. Nonverbal attending behaviors include eye contact, body orientation, facial expressions, and carefully-chosen use of pauses. These nonverbal behaviors may help clients identify their feelings by encouraging them to label their feelings that are reflected in their nonverbal behavior. - Nonverbal mirroring is when the therapist matches the client's body posture, facial expression, tempo, and intensity of speech c. More trust in therapist when verbal and nonverbal behavior are congruent.
Treatment Plan Writing Styles
Berman, 2015 o Assumption-based styles focus on the assumptions of a specific theory. o Symptom-based styles focus on symptoms. o Interpersonal styles focus on client's relationships with others and self o Historically-based focused around significant stressors in client's life o Thematically-based focused around important themes that epitomize the client's behavior or view of the world. o Diagnosis-based styles focused around formal diagnostic criteria
10.05-10.8: Sexual Intimacies
APA, 2010 I say go for it... right? No? · Current Therapy Clients & Significant Other(s) of Current Clients: No. Psychologists do not terminate therapy to circumvent this standard. · Former Sexual Partners: No · Former Clients: No, unless at least two years after cessation or termination of therapy AND burden of demonstrating that there has been no exploitation.
10.03 Group Therapy
APA, 2010 · Explain the roles and responsibilities of all parties and the limits of confidentiality.
10.04 Providing Therapy to Those Served by Others
APA, 2010 · Psychologists carefully consider the treatment issues and the potential client's/patient's welfare.
10.02 Therapy Involving Couples or Families
APA, 2010 · Psychologists clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person · Possibility of a conflicting role: reasonable steps taken to clarify and modify, or withdraw from the roles
10.01 Informed Consent to Therapy
APA, 2010 · Psychologists inform clients/patients as early as is feasible regarding course of therapy, fees, involvement of third parties and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions · When the therapist is a trainee, the client is informed about the trainee is being supervised and given the name of the supervisor.
Pereira, Ramos, Lobarinhas, Machado & Pedras, 2018
Amputee clients are more sensitive to errors of omission and commission. The most important thing is their subjective judgement of mobility when predicting outcome.
Barriers to implementing EBPs
Barlow, Bullis, Comer and Ametai, 2013 Minority population: not effective for them Comorbidity: it's high, but treatments targeting comorbid conditions are limited Nomothetic approach: despite idiographic approach being needed Relatively new" and marketing efforts are few, while drug companies grow
Reflective Listening
Berman and Shopland, 2005 Focuses the client's attention on their thoughts in response to certain events or issues being discussed. a. May simply reflect back what they heard the client say b. Demonstrates listening
ADRESSING Model
Berman and Shopland, 2005 Hays' model examines power differentials on several domains 1) age (adults vs children, adolescents and eldery) 2) disability (able-bodied vs. non) 3) Religion (Christians vs. everyone else) 4) Ethnicity (euro-american vs. everyone else) 5) Social class (land owning middle and upper class vs poor and working class) 6) Sexual orientation (hetero vs non) 7) Indigenous background (non-native vs native) 8) National origin (US born vs immigrant/refugee) 9) Gender (male vs female, trans, inter)
Redirection
Berman and Shopland, 2005 Provides a comment of emotional support, but then gently redirects the client to a specific topic. Redirection is typically used to provide clarity and helps prevent avoidance
Open-ended Questions
Berman and Shopland, 2005 Questions that tend to draw complex information from the client and allow the client room to determine how to respond. a. They are useful when the therapist wants in-depth information. b. Closed questions are used less frequently, but they can be instrumental in helping the therapist draw out brief, specific pieces of information.
Summarizing
Berman and Shopland, 2005 Reviews information that they have given you and allows the client to correct anything that you may have misunderstood Demonstrates listening, highlights themes, acts as a transition, and decreases emotional intensity
Key Features of Treatment Plan Development
Berman, 2015 o Selecting a theoretical perspective that is most appropriate for the client. o Premise: concise analysis of the client's core strengths and weaknesses. It is tied to assumptions of the theoretical perspective being used and sets up what follows. o Supporting material: in-depth case analysis to provides evidence for statements made in premise. o Conclusion: thoughts about the client's overall level of functioning, broad treatment goals, and potential barriers to goal attainment
Treatment Planning
Berman, 2015 - is this up to date o Long-term goal is followed by specific and attainable short-term goals. - Effective goals: client values the goal AND goals stated in concrete terms that the client understands. o A long-term goal should be the topic sentence of each support paragraph and should reflect the main concepts developed in the premise. o Short-term goals should help demonstrate progress, instill hope, and help with session planning
Step three of STS Model
Beutler & Clarkin, 1990 Consider Relationship Variables: Involves the therapeutic relationship along two lines. 1) Compatibility of matching criteria 2) Relationship enhancement skills
Step two of STS Model
Beutler & Clarkin, 1990 Consider Treatment Context a. Setting: inpatient vs outpatient b. Mode/format of therapy: psychosocial vs medical/somatic, individual vs. group/family/couple c. Frequency/duration of therapy: crisis, short-term, long-term, no treatment.
Best and Worst Therapists' Effectiveness
Bohart and Wade, 2013 Most are average, top and bottom 5% differ. Top better at complex cases, but mild/moderate cases same outcomes across therapists. Over a career, the top can help substantially more than the bottom, and far fewer deteriorate/make no progress.
Client In Psychotherapy - Personality Characteristics
Bohart and Wade, 2013 o When clients' motivation to work comes from within, either in terms of their readiness to change, autonomy motivation, or therapy not activating their resistance, they are more likely to do well
Client In Psychotherapy
Bohart and Wade, 2013 · Research suggests that clients make the single strongest contribution to outcome Attendance, Demographics, Pathology and Relationship, Personality Characteristics, Therapeutic Alliance o Extratherapeutic factors (client-related factors) account for approximately 40% of variance in outcome, while common factors account for 30%, technique accounts for 15%, and expectations/hope accounts for 15% (Lambert, 1992).
Alliance in couple and family therapy
Friedlander et al., 2011 · r=.26 (medium effect size) · There are multiple alliances that interact systemically. Do not ally too strongly with one member of the family. · It is important to create a safe space for every member and a shared sense of purpose.
Plan Formulation Method: Insights
Gazzilo, Dimaggio & Curtis, 2019 Insights onto Core Problems: Statements provided by either therapist or client that help to achieve goals. Often involves the content or source of pathogenic beliefs (obstructions)
Effectiveness
Lambert 2013 Refers to implementation in a clinical setting
Overall influences on outcomes
Lambert, 1992
How much therapy is needed?
Lambert, 2013 o Dosage= negatively accelerated curve- 14% improve before initial session. About 50% of clients who begin therapy in the dysfunctional range achieve clinically significant change in 21 sessions, with the assumption that 50 sessions are necessary for full recovery. o With a less stringent standard, half of clients, started in the functional range, respond by the 7th session and 75% by the 14th session. o Interpersonal problems of functioning are slower to respond (PDs) o 30% of clients make sudden gains after only 3 sessions and this is a positive indicator for total change. Median session was 5. o Good-Enough Level (GEL model) theorizes that the speed of recovery would predict the number of sessions. In other words, there is a "good enough" dose of therapy, and the individual rate of change determines the dose, rather than the number of sessions predicting recovery. - Research supports this model as a better description of the relationship between dose and individual patient recovery better than earlier dose-response models
Lake Wobegon Effect
Lambert, 2013 o Most therapists believe that they are "above average" o Over 90% believed they were above average! Experience does not make you a better therapist, but it may in a minority of complicated cases
Do patients maintain their gains?
Lambert, 2013 o Yes, many patients who undergo therapy achieve healthy adjustment for long periods of time; this remains true for individuals who have a long history of recurrent problems. o However, evidence does show a portion of patients who are improved at termination that relapse and then continue to seek help - Risk of relapse progressively decreases as recovery length increases - The probability of relapse diminishes from 20% within the first 6 months following a depressive episode to 9% after three years of maintaining gains
Five Pragmatic Concerns with EBP
Lilienfield et al., 2013 1. Time. Reading additional literature, obtaining appropriate training, and supervision can be consuming 2. Knowledge about training materials. There is a gap between those who are producing research/manuals and those who are using them. 3. Steep learning curve. may feel overwhelmed by information 4. Statistical complexity. research articles are difficult to comprehend 5. "Ivory tower" mentality. gap in the research vs the practice.
Client Expectations
Norcross and Wampold, 2011 Clients who are more hopeful do better
Attachment Style
Norcross and Wampold, 2011 Secure style clients typically do better in therapy
Stage of Change
Norcross and Wampold, 2011 client's stage of change in therapy also has an impact on outcomes. Those in the precontemplation stage minimize or deny problems and do not fare as well as those in later stages. Individuals in the contemplation stage acknowledge problems but are not yet ready to modify them. Clients in the most advanced stage (action) are eager to begin working on their problems and may benefit from skills training and behavioral methods
Reactance
Norcross and Wampold, 2011 defined by how the client interacts with therapist's interventions 1. High reactance clients are easily provoked and respond oppositionally to direct demands --> self-control methods and less structured treatments 2. Low reactance --> directiveness and explicit guidance
Mental Status Exam
Suhr, 2015 Common part of intake/assessment interviews o Review major systems of psychiatric functioning o Regularly used in psychiatric setting (inpatient); most of information from MSE can be obtained in interview in outpatient setting. o Can be used as more of a screener to determine the need for further testing in future.
Domains to Cover in Intake/Assessment Interviews
Suhr, 2015 o Identifying information (culture, name, referral source, problem) o Discuss purpose (clarifying misunderstanding, testing process, informed consent) o Background (history of problem, why now?, functional impairment-subjective, objective impairments- examples, identify collaterals, records needed, problem complexity/chronicity/timing, previous treatment, self coping/problem solving style, and insight level o Social, family history (history-med, psych, substance, dynamics/structure, trauma/changes, social support, diversity issues -open ended o Are presenting problems really the most important to address? May be unidentified antecedents that need to be addressed first?
Eysenck 1952
Thought that psychotherapy is no more effective than no treatment at all, as demonstrated by patients' spontaneous remission. Not true, you hasten recovery with treatment
Evidence for Various Common Factors
Wampold, 2015. Large, medium, small effect Goal consensus Empathy Alliance Positive Regard Therapists Genuineness Cultural Adaptation Expectations Treatment Differences had a .2 effect size.
Cultural competence - Huey, Tiley, Jones, & Smith, 2014
an awareness of culture and application to diverse clients, wherein interventions are modified to accommodate culture No agreed-upon definition
Beutler et al's (2004) Inferred States
includes therapeutic alliance and treatment model There is still no universal consensus on common factors vs. "evidence-based treatment" argument. There is a moderately strong effect for relationship qualities. Therapeutic alliance has been shown to be the greatest predictor of outcome. The therapeutic relationship probably accounts for 7 to 17% of the variance in outcome
Lambert 2013 on Efficacy
o Approximately 70% improve with therapy vs. 30% spontaneously remit o Psychotherapy has better effect sizes than many evidence-based medical practices! o Differences between various forms of therapy are not pronounced, although cognitive-behavioral therapies have shown marginally superior outcomes. - Medication and psychotherapy outcomes for depression are comparable. - Combination therapy may be somewhat more effective than meds alone. - SSRIs alone seem to be more effective than therapy alone. o Relapse rates were nearly 2x in pharmacotherapy vs. psychotherapy. o The most dramatic and consistent finding has been reported with behavioral and CBT treatment of panic disorder (effect size=.64).
DSM 5 Revision Principles
o DSM-5 primarily intended to be a manual used by clinicians, and revisions must be feasible for routine clinical practice o Recommendations for revisions should be guided by research evidence o Where possible, continuity should be maintained with previous editions o No a priori constraints should be placed on degree of change between DSM-IV and DSM-5
Does therapy exceed placebo?
o Psychotherapy surpasses placebo effects, sometimes by large margins, where psychotherapy goes beyond the instillation of hope. Lambert, 2013
Common Factors
o Started with Wampold (1997) meta-analysis of over 300 studies that suggests all bona fide treatments are equally efficacious, which supports that common factors across treatments are what make psychotherapy work. AKA Dodo Bird Hypothesis. Supporters of this hypothesis state that EBT proponents are influenced by researcher bias. o Three types of research support the idea of common factors - Placebo/supportive therapy literature: typically do better than waitlist and may involve common factors. - Comparative outcome literature: Different types of therapies showed similar effectiveness; dodo-bird verdict - Component analysis: taking out "essential" components of treatment has no effect on effectiveness
Deposition
pretrial proceeding to discover relevant information o Expert witness: an opinion or do an assessment o Fact witness: testify to what is in the client's records
Lilienfield (2007) on deterioration
proposes operationalizing treatments as Potentially Harmful Therapies (PHTs) - Demonstrated harmful psychological/physical effects in clients or others - The harmful effects are enduring and do not merely reflect a short-term exacerbation of symptoms during treatment - The harmful effects have been replicated by independent investigative teams.
Black, 2017
· Professional (which also has an institutional sub-category) and non-professional multiple relationships · Boundary crossings deviate from the commonly accepted plan but are not harmful to the client o Gift acceptance o Self-disclosure · Boundary violations are harmful and/or exploitative to the client o Accepting large gifts o Going to client's homes (even if invited) o Extending appointments (unfair practice) o And obviously anything sexual · All multiple relationships involve boundary crossings, not all involve boundary violations o Consider culture, context, intent, setting, etc
Goldberg et al., 2016
· Therapists generally did not improve with more experience · Large sample, good study · Experience may actually lead to deterioration in outcomes, .012 effect size per year o In reality, about 40% improved over time and 60% declined · But experience does make therapists better at preventing early termination and dropout, and because those are often more difficult cases, that may explain the counterintuitive result · They acknowledge assessing only quantity of experience, not quality
Asian-Americans - Considerations
(Berman & Shopland, 2005) diverse, with over 60% being foreign-born. o Problems: The "model minority" myth, based on academic and occupational "excellence" harms the group as a whole, both by pressuring children and families to conform to the standard (with shaming if unable to reach the standard due to the collectivist outlook). Acculturation difficulties form a large gap between parents and children, with hierarchical, patriarchal relationships and authoritarian parenting styles valued. Children are expected to remain polite and calm. This group is most likely to underutilize mental health care, out of the disgrace in admitting emotional problems and the belief in handling such problems within the family. Problems may present psychosomatically, consistent with the holistic view of the mind and body being inseparable. o Disconnection: client expecting concrete goals and strategies for treatment, a preference for the therapist to take an active role, and issues with discussing emotions (Sue & Sue, 2012).
Elderly - Considerations
(Berman & Shopland, 2005) o Problems: High suicide rates. Often, competency issues are necessary, in which case respect must be shown to the individual. Therapy should be slowed and the therapist should be aware of medications that may have an impact on mental symptoms. They may need guidance to deal with sense of attachment to belongings and people as they near the end of their lives.
Low SES - Considerations
(Berman & Shopland, 2005) o Problems: higher rates of depression, lack of access to services and resources (housing, healthy foods, healthcare), and poorer educational achievement. It may be harder for parents in Low SES households to be involved in their child's schooling (less time spent with children in general), as they are working a lot. They are more likely to live in dangerous neighborhoods and experience environmental racism (toxic/environmental hazards).
LGBTQ+ - Considerations
(Berman & Shopland, 2005) o Problems: may begin experiencing same-sex attraction between ages 8-10, which can result in loss of social support, not being taken seriously, or significant victimization. In some instances, conversion therapy may be requested. Suicide attempts, homelessness rates, and substance abuse are all higher among LGBT individuals. However, the psychologist should not assume that the problems are related to sexuality
African-Americans - Considerations
(Berman & Shopland, 2005) o Problems: self-esteem, suspensions, incarceration, or academic performance. o Strengths lie in a strong sense of community via religion and/or family, matriarchy, and support of assertiveness o Disconnection: Potential sources of disconnection with a majority therapist or other minority therapist include possibly coming from a lower social class than the clinician, differences in dialect, emphasis of short-term goals, and a belief in oppression (Sue & Sue, 2012).
Native Americans - Considerations
(Berman & Shopland, 2005) o Problems: substance abuse and violent crime. Direct eye contact is avoided and direct questions are not asked. Emphasis is placed on living in the present and not future, which may perpetuate poverty. Public displays of affection are limited, children are prized, and aging/life accomplishments establish status in the tribe. o Strengths: include a strong sense of identity tied to living on their ancestral land, a belief that good is stronger than evil, and bravery, fortitude, and wisdom o Disconnection: Present focus and a distrust of "Western" forms of healing, including psychotherapy (Sue & Sue, 2012).
Age and generational influences
(Berman & Shopland, 2005) o This includes Piagetian stages of development and problems related to aging individuals.
Latinos - Considerations
(Berman & Shopland, 2005) · diverse and often define themselves by country of origin. o Problems/Strengths: It is a collectivist culture, with a strong sense of hierarchy and respect for authority, with familismo placed over the personal needs of the individual. The Catholic church and gender roles (machismo and marianismo) may play a strong role. Parents are less likely to push children through developmental stages and personalismo (interpersonal friendliness) is emphasized. o Disconnection: Assumption that the therapist will solve their problems as an authority figure and a focus on solving short-term problems (Sue & Sue, 2012).
Beutler et al's (2004) Observable Traits
1. Therapist Sex: significant but small effect size favoring female therapists, but generally gender does not appear to contribute to outcome. Female better outcomes for LGBT clients. 2. Therapist Age: partially confounded by experience, but there appears to be a weak relationship between age and outcome. 3. Therapist Race: Most research assumed outcome is better when client and therapist share ethnic background and this is based on face validity, but this is unsupported. Studies found significant effect of patient-therapist ethnic similarity, but the effect is small and could be due to moderators.
Ethics Code: Law
APA, 2003 · Violations of the ethics code are not necessarily equivalent to violations of the law, but this depends on the state. · Psychologists have a duty to meet the higher ethical standard, but if ethical responsibilities conflict with the law, the psychologist must make known their commitment to the Code. Legal advice should also be sought in such instances · In legal cases, a subpoena (a legal document) requires that the psychologist provide documents or give testimony. o The psychologist may assert privilege on behalf of the client until the client consent or they are ordered to by the court. - Privilege: bars disclosure of confidential information in legal proceedings and can only be asserted by the client - Confidentiality is the duty not to disclose information about a client · In cases of sudden death or illness, it can be helpful to have a designated co-therapist to provide referrals and store client records. · Collecting overdue bills or giving a third party who is paying for therapy legal rights should be agreed upon at the outset
Overview of Treatment Planning
APA, 2006 · Involves setting goals and tasks of treatment collaboratively with the client. · It should consider the client's problems, prognosis, expected benefits, worldview, sociocultural context, and available resources. · The therapist must know the research that supports effectiveness of certain treatment interventions and relevant research to match interventions to patients.
10.09 Interruption of Therapy
APA, 2010 · Psychologists make reasonable efforts to provide appropriate resolution of care in the event that the employment or contractual relationship ends, with paramount consideration given to the welfare of the client/patient.
10.10 Terminating Therapy
APA, 2010 · Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service. · May terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship. · Psychologists provide pre-termination counseling and suggest alternative service providers as appropriate.
Boundaries/Sexual Intimacies
Barnett, 2014 · Exist in psychotherapeutic relationships to provide a sense of safety to the client · Although most boundaries permit some degree of flexibility, the manner in which the therapist engages with them can have serious consequences. · Avoiding a boundary: never engaging in the behavior (never touching client). · Boundary crossing: transgression that is not considered appropriate (shaking hand or hugging client). · Boundary violation: behavior that holds significant potential for harm or is unwelcomed by the therapist (sexual relationship). · The psychologist must consider several things: (1) the client's presenting problems, (2) their own intent, (3) whether the client welcomes the action or not, (4) psychologist's theoretical orientation, and (5) diversity issues · Sexually intimate relationships: originally conceptualized as a mismanagement of countertransference on the part of the therapist. · Rigid approach to boundaries can at times be destructive · Recommended: peer consultation to discuss boundary issues
Empathetic Comments
Berman and Shopland, 2005 Attempt to tell clients that their perspective is understood and valued. It validates the client's experiences Give the client emotional support and let them know that you understand
Interviewing Skills
Berman and Shopland, 2005 Attending Behavior (verbal and nonverbal) Open-ended questions Reflective listening Empathetic comments Summarizing Redirection Supportive Confrontations Process Comments
Process Comments
Berman and Shopland, 2005 Comments about the process that is occurring between the therapist and client (i.e. "in the room"). a. Process of how the client is relating to others and/or to the interviewer b. May help to clarify interpersonal patterns across relationship
Supportive Confrontation
Berman and Shopland, 2005 Confrontational remarks (surrounded by affirming statements) that bring attention to the negative consequences of the client's behavior. They should be specific and concrete.
Compatibility Matching Criteria
Beutler & Clarkin, 1990 Part of step 3 of the STS model: relationship variables i. Demographic similarities (age, gender, ethnicity, SES) aid in initial development of trust and alliance. Not as related to outcome as interpersonal attitudes. ii. Interpersonal Response Patterns 1. personal strivings Contrasting views are best. E.g. dependent clients with therapist who value autonomy, and autonomous client with affiliative therapists. 2. Beliefs: shared humanitarian and intellectual values, but discrepant views of personal safety and the value of interpersonal intimacy/attachment 3. Attributions: area of control most important. Similarity of attributed locus of control --> strong alliance
Relationship Enhancement Skills
Beutler & Clarkin, 1990 Part of step 3 of the STS model: relationship variables i. Role Induction Methods: educating clients about treatment roles and therapy before therapy begins by: 1. instructional method: direct information about therapy 2. observation/participatory learning: Pre-therapy modeling or practice. Videos or audiotapes to introduce basic elements of therapy. 3. treatment contracting: ranging from signed contracts to requiring the patient to deposit money as a contingency for achievement of goals. Help establish treatment as a collaborative experience. ii. In-Therapy Environment Management 1. Nonverbal styles: touch (suggested for emotional arousal, those with high affiliation needs, or between female therapist and client interactions). Prolonged gaze (contraindicated, as is touch, for two male members of the therapeutic dyad, especially if reactance level or competitiveness is high. 2. situational stimuli: the use of open or private spaces, seating arrangements, physical distance. Open spaces are contraindicated for SI or HI clients, while close proximity is contraindicated when initially forming a therapeutic relationship. Among the overcontrolled and emotionally insulated clients, physical distance and seating is used to increase arousal levels. 3. verbal behavioral styles: verbal activity level is dictated by patient disturbance level and verbal facility. Generally want to be close to matching verbal activity. High therapist activity is contraindicated for clients with few verbal skills or those who are extremely distraught or agitated.
Step one of STS Model
Beutler & Clarkin, 1990 Predisposing Client Variables: STS focuses less on diagnostic conclusions and more on patient predisposing variables in regards to treatment planning because the research suggests that the most powerful influence in effective treatment planning is the characteristics of the client. a. Functional Impairment (intensity of tx): family problems, social isolation, and supportive relationship. b. Coping Style (intervention selection): presence of externalizing (acting out or placing responsibility on environmental factors) and internalizing (passively react and turn inward) coping styles. i. Behaviorally and symptom focused for externzalizers ii. Conflict-focused for internalizers c. Resistance Level (relationship variables) involves one's inclination to respond to interpersonal influence oppositionally. i. Directive for low resistance ii. Non-direct style for high resistance d. Subjective Distress (prognosis and intervention) involves how bad the client is feeling, and can be trait-like or state level. i. Persistent emotional traits = poor prognosis ii. acute emotional reactions = good prognosis
Step four of STS Model
Beutler & Clarkin, 1990 a. Selecting focal targets of change: decide on main areas that need change. i. Symptomatic: patients with a simple unidimensional symptom or situation-specific problem, the treatment focus is one on behavior that define the problem ii. Conflictual: patient with complex problems, treatment foci are conflicts, but this approach is most likely to succeed if a symptom focus is first initiated. b. selecting levels of intervention: level of depth i. Symptom focus: in patients with low complexity, considerable flexibility in selecting procedures. CBT procedures common at this level ii. Conflict focus: if externalizer, use CBT as above, if internalize, use experiential/expressive procedures (EFT) such as two-chair. c. determining mediating goals: steps between now and goals. d. conducting therapeutic work: monitor and adjust as necessary. Indirect/direct observations and self-disclosure are techniques suggested to increase therapist's ability to recognize these ever changing moments. e. maintenance and relapse prevention. May benefit from booster sessions
Systematic Treatment Selection (STS) Model - Overview
Beutler & Clarkin, 1990 · Form of eclectism that provides systematic guidelines for developing and planning treatments using empirically founded principles of psychotherapy. · This stems from the common factors approach in psychotherapy, where accumulating evidence points to no single theory as more effective than others, and common factors shared among the various theories. · Four step to guide effective treatment planning 1) Predisposing client variables 2) Treatment Context 3) Relationship Variables 4) Intervention Selection
Client In Psychotherapy - Attendance
Bohart and Wade, 2013 o Associated with a number of predictors. Lower SES, ethnic minority status, older age, being male, fear of stigma, and ego-syntonic individuals are less likely to attend therapy regularly. o Early termination linked with certain diagnoses (personality disorders, eating disorders, sexual offenders, and psychopaths) and personality traits (resistance, impulsivity, hostility, and low motivation). o Educating clients about the duration of therapy may lead to reduced early dropout, specifically that the effects of therapy take time to occur. o Some early responders show significant positive change within a small number of sessions, and early dropout may be linked to their early reaching of goals. o Clients may also drop out due to not being happy with the therapy (progress, relationship with the therapist), as well as because of life-interfering circumstances (transportation, scheduling issues)
Client In Psychotherapy - Pathology and Relationship
Bohart and Wade, 2013 o Clients with higher initial levels of distress may show the most change, but they do not necessarily achieve the most positive outcomes. o Clients with comorbid problems are less likely to do well. PD comorbidity almost uniformly predicts poorer outcome
Client In Psychotherapy - Demographics
Bohart and Wade, 2013 o Results are generally inconsistent with regard to the relationship of demographic variables to outcome. Little evidence exists of a relationship between either SES or ethnicity and outcome. o Social support has a weak relationship to outcome, but social support makes some differences for some.
Client In Psychotherapy - Therapeutic Alliance
Bohart and Wade, 2013 o The relationship is one of the most helpful aspects of therapy o Client's rating > therapist ratings. o Clients prize "therapeutic presence", the ability of the therapist to remain completely in the moment. Clients being "present" and "real" bring about similar responses in the therapist. o Clients of ethnically diverse backgrounds reported better experiences when their therapists acted with awareness of the impact of ethnic differences in the relationship. Their perceptions of the therapists' multicultural awareness and sensitivity are positively correlated with the alliance. o Clients found it more important that the therapist was trained to address spiritual matters openly and nonjudgmentally than to have a match o Clients are generally mistrustful of confrontational therapists, unless the client was being manipulative or avoiding certain topics, in which case they appreciated the input. o Client being "present" and "real" bring about similar responses in therapist o Clients vulnerability/pain à therapist empathy o Client optimism/hope à therapist hope o Client's given feedback about progress --> some improve and some deteriorate o Positive change may still occur even if the client's and therapist's theories of the origins of the problem differ o Clients are IVs to outcome, not just DVs influenced by therapy
· Behavioral assessment
Common component of intake/assessment interviews o Behavior: cognitive/physical events observable motor responses, and thoughts, expectancies, environment(s) reaction, and interactions, observable behaviors o Is behavior due to unseen characteristics? What effects behavior o Specific behavior measurement: how does it manifest (where and when?), response contingencies (reinforcements)? Multiple informants, multiple parameters (rate, duration, intensity, etc.), multiple methods o Behavioral self-monitoring more reliable than retrospective (memory problems)
Resistance to Cultural Competence and Interventions (Sue et al., 2009)
Concerns of resistance and Interventions Resistance o Are CC proponents stereotypic ethnic minority groups? What about people who are fully acculturated? o Are we discriminating against or ignoring other diversity factors like gender, sexual orientation, and social class? o Is the role of culture in mental health overemphasized? May be ignoring important intrapsychic conflicts responsible for their condition o Is the emotional and political context of the debate creating incivility? Those who deemphasize CC seen as immoral when it may be justified Interventions o Different methods of delivery: language, translating materials, varying interpersonal style, providing cultural context o Different content: focus on cultural experiences and background o Specific tailored interventions: techniques (storytelling for Hispanics), adapting approach (family therapy and respecting cultural beliefs about family structure), and culturally adapted manuals (CBT)
Plan Formulation Method: Goals
Gazzilo, Dimaggio & Curtis, 2019 Goals: the clinician aids in developing developmentally appropriate, adaptive goals. These may be broad or specific. Therapists should be aware that patients may be ashamed to admit goals they find to be too abstract or ambitious, so some coaching and inference is required on the therapist's part. Goals should be agreed upon and presented in regular language, free of jargon, so as to be understandable and achievable by the client.
Plan Formulation Method: Integration
Gazzilo, Dimaggio & Curtis, 2019 Integration: Each goal is associated with an obstruction, each obstruction with a trauma causing it, the tests that could be used to address it, and insights as to the nature of the trauma's impact
Plan Formulation Method: Obstructions
Gazzilo, Dimaggio & Curtis, 2019 Obstructions: the pathogenic beliefs or schemas that prevent the client from achieving those goals. These may be noticeable or automatic, requiring more exploration. Using an if-then format helps to identify obstructions - "if you didn't believe this person needs you to survive, you could take more time for yourself." Traumas: not trauma in the DSM sense, but rather the adverse relational
Plan Formulation Method: Tests
Gazzilo, Dimaggio & Curtis, 2019 Tests: patient behaviors meant to prove/disprove maladaptive schema's. These are largely dynamic in nature. - Transference tests involve the patient behaving in a way towards the therapist to gauge whether their assumptions of negative reactions are true - Passive-into-active Tests are when the patient responds to the therapist the way they wanted others to respond to them.
Plan Formulation Method: Traumas
Gazzilo, Dimaggio & Curtis, 2019 Traumas: not trauma in the DSM sense, but rather the adverse relational experiences that lead to obstructions. For example, frequent hospitalizations as a child may lead a person to assume their health is always a problem, then comes health anxiety
EBP Supporters on Common Factors
Generally accept that common factors are highly relavant/important, but... o A Critical review of the Wampold meta-analysis, pointing out that a number of the studies referenced were in fact comparisons of different CBT types (Crits-Cristoph, 1997). - Of the remaining studies, the majority did find differences between therapeutic families o Some therapies have been found to be better than others in the treatment of certain disorders (Chambless & Hollon, 1998).
Countertransference
Hayes, Gelso, and Hummel, 2011 · Countertransference is a therapist's internal and external reactions to a client that are influenced by the therapist's personal vulnerabilities and unresolved conflicts. · Therapists with high self-insight, empathy, and anxiety management have been found to be better at dealing with problematic reactions. Therapists who successfully manage their CT can use their reactions to gain a better understanding of their work with clients · Therapists' unresolved inner conflicts seem to be related to the likelihood of antitherapeutic effects of CT, which in turn are associated with poorer client outcomes. CT management can probably facilitate positive treatment outcome · Therapeutic Practices: o Therapists are encouraged to resolve such conflicts via personal reflection, supervision, or both o Manage internal CT reactions in ways that prevent them from manifesting them behaviorally in session o The clients may benefit from examined, thoughtful disclosures of countertransference in gaining a better understanding of the reactions they evoke in others
Intro Therapeutic Alliance
Horvath, Del Re, Fluckiger, & Symonds, 2011 · Definition: an emergent quality of partnership and mutual collaboration between the therapist and client. · It is built on: o Positive emotional bond between the therapist and client o Ability to agree on the goals of treatment o The establishment of a mutual consensus on tasks in therapy. · The relationship between therapist success and strong alliance (r=.275) is one of the strongest validated factors in therapy, and the correlation increases with the course of therapy. · The development of a good alliance is essential for treatment success, regardless of type of treatment. · Steps to build positive alliance o Actively monitor the alliance from the client's perspective because the therapist and client often judge the quality of alliance differently. - Alliance formulation is recurrent! o Respond non-defensively to a client's hostility or negativity. o Client's evaluation of the quality of the alliance is the best predictor of outcome · A client who is open, agreeable, extraverted, and conscientious is more likely to build a strong alliance. Not surprisingly, clients who struggle with interpersonal relationships, particularly clients with PDs, find it difficult to form a relationship with the therapist. · The therapist must be professional, friendly, empathetic, and flexible to support a therapeutic alliance.
· Cultural-Related barriers to accessing treatment
Huey, Tiley, Jones, & Smith, 2014 (1) differences in help-seeking attitudes and behaviors (2) clinician bias in the diagnosis and evaluation of mental health problems (3) discrepancy in treatment expectations between client and clinician
Effectiveness and ethnicity
Huey, Tiley, Jones, & Smith, 2014 Does not differ substantially by ethnicity: · Approximately 60-70% of randomized trials or meta-analyses that examined ethnic differences found no significant moderator effects. o Results appear to support an "ethnic invariance" perspective, that certain treatments may favor white participants under some circumstances, but ethnic minorities under others.
Skills-based model
Huey, Tiley, Jones, & Smith, 2014 cultural competence is reflected in providers' cultural self-awareness and knowledge of other cultures (not much research) - Awareness of their own assumptions, values, and biases - Understanding of the client's worldview - Ability to develop culturally appropriate interventions
Adaptation model
Huey, Tiley, Jones, & Smith, 2014 systematic modifications to service delivery, therapeutic process, or treatment components (greatest research) - These modifications can be either at a surface level (changing superficial characteristics) or a deeper level (targeting cultural values and traditions). (Greatest research) - 8 dimensions of adaptation: 1) language (e.g., linguistic match) 2) persons (e.g., ethnic matching or discussion of racial issues) 3) metaphors (e.g., use of culturally familiar symbols and concepts) 4) content (e.g., incorporation and application of cultural knowledge) 5) concepts (e.g., presenting the problem in a manner that is consistent with the client's belief system) 6) goals (e.g., ensuring congruence between therapist and client goals) 7) methods (e.g., ensuring compatibility of treatment methods/procedures with the client's culture) 8) context (e.g., considering the impact of contextual processes).
Clinical implications of culture and EBT
Huey, Tiley, Jones, & Smith, 2014 · clinicians use EBTs as a line of treatment, adopting cultural elements only when it is already embedded in an existing EBT · Remember, evidence-based practice (3-pillars) involves patient characteristics, culture, and preferences!
Cultural Tailoring of Treatment
Huey, Tiley, Jones, & Smith, 2014 · recommended, it appears to only have a small effect on enhancing treatments and it is unclear whether they are more efficacious than untailored models. o Possible that tailoring is best for older, less acculturated individuals and that directly addressing cultural differences is helpful. o Congruence on treatment goals and using metaphors/symbols that match client worldview strengthens treatment efficacy o Incorporating client beliefs about symptoms, etiology, consequences, and treatment improves outcomes.
Beutler et al's (2004) Inferred Traits
Include therapist personality and values 1. Research is mixed. 2. Therapist well-being and freedom from distress has a positive, though modest, correlation with outcome. The role of therapist values remains unclear
Approaches to Ethics Code
Knapp et al., 2013 · Some rely too heavily on the Ethics Code (see it as law), while others disproportionately emphasize their personal beliefs and treat clients like they were friends. · Both extremes can have serious negative consequences à strive for balance
Efficacy
Lambert 2013 Determined by RCTs when variables are controlled
Monitoring Progress in Therapeutic Practice
Lambert and Shimokawa, 2011 · Recommended to use real-time client feedback to monitor client responses to psychotherapy and satisfaction with the therapy relationship to improve psychotherapy outcomes, specifically for clients for are at risk for deterioration or dropout. · This can compensate for the therapist's limited ability to accurately judge possible treatment failure (Hatfield et al., 2010) o Strong evidence that clinical judgements are usually inferior to actuarial methods. Therapists' confidence in their clinical judgement is a barrier to implementation of monitoring and feedback systems. · Caution is advised for clients who are motivated to understate/overstate their problems and produce inaccurate ratings on feedback systems because the systems are predicted on accurate self-reporting. · Supplement with clinical support tools, like problem-solving and decision-enhancement tools. · Electronic versions of feedback systems expediate and ease practical difficulties. · At-risk clients who used the OQ-45 were 70% better off than their counterparts · limited knowledge, limitations in training, burden on clients, and concerns regarding additional work and time
Does efficacy research generalize to applied settings?
Lambert, 2013 o Efficacy research often generalizes to applied settings, but the degree depends upon how similar the trial settings are to clinical settings. - In real life, therapists may not stick with specific guidelines of a therapeutic technique, making that technique less effetive o Efficacy studies emphasize the internal validity of experimental design o Effectiveness studies emphasize the external validity of the experimental design and attempt to demonstrate that the treatment can be beneficial in a clinical setting. o RCT's can, but don't always generalize to clinical settings; it depends on the degree to which studies are similar in design to the RCT. The more they depart from what is done in the RCT, the smaller the impact of treatment is compared to the RCT. o Comorbidity of disorders may be a key reason that effectiveness does not match efficacy, as comorbidity is usually ruled out in clinical trials.
Do patients ever get worse?
Lambert, 2013 o Yes, sometimes clients can get worse in therapy. o Deterioration: worse at the end of therapy than at the start - Causes: inept application of treatment, negative attitudes, or a poor combination of treatment technique and patient problem o 5-10% of adults and 14-24% of children deteriorate in treatment (Warren et al., 2010) o In the substance use treatment literature, client deterioration has usually been on the high end, averaging around 10% to 15%. o It does not mean that all instances of worsening are the product of therapy, as there may be events outside the control of therapy like losing a job or a loved one. o Recommendation: OQ to monitor patient's treatment response - Deterioration: OQ increased by 14 points (margin of error) - Recovery: OQ score under 64. An early responses is a good indicator for therapy (2-3 sessions)
Do patients make changes that are clinically meaningful
Lambert, 2013 o Yes; shown using the OQ Reliable change index (14 point decrease; 35%) o Belief that these gains are typically maintained. o 25% of therapy clients relapse vs. 50% of medicated patients. o Psychotherapy can cause people to utilize less medical services
Mataanalyses in the CF/EBP debate
Lambert, 2013 · critical in the field of outcome research, but there are threats 1) File drawer: tendency for studies of no effect to never get published 2) Garbage in, garbage out: mixing poor-quality and high-quality studies 3) Apples and oranges: wrongly combining studies of different phenomena
Insurance Companies' Role in EBP/CF
Lambert, 2013 (surprise!) o Lambert argues that companies should reimburse therapy more than medication management because even though both are effective, relapse rates are higher among individuals who only received medications o Medications may be more effective for chronic and severe problems o Companies should be careful to cover enough sessions (eight is too few)
Reluctance to implement EBT
Lilienfield et al., 2013 1. Naïve realism, or the belief that the presentation of the world is an accurate representation for how it really is, makes clinicians overvalue their unguided intuition. A more intuitive thinking style associated with naïve realism. 2. Disproven myths about human nature may serve to foster belief in outdated techniques (e.g., hypnosis or dream interpretation). 3. Application of nomothetic research to idiographic cases is always flawed. Moderators can help to identify specific subgroups who will be helped or harmed in regards to treatment. Effective science reduces uncertainty in our generalizations. 4. Not yet been disproven, it must be correct. Absence of evidence does not equate to evidence of absence 5. Eight mistaken assumptions 6. Five pragmatic concerns
Eight mistaken assumptions of EBP
Lilienfield et al., 2013 1. Stifles innovation: Doesn't prevent development of new interventions. 2. "One-size-fits-all" response: Practitioners should follow the blueprint and rough guidelines, but also be flexible with individualized treatment 3. Excludes common factors: EBP does not exclude these 4. "Dodo Bird Verdict: Unnecessary because all treatments are equally effective. Behavioral and cognitive treatments shown to be more efficacious. 5. Neglects evidence other than RCTs: Includes other forms 6. Does not generalize: Specifically to individuals who have not been examined in controlled studies à some is better than none 7. Therapeutic changes cannot be quantified. There has been an increase in the development of well-validated implicit measures 8. Human behavior is impossible to predict. Possibility of substantial main effects of certain treatments relative to others. We can make reasonable generalizations.
Client-Therapist Matching
Matching client with a therapist on cultural variables and personality style may help in developing working alliance, depending on patient characteristics and values. This matching should be done genuinely and honestly. If not possible to culturally match, create pseudo-match (Beutler et al., 1994). o To do this, the therapist must educate themselves about issues relevant to client that they are unaware/under-aware of (Sue & Sue, 2012). o The information in based on groups of people, not individuals. It is important to avoid assuming all clients from ethnic groups are the same/have had identical experiences. o Therapists must do their best to educate oneself about issues relevant to the client to the best of their ability and also to ASK clients how they self-identify, as they are EXPERTS in their own cultural issues o Ask clients how they perceive you and what differences they perceive exists that may hinder development of good working relationship. o Differences in communication style can hinder your ability to help a client, and admitting this can lead the client to perceive you as more trustworthy (Sue & Sue, 2002).
Interviewing - Biopsychosocial Model
Meyer and Melchert, 2011 · Intake assessment is a critical component of mental health treatment, where the information is analyzed and integrated in order to inform diagnosis, case conceptualization, and course of treatment. Bio: genetic risks, drug effects, current health problems, TBI Psycho: Coping skills, social skills, family relationships, self-esteem, mental health Social: social support/network, family circumstances, work/school stress, living situation · The model was introduced by Engel in 1977 in response to the prevailing biomedical approach that influenced medicine. He stated that by ignoring important psychological and sociocultural factors, the biomedical approach mistakenly implied that disorders resulted from a single cause and not multiple factors.
Partners for Change Outcome Management System
Miller et al., 2005 PCOMS is another valid and reliable measure to assess client treatment response. It includes the Outcome Rating Scale to determine change between sessions and the Session Rating Scale, given at the end of a session to assess client response to each session. May be more valuable than the OQ in monitoring the alliance due to inclusion of the SRS.
Repairing Alliance Ruptures
Miller-Bottome Talia Safran Murran, 2018 · Episodes of tension or breakdown in the alliance. Exploring and repairing alliance ruptures when they occur can be an important element contributing to positive treatment outcome. · Therapeutic Practices o Rupture-repair episodes are positively related to therapy success. Rupture resolution training/supervision leads to small but statistically significant patient improvements o It is important for the therapist to be attuned to ruptures in the relationship and to take the initiative in exploring what is transpiring during ruptures and repairing them. o It can be helpful for patients to express negative feelings about the treatment to the therapist should they emerge or to assert their perspective on what is going on when it differs from the therapist. o When ruptures occur, therapists should respond empathically and accept responsibility for their contribution, as opposed to blaming the client for misunderstanding or distorting.
Beginning of EBPs and Results
Munder et al., 2019 · Hans Eyseneck wrote a seminal article about the ineffectiveness of psychoanalytically-oriented psychotherapy and this surged the conceptualizations of psychopathology to become more empirical and specific. However, his conclusions were based on weak evidence. · Success of EBPs: (1) greater understanding of the nature of psychopathology, resulting in new, more targeted treatments: (2) clinical research methods have improved, like designs, ruling out threats to validity, and including common factors; (3) health care and government are adopting and promoting EBPs due to strong evidence supporting them. · Despite the progress of EBT research, clinicians are not utilizing them to the extent that they should, and off-label pharmacological treatment use has skyrocketed.
Evidence-Based Therapy Relationships
Norcross and Lambert, 2011 · The therapy relationship makes substantial and consistent contributions to patient success in all types of psychotherapy. · Therapy relationship: "The relationship is the feelings and attitudes that therapist and client have toward one another, and the manner in which these are expressed." · It accounts for why clients improve in therapy similarly to treatment method. · Practitioners should routinely monitor patients' responses therapeutic relationship · Attempts to promote best practices need to describe this relationship
Culturally-adapted Interventions
Norcross and Wampold, 2011 May be helpful, but many studies have methodological problems that make results difficult to interpret (Bohart & Wade, 2013). However, one study did find that there was an advantage to receiving culturally adapted treatments (d=.46). This may involve using the client's preferred language and matching clients with therapists of similar ethnicity/race
Coping Style
Norcross and Wampold, 2011 affects the best orientations used 1. Internalizers: interpersonal and insight-oriented treatments as they tend to blame themselves and withdraw more 2. Externalizers: symptom-focused and behavior skills/skills building treatment as they act out
Evidence-based Practice
Norcross and Wampold, 2011 · "the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences" · The patient, therapist, and research need to be alignment
Religion
Norcross and Wampold, 2011 · incorporating their beliefs into their experience is equivalent or superior to no incorporation. Therapist's open/ nonjudgmental attitude most important.
· Ethical Issues for Feminist Therapists
Rave & Larson, 1995 · Cultural Diversities and Oppression: accessible to diverse population, aware of own background, and evaluate bias/discrimination · Power Differentials: acknowledge and educate clients on their rights · Overlapping Relationships: Sensitivity; monitor relationship; no sex · Therapist Accountability: practice within limits of competence, current on therapy and practice, recognize personal and professional needs, and self-care · Social Change: evaluates other practices and intervene if necessary; seek avenues of change
Smith and Glass, 1980 and Lipsey and Wilson, 1993
Seminal meta-analyses that showed the positive effects of psychotherapy The size of treatment: effect size approximately .60; 65% of treated patients vs. 35% on waitlist will have a positive outcome
EBP conceptualization: Three legged stool
Spring et al., 2007 1. Research-based evidence on a therapy's efficacy and effectiveness. Certain questions in the field require certain kinds of research evidence, so methodology used to demonstrate effectiveness may vary based on the question being answered (RCTs vs. Case Studies) 2. Clinical judgment and experience. Informed by scientific data, but requires competencies in delivering particular practice. Controversy due to issue of clinical "opinion" or "unquestioned intuition" The great controversy here is due to the issue of clinical "opinion" or "unquestioned intuition." 3. Client preferences and values is the least developed. We must achieve two things a. depart from a paternalistic care model b. make progress towards a more culturally informed shared model of care
Assessment Interview Structures
Suhr, 2015 · Exploratory vs. diagnostic; Directive vs. flexible Unstructured o Pros: more versatile, rapport building, tailored to specific problems. o Cons: no reliability/validity, Not as useful for diagnosis, Depends on clinical skills, open to bias and halo effect, and attribution bias. Structured o Pros: psychometric data, diagnostic criteria, can be fast, more standardized à less bias, greater coverage of specific areas o Cons: lack of flexibility, may miss specific client info, and can be time consuming Semi-structured (best option) o Begin with broad-open ended question (hear own take on problem, client's priorities and perspective, assess how they respond to unstructured, opportunities to build rapport) o Ask more targeted questions (intermediate directness, clarification, request examples, define their "terms", how symptoms effect client, reflect to ensure understanding, confrontation of inconsistencies may be necessary, probing questions to determine level of insight, use empathy, listening skills, summarizing. Narrow questions (frequency, intensity, duration, setting/context)
Henson, Peck & Torous, 2019
There is insufficient evidence on the therapeutic alliance for digital platform therapy and this is a massive empty space. It may make the relationship less effective and therefore detract from overall outcomes, or it may allow clients to work from safe areas and actually help. We don't know.
Patterson Silver Wolf et al., 2019
There is, at the very least, sufficient evidence to suggest that demographic matching might be beneficial for the treatment of substance use disorders. Jury is still very much out, but it is worth pursuing.
Behaviors not conducive to therapy
Wampold and Norcross, 2011 o Confrontational style o Negative processes (attacking the client instead of their behaviors) o Assumptions of client's perceptions of the therapeutic relationship and treatment progress o Therapist-centricity (overreliance on therapist's perspective) o Rigidity of treatment o Inappropriate imposition of the uniform treatment; ignore the client's unique needs.
The Contextual Model of Common Factors
Wampold, 2015 There are three pathways through which psychotherapy produces benefits. That is, psychotherapy does not have a unitary influence on patients, but rather works through various mechanisms. The mechanisms underlying the three pathways entail evolved characteristics of humans as the ultimate social species; as such, psychotherapy is a special case of a social healing practice. Pathway One - The Real Relationship: the personal relationship between therapist and patient marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that befit the other. Pathway Two - Expectations: The burgeoning research on the effects of placebos documents the importance of expectations, as placebos have robustly shown to alter reported experience as well as demonstrating physiological and neural mechanisms. Pathway Three - Specific Ingredients: Though these change between therapies, they all share the common trait of promoting salubrious action.
Outcome Questionnaire-45
Whipple and Lambert, 2011 · Related specifically for therapist to assess changes in adult psychotherapy and to identify deterioration and improve patient outcome prior to treatment termination. · 45 self-report items designed for repeated administration throughout the course of treatment and at termination. 14 point margin of error (change of 14 = significant) · Conceptualized and designed to assess three domains of patient functioning: o Psychological disturbance (especially anxiety and depression) o Interpersonal problems o Social role functioning. · The Total Score is based on the subscale scores, as well as the three domains. · If the therapist gets information about what seems to be working/not working, the responsiveness to the clients will improve. · Most clients benefit from psychotherapy, but between 5% to 10% deteriorate after receiving services (Lambert & Ogles, 2004). · Clinicians are poor predictors of their patients' negative treatment response (Hatfield et al., 2010). o Most therapists believe they have excellent clinical judgment (Garb, 1998). · Client outcome can be improved when clinicians receive feedback about deterioration and use of clinical support tools in addition to feedback further enhances outcome. · More research is necessary for use with children and adolescents because children are two or three times more likely to deteriorate in therapy · Despite the fact that six studies demonstrate the effects of feedback on outcome using the OQ Measures System, there is a need for research that shows the boundaries of this effective practice.
DSM 5 Goals
o Goal 1: Miscellaneous categories and NOS diagnoses were to be trimmed - But, they actually increased the specificity of disorders, which increased the number of individuals that did not meet criteria. o Goal 2: Add dimensional measures of symptoms and severity (especially for PDs). This is more clinically useful and descriptive. o Goal 3: better align the DSM with the ICD 11 o Goal 4: It planned to reflect the most current scientific evidence.
Increasing Treatment Effectiveness
o Tailor the treatment: - Match the client's disorder with a particular treatment method - Match psychotherapy to the person, not just the disorder. - Different clients requires different treatments and relationships o Routinely monitor the client's response to therapy to improve upon the treatment strategy and therapeutic relationship. - increased opportunities to repair alliance ruptures, improve the relationship, modify technical strategies, and avoid premature termination. Wampold and Norcross, 2011
General Principles of Code of Ethics (APA, 2010)
· Beneficence and non-malfeasance: provides benefit, do no harm, self-care, and resolve conflict. · Fidelity and responsibility: establish trust, consult/refer, responsibility to community, and pro-bono work. · Integrity: honesty, keep promises, no unwise commitments, no stealing/cheating/lying/fraud. · Justice: good judgement, watch for bias, quality of service to all, work within competence. · Respect for the rights and dignity of others: rights to privacy, confidentiality, self-determination, and diversity.
Therapist Characteristics and Outcome (Norcross & Wampold, 2011)
· Don't really know! · Licensed psychologists obtained positive outcomes in fewer sessions, and that the most efficient therapist needed 6-7 sessions to help the client recover, while less efficient therapists needed 94 sessions (Okiishi et al., 2003). · The interpersonal skills of the therapists in the Okiishi study were examined and Facilitative Interpersonal Skills (FIS; the therapist's ability to respond to challenging therapy situations) and clinical outcomes were highly correlated. This could imply that the way the therapist reacts to challenging situations in therapy partly explains why some therapists are more effective than others (Anderson et al., 2009). · Many therapist effect findings seem related to common factors (Laska, Gurman, & Wampold, 2014). There is mounting empirical data that better outcomes are associated with therapists explaining the rationale behind the proposed treatment plan and how it fit with the client's presenting concerns, while making room for discussion and negotiation.
Kivilighan et al., 2019
· Failed to support the Good Enough Level model (Barkham, 2006) · A lot of people drop out prematurely due to fast progress early on. Does that mean they're recovered?
Larsson, Falkenstrom, Andersson & Holmqvist, 2018
· Good alliance = good outcomes · Ruptures only = bad outcomes · Ruptures + repairs = better outcomes (only in long-term therapy)
Miller-Bottome, Talia, Safran & Murran, 2018
· Insecurely attached clients respond poorly to ruptures, even when attempting to repair them
Ionita, Ciquier & Fitzpatrick, 2020
· Main reasons people don't use tracking measures like the OQ · limited knowledge, limitations in training, burden on clients, and concerns regarding additional work and time
Munder, 2019
· Said Cuijpers actually came up with a .7 effect size, which reduced to between .2 and .3 after controlling for bias · Suggested Cuijpers exclusion of wait-list controls turned the study into a comparative one, not an effectiveness study. Instead including "care as usual" and "other control" designs, but failed to define what that means · They also had unrealistic exclusion criteria (though this argument seems much more of a judgement call that the previous), and excluded non-western studies where the effects are typically higher (that's surprising) · Cuijpers gave them his/her (?) data and they calculated a .75 effect size vs wait list o Found no statistically significant differences between therapy types à Dodo Bird à Common factors wins again!
