Clinical Treatment

Acceptance and commitment therapy (ACT) pain= universal/normal and part of what makes us human". inflexibility causes probs, a "rigid dominance of psychological reactions over chosen values and contingencies in guiding action".

Clean pain, clean discomfort= natural levels of discomfort, inevitable and can't control. Dirty pain, dirty discomfort= suffering caused by attempts to control or resist clean pain. Tx: ^ flexibility, t foster acceptance, mindfulness, w/6 core processes: Experiential acceptance embrace of private experiences without unnecessary attempts to change their frequency or form. Cognitive defusion distance oneself from one's thoughts and feelings as experiences rather than reality. Being present counters attentional rigidity to the past and future and involves being in the present moment. Awareness of self-as-context counters attachment to the conceptualized self. view oneself as the context in which one's thoughts and feelings occur rather than as the thoughts and feelings themselves. Values-based actions counter unclear, compliant, or avoidant motives and depend on the ability to use one's freely chosen values to guide one's behaviors. committed action to continue to act in ways consistent with one's values in the future. Ix: metaphors, mindfulness strategies, and experiential exercises. for chronic pain, psychosis, depression, anxiety disorders, and obsessive-compulsive disorder.

Cultural Encapsulation:

inability of some mental health professionals to work effectively with members of different cultural backgrounds. insensitive to cultural differences and believe that their own cultural assumptions about what constitutes mental health or normality applies to people from all cultural backgrounds.

Structural Family Therapy: Minuchin's assumption Sx related to problems in the family's structure. Subsystems and Boundaries

Subsystems smaller units responsible for carrying out specific tasks. ie: parental subsystem consists of family members who are responsible for caring for the children. Boundaries are implicit and explicit rules that determine the amount of contact that family members have with each other. At one end of the continuum are boundaries that are overly diffuse and lead to enmeshed relationships; at the other end are boundaries that are overly rigid and lead to disengaged relationships. Midway between the two are clear boundaries that let family members have close relationships while allowing each member to maintain a sense of personal identity.

Prevention: Caplan's Model: three types of prevention: primary, secondary, and tertiary.

primary prevention reduce occurrence of new cases. entire population or groups, not individuals, may or may not be restricted to those known to be at elevated risk for the disorder. ie- ed @dep and suicide, preparatory program for fifth graders, prenatal care for low-income. is to reduce the prevalence of a mental or physical disorder in the population through early detection and intervention. Secondary preventions for specific indi w/elevated risk. ie- tutoring students w/ difficulties, testing to ID indiv at risk for depression and providing counseling tertiary prevention reduce severity/duration of a Dx. target those already w/a Dx and include relapse prev and rehab. Social skills training for patients with schizophrenia, halfway houses, and Alcoholics Anonymous are tertiary preventions.

Cross's Black Racial Identity Development Model: five stages:

1. Pre-Encounter: idealize White culture. neg att @ own culture and may view it as an obstacle and stigma. 2. Encounter: Q views B/W cultures from events that cause them to become aware of the impact of racism on their lives. interested in more connection to own culture. 3. Immersion-Emersion: reject White and idealize/immerse in own culture. 4. Internalization: race defensiveness and emo intensity decreases. pos Black ID and tolerate/respect differences. 5. Internalization-Commitment: internalized a Black ID and committed to social activism to reduce all oppression. Later combined internalization and internalization-commitment stages. then changed to Black Racial Identity Dev Model and reduced it to three stages, with each stage including multiple identity subtypes. The first stage is the pre-encounter stage (assimilation, miseducation, and self-hatred subtypes), immersion-emersion stage (intense Black involvement and anti-White subtypes), and internalization stage (Black nationalist, biculturalist, and multiculturalist subtypes).

Troiden's Model of Homosexual Identity Development: most fully realized when self-identity, perceived identity, and presented identity coincide; where an accord exists among who people think they are, who they claim they are, and how others view them". four stages:

1. Sensitization: childhood, feeling diff from same-sex peers. 2. Identity Confusion: middle/late adolescence, start to feel sexually attracted to ind of same sex and suspect they're gay=> uncertainty and anx, attempt to alleviate with denial, avoidance, repair (attempting to change), redefinition (viewing homosexual feelings as a phase), or acceptance. 3. Identity Assumption: person begins to accept identity, usually btw 19- 21 for males and 21-23 for females. seek out gay social and sexual relationships and disclose sexual orientation to gay peers and adults and some heter fam/friends. 4. Identity Commitment: internalized gay ID, accepted as a way of life, and comfortable disclosing to heteros: fam, friends, coworkers.

Positive Psychology:

"is about valued subjective experiences: well-being, contentment, and satisfaction (in the past); hope and optimism (for the future); and flow and happiness (in the present)". emphasis on scientific method PERMA model, the five essential elements of well-being: Positive emotions (P) refers to experiencing pleasure, hope, gratitude, love, and other positive emotions. Engagement (E) refers to being truly engaged in situations or tasks and is characterized by being in a state of "flow" - i.e., a state of being totally immersed in an activity accompanied by a high level of joy and sense of fulfillment. Relationships (R) refers to having positive and meaningful interpersonal relationships. Meaning (M) refers to being dedicated to a cause that's bigger than oneself. accomplishment-achievement (A) refers to striving to better oneself and accomplish one's goals.

Minuchin identified four rigid family triads, which are boundary problems that help parents obscure or deny their conflicts:

(a) A stable coalition occurs when one parent and a child form an inflexible alliance against the other parent. (b) An unstable coalition is also known as triangulation and occurs when each parent demands that the child side with him or her. (c) A detouring-attack coalition occurs when parents avoid the conflict between them by blaming the child for their problems. (d) A detouring-support coalition occurs when parents avoid their own conflict by overprotecting the child.

Beck's cognitive behavior therapy (CBT)

(a) Cognitive schemas core beliefs from childhood as the result of experience and bio factors. enduring, maladaptive or adaptive, and are revealed in automatic thoughts. diff Dx= diff maladaptive schemas, cognitive profiles.depression consists of neg beliefs about oneself, the world, and the future. (b) Automatic thoughts self-statements or mental images when triggered, pos or neg. Neg are distortion of reality, emotional distress, and/or interference with goals. Dysfunctional Thought Record (DTR) whenever they feel their mood is worsening. (c) Cog distortions systematic errors in reasoning, triggers a dysFx schema that affects automatic thoughts. Arbitrary inference neg conclusions w/o evidence. Selective abstraction attention to and exaggerating minor negdetail while ignoring other aspects. Dichotomous thinking classify events as representing one of two extremes . Personalization concluding actions caused an ext event w/o evidence. emotional reasoning using emos to=> conclusions @ oneself, others, and situations. Tx: correct faulty info processing and modify assumptions that maintain maladaptive behaviors and emotions. Cog techniques redefining the problem, reattribution, and decatastrophizing; beh techniques activity scheduling, beh rehearsal, and exposure therapy. collaborative empiricism, collaborative therapeutic alliance as coinvestigators Socratic dialogue, Qs to clarify probs, ID assumptions that underlie them, and evaluate consequences of maintaining them

Therapy focuses on promoting behavior change rather than insight and consists of three overlapping phases - joining, evaluating, and intervening:

(a) Joining establish a alliance with the family. relies on three techniques: Mimesis involves adopting the family's affective, behavioral, and communication style; tracking involves adopting the content of the family's communications; and maintenance entails providing family members with support. (b) evaluate to make a structural Dx and Ix. family map depicts the family's subsystems, boundaries, and other aspects of the family's structure. (c) Then: Reframing constructive reframing of a problematic behavior. Unbalancing: alter hierarchical relationships, when the therapist aligns with a family member whose level of power needs to be increased. Boundary making alter degree of proximity between family members. enactment: members role-play a prob for info for therapist about the interaction, then encourage family members to interact in an alternative way.

Narrative Family Therapy: probs= oppressive socially constructed stories which dominate the person's life. replace problem-saturated stories with alt

(a) Meeting family members: getting to know them separate from probs by asking about ADLs. (b) Listening: paying att to ID dom discourses and unique outcomes, "sparkling moments", experiences not consistent with problem-saturated stories. (c) Separating family members their problems involves externalizing the problems. (d) Enacting preferred narratives ID alt stories that lead to more satisfying realities and identities. (e) Solidifying strengthening alt stories collaborator and uses Qs etc to help family members identify current stories and construct alternative, healthier ones. externalizing questions help clients view their problems as being outside themselves opening space questions help family members identify unique outcomes. therapeutic letters to family members to reinforce their emerging alternative stories. Therapeutic certificates are given to family members toward the end of therapy to acknowledge their accomplishments. definitional ceremonies opportunities to tell others how they overcame their problems and celebrate changes

racial microaggressions indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color". three types:

(a) Microassaults explicit racial derogations usually intentional: name-calling and explicit discriminatory acts, "old-fashioned" racism. (b) Microinsults verbal/nonverbal, demean background. Implying that an AfAm employee was hired only because of affirmative action. (c) Microinvalidations "exclude, negate, or nullify thoughts, feelings, or experiential reality of a POC". Complimenting an Asian American on his "good English".

Transtheoretical Model: multiple approaches- strategies are most effective when they match the person's stage of change. six stages of change, and the primary goal of the first five stages is to help the client advance to the next stage (PC-PAM-T): (brief therapy)

(a) Precontemplation: no intention of taking action to change their behaviors in the next six months. denial about prob, unsuccessful attempts to change. resist advice/interventions, benefit from consciousness raising, dramatic relief (experiencing and expressing emotions), and environmental reevaluation (examining how the environment affects their behavior). (b) Contemplation: plan change in next six mo. ambivalent=> difficult to next stage. benefit from self-reevaluation (evaluating how they feel about the situation) in addition to the strategies that are useful for individuals in the precontemplation stage. (c) Preparation: plan to take action within next month. Tx: support decision to change and include self-reevaluation and self-liberation (believing that change is possible and making a commitment to change). (d) Action: taking action. Tx: contingency management, stimulus control, and counterconditioning. (e) Maintenance: after maintained for six months.Tx: relapse prevention, same strategies useful for individuals in the action stage. (f) Termination: confident their risk for relapse is low. motivation to change is 3 Fx: Decisional balance strength of beliefs about pros and cons of changing; most important determinant of motivation during the contemplation stage. Self-efficacy confidence about ability to change and avoid relapse. determinant of whether a person transitions from contemplation to preparation, then from the prep to action. Temptation is the intensity of the urge to engage in the undesirable behavior and is usually strongest during the first few stages of change.

Howard and Colleagues: relationship between duration of Tx and its outcomes. two models to describe this relationship: Dosage and Phase

(a) The dosage model (dose-effect)= predictable relationship btw # of sessions and probability of Sx improvement. predicts 50% exhibit a clinically significant improvement in Sx by six to eight sessions, 75% by 26 sessions, and 85% by 52 sessions. (b) phase model Tx outcomes in 3 phases, diffe measures should be used during different phases: remoralization first few sessions ^ in hopefulness. remediation phase, next 16 sessions, reduction Sx. rehabilitation phase "unlearning mal beh and est new beh.

Asian American

(a) consider etc (b) ID env (c) differences in acculturation within families may be a source of conflict; (d) view of mind and body and somatic Sx; (e) tend to be hierarchical/ patriarchal, traditional gender roles,fam over ind (f)fear of losing face and shame powerful motivators, may affect willingness to discuss probs (g) maintain a formal style during the course of therapy (h) periods of silence and avoidance of eye contact are expressions of respect and politeness. prefer CBT and other brief structured goal-oriented, problem-focused approaches that focus more on fam than the ind. expect the therapist to be expert, give advice and suggest specific courses of action while also encouraging their participation

American Indian

(a) consider the client's cultural ID, acculturation, worldview; (b) ID env contributors (c) incorporates the family, community, and tribe; (d) cooperation, sharing, and generosity important values and family/tribe over the ind (e) mind, body, and spirit and illness as the result of disharmony; (f) more emphasis on nonverbal than verbal, listening, direct eye contact sign of disrespect and a firm handshake as a sign of aggression; (g) collaborative by demonstrating familiarity with and respect for the client's culture and admitting any lack of knowledge. avoid directive. network therapy, which helps empower clients to cope with life stresses by mobilizing relatives, friends, and tribal members

Hispanic/Latino American

(a) consider the client's cultural identity, level of acculturation, and worldview; (b) ID env to Sx; (c) often express psychological symptoms as somatic complaints; (d) religious might relate; (e) emphasize family welfare over ind (f) may be patriarchal and stress machismo (male dominance) and marianismo (female submissiveness) (g) formal (formalismo) initially, more personal (personalismo) later. Ix: likely to prefer CBT, solution-focused, family, and group. incorporate culturally congruent techniques such as cuento therapy (the use of folktales to present models of adaptive behavior) and dichos (the use of proverbs and idiomatic expressions to help clients express their feelings).

African Americans:

(a) consider the client's cultural identity, level of acculturation, worldview (b)racism and other env factors contribute to Sx; (c)kinship=extended fam, church and community; (d) fam roles often flexible, egalitarian; (e) helpi acquire skills needed to control life. Ix: usually prefer egalitarian reland a time-limited, problem-solving approach. multisystems, intervening in numerous systems and at multiple levels that include family, friends, church and community social service agencies.

Acculturation: when members of a minority group are in contact with a majority group, one of four acculturation strategies, diff combos of retention/rejection of own minority culture and the majority culture:

(a) integration strategy retain their own minority culture and adopt the majority culture. (b)assimilation strategy reject their own minority culture and adopt the majority culture. (c)separation strategy retain their own minority culture and reject the majority culture. (d) marginalization strategy reject their own minority culture and the majority culture.

Gestalt Therapy:

(a) motivated to maintain a state of homeostasis, which is repeatedly disrupted by unfulfilled phys/psych needs, (b) seek something from env to satisfy unfulfilled needs to restore homeostasis. Neurosis (maladjustment): persistent disturbance in the boundary between the person and the environment that interferes with the person's ability to fulfill needs. Boundary disturbances: Introjection: adopt the beliefs, values of others w/o eval. Projection: attribute undesirable aspects to other people. Retroflection: do to themselves what they'd like to do to others; Deflection: avoid contact with the env. Confluence: blur distinction between themselves and others. Awareness of thoughts, actions is curative Fx. Tx: Dream work involves having the client role-play disowned, interacting w/opposing aspects of his/her personality (e.g., top dog and underdog) or to resolve "unfinished business" with a sig person from past or present. In contrast to psychodynamic, do not foster or interpret a client's transference but, instead, help the client distinguish between his/her "transference fantasy" and reality.

worldview is affected by culture and can be described in terms of two dimensions: locus of control and locus of responsibility:

(a)internal locus of control and internal locus of responsibility (IC-IR) in control of own outcomes and are responsible for own successes and failures. characteristic of mainstream American culture (b) internal locus of control and external locus of responsibility (IC-ER) could determine own outcomes given the chance but others responsible for keeping them from doing so. (c)external locus of control and external locus of responsibility (EC-ER) little or no control of outcomes and not responsible for them. (d)external locus of control and internal locus of responsibility (EC-IR) little control over their outcomes but tend to take responsibility for own failures.

Mental Health Consultation: four types of MH consultation. Each type consists of a triad that includes a consultant, a consultee (therapist or program administrator), and a client or program.

1. Client-Centered Case Consultation: focuses on a particular client of the consultee. The consultant provides a plan that will benefit the client. 2. Consultee-Centered Case Consultation: focus on consultee to improve ability to work effectively with current and future clients who are similar in some way - e.g., brain injury, specific racial group. Work on consultee's lack of objectivity. theme interference, consultee's biases and unfounded beliefs interfere with objectivity with certain types of clients. 3. Program-Centered Administrative Consultation: work with program administrators to clarify/resolve problems w/a MH program. The consultant's goal is to provide administrators with recommendations. 4. Consultee-Centered Administrative Consultatio: improve the prof Fx of program administrators so they're better able to develop, administer, and evaluate MH programs. MH consultation different collaboration in several ways. consultant has little or no direct contact with a consultee's client, not responsible for the client's outcomes. a collaborator usually direct contact and shares responsibility.

Atkinson, Morten, and Sue's Racial/Cultural Identity Development (R/CID) Model: how minority groups view members of their own minority group, other minority groups, and the majority group.

1. Conformity: neutral or neg att toward own and other minority groups and pos toward majority. accept neg stereotypes of own group and consider majority to be superior. prefer therapist of majority and attempts to help them explore their cultural identity is threatening. 2. Dissonance: after info that contradict their worldview, Q their att toward own, other, and majority groups.aware of effects of racism and interested in learning@ own culture.may prefer majority therapist but want them to be familiar with their culture. 3. Resistance and Immersion:pos att toward own group, conflicting att @ other minorities, and neg att @ majority group. Unlikely to seek Tx, bc suspicious. When do, likely to attribute their probs to racism and prefer therapist from own group. 4. Introspection: Q unequivocal allegiance to own group, concerned @ biases that affect their judgments of other groups. comfortable with their cultural ID, but also concerned about their autonomy. may prefer therapist from own group but consider therapist from another group who understands them, and they're interested in exploring new sense of ID. 5. Integrative Awareness: aware of pos/neg of all cultural groups.secure in their cultural ID, committed to eliminating all oppression and becoming more multicultural. preference based on similarity of worldview, and most interested in strategies aimed at community and societal change.

Helms's White Racial Identity Development (WRID) Model: two phases - abandonment of racism and defining a nonracist White identity. Each phase includes three statuses, and each status is characterized by a different info processing strategy (IPS):

1. Contact: lack of awareness of racism and satisfaction w/status quo. usually limited contact with minority groups, "colorblind." IPS: obliviousness. 2. Disintegration: become aware of contradictions that create moral dilemmas - all are equal yet unwillingness @ integrated neighborhood. cause confusion and anxiety. IPS: suppression and ambivalence. 3. Reintegration: attempted to resolve dilemmas by believing Whites are superior, blaming minorities for own problems. IPS: selective perception and negative out-group distortion. 4. Pseudo-Independence: faced w/event where Q their beliefs@ Whites and minoriteis. superficial tolerance of minoriteis, may be accompanied by paternalistic att and beh perpetuate racism. IPS: reshaping reality and selective perception. 5. Immersion-Emersion: search for personal meaning of racism and understanding what it means to be White and privilege. IPS: hypervigilance and reshaping. 6. Autonomy: develop a nonracist ID, value diversity, and explore issues without defensiveness. IPS: flexibility and complexity. progressive therapist-client relationship is optimal for the dev of pos alliance, when therapist has more integrated/flexible racial ID than client. research shows that White therapists with ^ racial ID also ^ levels of multicultural competence

Common Factors in Psychotherapy: attribute

30% of variability in psychotherapy outcomes to patient contributions, 12% to the therapeutic relationship, 8% to the treatment method, 7% to therapist characteristics, 3% to other factors, and 40% to unexplained variance.

Autoplastic vs. Alloplastic Interventions:

Autoplastic interventions changes so client can successfully adapt to the env; Ix: gain insight into probs or change his or her beh. Alloplastic interventions alter env or situation to fit the needs, desires, or other attributes. Removing oneself from a stressful situation - for example, by changing jobs

Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) Clients: more than twice as likely to have a mental Dx, esp anxiety, depression, and substance misuse

Coming out acknowledging/disclosing. Many report being aware from childhood, but median age for being aware of their sexual orientation is between 13 and 15. the more widely disclosed their sexual orientation to others, ^self-esteem and lower their anx. In contrast, in other study: disclosure associated with ^ in-school victimization and ^ higher levels of self-esteem and decreased depression. Internalized heterosexism (homophobia) neg about own orientation. component of stress linked to neg Sx. Tx: combining EB practices w/competent services. provide affirmative therapy: integrate knowledge of therapist n unique dev of LGBTQ ind, and translate to skills at all stages of Tx''. w/ CBT, distinguish between maladaptive thoughts and thoughts that reflect a normal response to stigma (a) Stigmatization: neg social attitude. can lead to prejudice or discrimination against the individual" Heterosexism (b) Recognize that same-sex attractions and beh are normal variants of human sexuality but avoid adopting a "sexual orientation blind" ignoring unique experiences (c) Consider own attitudes @LGB issues (d) Distinguish btw orientation, and aware may act in gender conforming or gender non-conforming ways. (e) Recognize tintersectionality

Economic Evaluation: Cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis are three methods of economic evaluation.

Cost-benefit analysis (CBA) compare costs and benefits of one or multiple interventions, both expressed in monetary terms. compared individual placement and support (IPS) and standard vocational rehabilitation: IPS produced a greater net benefit. Cost-effectiveness analysis (CEA) costs and benefits of 2+ Ix when benefits cannot be expressed as monetary values. comparing C/Bs of IPS and standard vocational rehabilitation. IPS was found to be more effective than vocational rehabilitation for all three benefits. cost-utility analysis (CUA) compares 2+ Ix on quality-adjusted life-years (QALYs), gain in the health-related quality and the quantity (duration) of life: Compared cognitive therapy (CT), rational-emotive behavior therapy (REBT), and fluoxetine (Prozac). CT and REBT both had greater cost-utility than fluoxetine but did not differ sig from each other.

Credibility and Gift Giving: credibility and gift giving important with Asian Am and others.

Credibility: Ct perception of the therapist as trustworthy, determined by therapist's ascribed and achieved status: Ascribed status: role assigned to the therapist by the client's culture. e.g., the therapist's experience working with members of the client's culture. Gift giving: direct benefits that a ct perceive from Tx. direct benefits must be given as soon as possible in Tx to help est achieved credibility and reduce premature termination w/rel btw therapy and the alleviation of the client's problems.

Evidence-Based Practice and Culturally Adapted Interventions:

Culturally adapted interventions "modification of (EBT) to consider compatiblity with cts culture; content that's culturally appropriate and relevant, altering treatment so culturally compatible. has created a "fidelity-adaptation dilemma", determines what degree they will adopt "standardized nomothetic scientific top-down approach that demands fidelity in its implementation and the idiographic casewise bottom-up approach that demands sensitivity and responsiveness to each person's unique needs" conclude that culturally adapted interventions provide benefit, more apparent in adults. (a) ^effective when involve adding features to an Ix than when they involve replacing a component of an intervention (b) most beneficial for who have the ^ need for them - ie, who are not fluent in English

Efficacy and Effectiveness Research:

Efficacy research studies clinical trials, maximize internal validity (the ability to draw conclusions about the cause-effect relationship between Tx and outcomes) by maximizing experimental control. effectiveness research studies maximize external validity (the ability to generalize study conclusion) w/ naturalistic Tx. Both approaches have strengths and weaknesses, and a useful strategy for evaluating treatment outcomes is to first conduct an efficacy study to determine a treatment's effectiveness in well-controlled conditions, and then conduct an effectiveness study in "real world" settings to determine its generalizability, feasibility, and cost-effectiveness

Healthy Cultural Paranoia: unwillingness to disclose personal information to a White therapist may be due to one of two types of paranoia:

Functional paranoia pervasive suspicion and distrust. An ethnic minority client with functional paranoia is unwilling to disclose to an ethnic minority or White therapist. healthy cultural paranoia also suspicion and distrust, but it's a normal reaction to prejudice and discrimination. self-disclose to an ethnic minority therapist but not to a White therapist unless certain conditions are met - i.e., the therapist discusses the meaning of the cultural paranoia with the client and encourages the client to distinguish between when it is and is not safe to self-disclose.

Inclusion and Exclusion Considerations: (Group therapy)

Group therapy best for "highly motivated, active, psychologically minded and self-reflective, self-disclose n capacity for interpersonal relationships". vs ppl suicidal, delusional, likely to incorporate the group into their delusions, or threat because unable to control impulses. antisocial PD do in homogeneous groups but not in heterogeneous groups

High- vs. Low-Context Communication:

High-context comm: group understanding, nonverbal messages, and the context in which the comm occurs and is characteristic of several cultural minority groups. low-context comm: verbal message, is independent of the context, and is characteristic of the White (mainstream) culture. probs when the therapist and client have diff comm: "the fact that AfAm may communicate more by HC [high context] cues has led many to characterize them as nonverbal, inarticulate, [and] unintelligent"

Older Adult Clients: mental disorders are lower among older adults than their younger and middle-aged counterparts

However, many experience MH prob diff from younger. Tx: comparable for older and younger adults but older maybe ^ slow and benefit most when Tx tailored to cognitive, sensory, and physical needs. (a) Consider own attitudes @ aging (b) Be aware that "the heterogeneity among older adults surpasses that seen in other age groups" and other factors may affect Sx (c) Be familiar with normal biological changes and to distinguish (d) older respond favorably to variety of Tx but some Ix particularly effective (e.g., CBT and reminiscence therapy for dep). (e) modifying Ix - slowing the pace of therapy; accommodating hearing loss by reducing ambient noise; and addressing physical illness, grief, cog decline, and other probs that are experienced more often by older than younger adults.

Interpersonal (IP) Psychotherapy: (brief therapy)

IP Fx contribute to Sx; med mod, views dep etc as treatable med illnesses; prim goals Sx relief and improved IP Fx. OriginallyTx for acute depression, now for BP, ED, etc. Tx 3 stages: (a) initial stage therapist determines Dx and IP context of Sx. This info identifies primary prob of Tx. For dep= IP role disputes, IP role transitions, IP deficits, and grief. this stage, clients assigned "sick role" to allow them to be ill without blaming themselves for their symptoms and to view their illnesses as temporary and treatable. (b) middle phase: strategies to address the problem area identified in the initial stage. Ie: encouragement of affect, role-playing, communication analysis, and decision analysis. (c)final stage: the therapist addresses issues related to termination and relapse prevention.

Internalized Racism and Colorism:

Internalized racism (oppression): accepts society's neg beliefs related to own racial group. Colorism (color consciousness): based primarily on skin color or hair texture and eye color. The use of skin-lightening products by people of color is a manifestation of colorism.

Mindfulness-Based Interventions: "moment-to-moment awareness of one's experience without judgment", the core strategy of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).

MBSR help cope with stress, pain, and illness and consists of an 8-session group program. MBCT = MBSR + CBT. effective Tx not only for depression but also anxiety, chronic pain, and insomnia. Tx: enable clients to become self-aware, so they can learn to de-centre from distressing thoughts and 8-session groups. mindfulness-based interventions effective for treating both psychological disorders and med conditions but are more effective for psychological disorders, especially depression, anxiety, and stress. the primary mechanisms are attention regulation, emotion regulation, body awareness, which is awareness of one's internal states, and decentering, which is also known as reperceiving and is the ability to separate oneself from one's thoughts and emotions and view them objectively as transient mental events.

Sellers, Smith Bynum, Rowley, and Chavous's Multidimensional Model of Racial Identity: not sequential, proposes may vary across time and situations. distinguishes between four dimensions of racial identity:

Racial salience extent race is relevant part of self-concept at particular time and situation. Racial centrality extent one normatively defines @ race and affected by importance relative to other Ids, ie-gender and religion. Racial regard: Private regard extent to which a person feels pos/neg toward AfAms and how pos/neg feels about being an AfAm. Public regard extent one feels others view AfAms pos/neg. not necessarily related: ie neg private and public regard or pos private and neg public. Racial ideology one's beliefs @how AfAms should live and interact with society. Sellers and his colleagues distinguish between four racial ideologies: (a)nationalist ideology: AfAm experience is unique and AfAms should control own destinies with minimal input from others. (b)oppressed minority ideology emphasize similarity of AfAm oppression and other minorities, interested in forming coalitions w/other groups. (c)assimilationist ideology emphasize similarities btw AfAms and American society, believe AfAmss should work w/system to change it. (d)humanist ideology emphasize similarities of all, race low centrality, more concerned with issues facing the human race.

4. Motivational Interviewing: (brief therapy)

Rogers's person-centered therapy and transtheoretical and concept of self-efficacy and notion of cog dissonance. Like the transtheoretical model, it assumes that interventions are most effective when they match the client's stage of change, most useful for precontemplation or contemplation stage. Tx: expressing empathy, supporting self-efficacy, developing a discrepancy (helping clients see the difference between their behaviors and goals), and rolling with resistance (decreasing client resistance by avoiding arguments and power struggles). questions, reflections, affirmations, and other strategies to elicit and reinforce a client's "change talk" - i.e., statements that move the client toward making positive changes in behavior.

strategic family therapy: struggles for power and control are core to family Fx and Sx adaptive. power and control are determined by hierarchies within a family and that mal Fx is related to unclear/inappropriate hierarchies.

Tx: alter family interactions that maintain Sx. active role and change beh rather than insight. The initial session is highly structured and consists of four stages: social stage, the therapist welcomes the family and observes interactions. problem stage, elicits each family member's view of the family problem and its causes. interactional stage, family members discuss their different views probs, and therapist observes how family members interact when addressing the problem. goal-setting stage, the therapist helps family define problems and goals. therapist then straightforward and paradoxical directives. Straightforward directives: instructions to engage in specific behaviors that will change how family members interact. Paradoxical directives help family members realize that they have control over problematic behavior or use the resistance of family members to help them change in the desired way. They include prescribing the symptom, restraining, and ordeals: Prescribing the symptom instructing family members to engage in the problematic beh, often exaggerated. Restraining: encouraging not to change or warning not to change too quickly. ordeal is an unpleasant task that a member is asked to perform when engages in the undesirable beh

Milan Systemic Family Therapy: "the family as a whole protects itself from change through homeostatic rules and patterns of communication". Patterns of communication are referred to as family games, and family games associated with problematic behaviors are rigid, involve power struggles between family members, and are known as "dirty games."

Tx: alter problematic fam rules and comm. Provide info that challenges family games and develop comm that ^ family's ability to adapt to change. therapeutic team and five-part therapy sessions (pre-session, session, intersession, intervention, and post-session) and gaps between therapy sessions of four to six weeks. Hypothesizing continual interactive process of speculating and making assumptions about the family situation. Neutrality therapist's interest in situation and acceptance of each's perception of the problem. Circular questioning asking each same Q to ID differences in perceptions and uncover fam comm patterns. Positive connotation reframing that helps members view Sx as beneficial bc maintains cohesion. to change the family's perception of a symptom from an individual family member's illness to, instead, a behavior that's voluntarily controlled and well-intentioned and involves the entire family system. Family rituals activities between sessions, designed to alter problematic family games. ie: when parents are competitive in their control, the therapist might instruct mother to make decisions on odd-numbered days and father on even-numbered

Prevention: Gordon's model- universal, selective, and indicated prevention:

Universal preventions for entire pop/groups (not indiv) at risk for a Dx.drug prevention for all students. Selective preventions for indivs at ^ risk for a Dx. prevention program kids whose parents have a subst Dx. Indicated preventions those at high-risk w/early or minimal Sx. prevention program for adolescents who have experimented with drugs. continuum of care model includes prevention, treatment, and maintenance. universal, selective, and indicated preventions are restricted to people who have not received a Dx. Tx for those who w/a Dx, and maintenance for people who have received Tx for a Dx and focus on preventing chronicity or relapse and rehab.

Rational Emotive Behavior Therapy: (REBT)

absolute (or dogmatic) irrational beliefs and are expressed in the form of 'must's,' 'should's,' etc, lead to neg emo that interfere with goals. A-B-C-D-E model: Activating event B iirrational belief about that event C emo or beh consequence of that belief D dispute the irrational belief E effect of these techniques, which is the replacement of the irrational belief with a more rational one. Tx: active disputation of irrational beliefs, rational-emotive imagery, systematic desensitization, and skills training. effective for dep, anx, conduct problems, anger, and other Dx

constructivist or social constructionist perspective (family/group Tx)

assume that there are multiple viewpoints and realities. They view family therapy as a shared process in which the therapist forms a collaborative relationship with the family and helps family members identify alternative ways of interpreting and resolving problems.

Jung's Analytical Psychology:

beh driven by pos and neg, personality continues to develop thru lifespan, and beh affected by the past and the future. personal unconscious: person's own forgotten or repressed memories. collective unconscious memories shared by all, passed thru generations, contains universal archetypes (myths, symbols, dreams and include the persona, shadow, hero, and anima and animus). bring unc to con=>individuation, during the second half of life: person becomes a psychological 'in-dividual,' that is, a separate, indivisible unity or whole". dream interpretation analysis of transference (viewed as being due to the projection of elements of the personal and collective unconscious.)

Object Relations Theory:

beh motivated by desire for relationships, focus on child and primary caregivers (objects). object constancy, dev of mental representations (introjects) of the self and objects that allow value an object for more than individual's needs. dev of object constancy takes place during three stages: normal autistic stage (first few weeks): infants self-absorbed. normal symbiotic stage infants become aware but unable to differentiate from their caregivers. separation-individuation stage (five months to three y/o)- object constancy gradually develops: differentiation, practicing, rapprochement, and beginning of object constancy. Dxs come from sep-ind process that cause a pervasive failure of object constancy. Tx: corrective reparenting experience in order to replace maladaptive introjects with more adaptive ones and thereby improve relationships. provide empathic acceptance and # of psychoanalytic strategies in therapy including the analysis of resistance and transference.

Evidence-Based Couple and Family Therapies: three levels of evidence

best couple and family treatments. Level I : evidence-informed, supported by pre-existing research. not been empirically evaluated themselves and/or for specific pops/Dx. Level II promising interventions, preliminary evidence but not been replicated for specific pops/Dx. Level III interventions supported by systematic high-quality research. divided into four categories: Category 1 (minimum criteria) evidence of efficacy when compared to no treatment (absolute efficacy) Category 2 efficacy compared to alternative treatments (relative efficacy). Category 3 efficacy of an intervention's model-specific change mechanisms (verified mechanisms of action). Category 4 evidence of beneficial outcomes for specific client populations/ problems, and for different service delivery systems (contextual efficacy).

Effects of Age, Gender, and Socioeconomic Status on Psychotherapy Outcomes:

best overall conclusions= little or no impact on outcomes and that apparent differences are due to other factors. ie: when initial severity of Sx was controlled, client age explained essentially none of the variance in outcomes. some studies have linked low SES to premature termination, there's evidence that this relationship is due to transportation difficulties and other factors.

Emotionally focused therapy (EFT)

brief EBT: attach Tx, humanistic-experiential approaches, and systems theory. (a) emotions are essential to the org of atta beh and influence how people experience themselves and their partners (b) the atta needs of partners are essentially healthy and adaptive but probs arise when needs are enacted insecurities (c) distress maint by ways in which interactions between partners are organized and by the dominant emotional experiences of each. helping partners express and deal with their emotions is fastest, most effective way to solve probs, and primary goal is to expand and restructure the emo experiences to develop new interactional patterns and experience atta security. three stages: assessment and cycle de-escalation, changing interactional positions and creating new bonding events, and consolidation and integration.

General systems theory (family/group Tx)

by biologists to describe the functioning of living and non-living systems. It predicts that all systems consist of interacting components, are governed by the same general rules, and have homeostatic mechanisms that help them maintain a state of stability and equilibrium.

Communication theory: Symmetrical complementary interactions (family/group Tx)

certain types of repetitive patterns of communication and interaction produce problematic behavior. schizophrenia to double-bind communication, when a person receives two contradictory messages from a family member and is not allowed to comment on the contradiction. Symmetrical interactions reflect equality and occur when the behavior of one person elicits a similar type of behavior from the other person. can escalate in intensity and become a "one-upmanship game." complementary interactions reflect inequality and occur when the behavior of one person complements the behavior of the other person. ie-1 person assumes dominant role, other subordinate. Problems occur in families when interactions between family members are exclusively symmetrical or complementary.

Reality Therapy: Glasser's

choice theory: 5 innate needs (love and belonging, power, fun, freedom, and survival). How needs are met determine a success or failure identity: responsibly (pos, don't infringe on others)= adopted success identity. irresponsibly (neg, infringe on others and do not always help the person get what he/she wants) = adopted failure identity. replace failure with success identity thru assuming responsibility for actions and adopt more appropriate ways to fulfill needs. WDEP system: ask about wants and needs, determine what the client is currently doing to foster awareness of his/her behaviors, encourage the client evaluate behaviors, and help the client create a plan of action.

Self-instructional training, five stages:

cog modeling stage, children observe performing task w/verbal instructions. overt external guidance stage, children perform same task while the model verbalizes the instructions overt self-guidance stage perform task w/ instructions aloud themselves. faded overt guidance stage perform task while whispering the instructions. covert self-instruction stage task while repeating the instructions subvocally. address four skills: -identifying the nature of the task, -focusing attention on the task and the behaviors needed to complete it, -providing self-reinforcement that sustains appropriate behavior, -and evaluating performance and correcting errors.

Smith, Glass, and Miller: meta-analysis to

combine the results of studies that compared the outcomes of patients who received psychotherapy to the outcomes of patients in either a no-Tx or an alternative (non-therapy) Tx group. 475 studies and produced a mean effect size of .85, which means that the average patient who received psychotherapy was "better off" than 80% of patients who did not receive psychotherapy.

Stepped care two fundamental features: Tx is least restrictive, but still likely to provide sig gain.And is self-correcting= monitored systematically. primary goals: ^ the efficiency of services and accessibility through better allocation.

commonly cited models for depression usually include four steps: Step 1 - Assessment and Monitoring: evaluating Sx and "watchful waiting" and monitoring of Sx. Step 2 - Interventions Requiring Minimal Practitioner Involvement: psychoeducation; bibliotherapy for high risk prevention; computer-based Ix track Sx. Step 3 - Interventions Requiring More Intensive Care and Specialized Training: may include group therapy, ind, and/or med. Step 4 - Most Restrictive and Intensive Forms of Care: for pt with severe Sx and consists of voluntary or mandated inpatient care.

TELE- Major Depressive Disorder:

comparing tele and in-person Tx, most studies= sig decreases in Sx following tele, with no statistical diff btw tele and in-person groups receiving the same Ix. useful for alleviating the insomnia and chronic pain that often accompany depression. a study evaluating tele CBT found it to have a lower attrition rate than in-person CBT had, other studies have found that attrition rates for other modes of telepsychology vary, depending on the pop and type of Ix

Psychological Interventions and Medical Costs:

courses of psychotherapy reduce overall medical utilization and expense". participation in Tx by pt undergoing surgery, pt with a history of medical overutilization, and pt receiving treatment for substance misuse or other Dx usually resulted in a medical cost offset. 90% of the studies included in their analysis reported evidence of a medical cost offset and that the ave savings was 20%.

Stress Inoculation Training:

deal better with ongoing and future stress w/effective coping skills. 3 phases. conceptualization/education phase, info @ stress and its effects and view as "problems-to-be-solved". skills acquisition and consolidation phase, clients learn a variety of cog and beh coping skills which may include relaxation, self-instruction, and problem-solving. application and follow-through phase, clients use newly acquired coping skills, first in imagined and role-playing situations and then in real life situations.

Freudian Psychoanalysis:

deterministic and pessimistic. current psychological probs = unc unresolved conflicts from childhood. cause anx and are the result of the divergent demands of - the id, ego, and superego: (a) The id (birth): life (sexual) and death (aggression) instincts are primary. pleasure principle, seeks immediate gratification of its instinctual needs using unconscious irrational means. (b) ego (6mo): reality principle: seeks to partially gratify the id, in realistic rational ways. (c) The superego: internalization of society's values and standards and acts as the conscience. It attempts to permanently block (rather than gratify) the id's instincts. when ego unable to resolve id and superego using rational means, esorts to one of its unc defense mechanisms: repression, reaction formation, projection, and sublimation: Repression is the basis of all others keeping undesirable thots out of conscious awareness. Reaction formation = defending against an unacceptable impulse by expressing its opposite, projection =attributing an unacceptable impulse to another person sublimation channeling an unacceptable impulse into a socially desirable (and often admirable) endeavor. free associations, dreams, resistance, and transference, and the process of analysis consists of four steps: (1) Confrontation helping clients recognize unaware beh and their possible cause. (2) Clarification sharper focus by separating important details from extraneous material. (3) Interpretation linking con beh to unc processes. (4) Repeated interpretation leads to catharsis (the experience of repressed emotions) and insight into the connection between unc material and current beh and then to working through

Eysenck's (1952) conclusions about the effectiveness of Tx were based on 24 outcom in psychoanalytic or eclectic Tx.

did not include no-Tx controls, used other studies to estimate the spontaneous remission rates of neurotic 44% of psychoanalytic, 64% eclectic , and 72% w/no Tx= improvement in Sx. showed Tx ineffective n may be neg. challenged bc his of methodological flaws. Pt not randomly assigned to groups so initial differences in Pts could account= differences in recovery. criteria used to determine recovery were questionable; use of diff criteria =recovery of 83% in psychoanalytic and 30% for no Tx.

Extended Family Systems Therapy: Emotional Triangles

dyad tension may recruit a third family member to form an emotional triangle which helps alleviate tension and increase stability. likelihood an emotional triangle will develop increases as the levels of differentiation of family members decrease.

Client-Therapist Matching: effects of client-therapist matching in terms of race and ethnicity vary, depending on the outcome measure and clients' race or ethnicity.

effect size of .32 for the impact of matching on clients' perceptions of their therapists but an effect size of only .09 on measures of therapy outcome. varied, depending on client race/ethnicity: racial/ethnic matching reduced termination rates for Asian, Hispanic, and European American's but not for AfAms clients and matching associated with ^ Tx outcomes only for Hispanic American clients. "clinicians' cultural competence, compassion, and ... worldview were more important than ethnic matching between client and clinician"

Etic vs. Emic Perspective:

emic perspective: beh affected by culture and Tx that apply to members of one culture may not apply to others. etic perspective beh is similar across cultures and the same Tx are appropriate for everyone, regardless of background.

Telepsychology and Evidence-Based Psychotherapy:

evidence-based psychotherapy (EBP) via tele associated w/ benefits over in-person: decreases patients' and providers' costs; increases access for ind who have no or limited access; and reduces stigma and embarrassment that some ind exp. in most cases, telepsychology-delivered EBP provides roughly equivalent outcomes for members of diverse populations and a variety of disorders.

Extended Family Systems Therapy: Multigenerational Transmission Process:

extension of the family projection process- transmission of emotional immaturity from one generation to the next. It occurs when the child most involved in the family's emotional system becomes the least differentiated family member and, as an adult, chooses a spouse or partner who has a similar level of differentiation. This couple then transmits an even lower level of differentiation to one of its children. This process continues in subsequent generations and eventually results in the development of severe symptoms in a child.

Utilization of Mental Health Care Services: utilization rates of services vary, depending on gender, age, sex orien, and race.

gender and age, rates ^ for female adults than men and adults 35-49. sexual orientation, sexual minority men and women ^ rates than heterosexual. lesbian and bisexual women ^ seeking substance misuse and Tx, followed by gay and bisexual men, heterosexual women, and heterosexual men. racial/ethnic minority groups: annual ave 2008-2012 highest for who are two+ races followed by, in order, White, American Indian or Alaska Native, Black or African American, Hispanic American, or Asian. For inpatient services, ^ American Indian or Alaska Native then, in order, Black or African American, two or more races, Hispanic American, White, or Asian.

Group: therapeutic factors

group cohesiveness, instillation of hope, universality, altruism, imparting information, development of socializing techniques, corrective recapitulation of the primary family group, interpersonal learning, imitative behavior, catharsis, and existential factors. group cohesiveness is considered to be the analogue of the therapeutic alliance in ind Tx, viewed as a precondition for the other factors, and most consistently found to be a strong predictor of pos group Tx outcomes.

TELE- Bulimia Nervosa:

has beneficial effects but is not necessarily as effective as in-person treatments. results= 2 versions had similar attrition rates and both produced beneficial effects on outcome. some diff: pt receiving in-person CBT had non-significantly ^ rates of abstinence from binge eating and purging and sign greater reductions in eating disordered cog and dep. Pt in both groups experienced a decrease in binge eating and purging and comorbid Sx of dep and anx by the end of Tx but that there were some group diff: Immediately after Tx ended, pt receiving face-to-face group Tx had a greater decrease in abstinence rates and anx Sx, but the gap btw the two groups on these measures narrowed at the 12-month follow-up, indicating that the pace of recovery was slower for pt who received tele therapy.

Personal Construct Therapy: Kelley

how people construe events-- alt ways of doing so and that can change the way they construe events to alleviate undesirable beh and outcomes. personal constructs, bipolar dimensions of meaning (e.g., fair/unfair, friend/enemy, relevant/irrelevant) arise from experiences, unc or con. therapist and client work together to help identify and replace maladaptive personal constructs. fixed-role therapy to help clients try out alternative personal constructs= client role-play a fictional character that is described by the therapist and construes events in alternative ways.

Extended Family Systems Therapy:

intergenerational and transgenerational family therapy. the transmission of certain emotional processes from one generation to the next is responsible for the development of schizophrenia in a family member. increasing differentiation in one family member facilitates greater differentiation in other family members.therapy is to increase each family member's differentiation, and several strategies are used to achieve this goal: genogram, ask questions that are designed to defuse emotions and help family members identify how they contribute to family problems. They also teach family members how to interact with their families-of-origin in ways that alter triangulated relationships. assume the role of coach and stay connected with family members but remain neutral and avoid becoming involved in the family's emotional processes. To reduce emotional reactivity, they have family members talk directly to them rather than to each other.

Formative Phases of Group Therapy: According to

intial orientation, hesitant participation, search for meaning, and dependency stage, group members are concerned with clarifying the nature and purpose of the group and depend on the leader for structure, acceptance, and answers to their questions. Interactions between members often focus on describing symptoms and previous treatments and involve giving and seeking advice. conflict, dominance, and rebellion stage: compete for power and control and attempt to establish a pecking order. critical of each other, some hostile and resentful toward therapist as they become aware that they're not going to become the therapist's "favorite child." development of cohesiveness stage: conflict btw members decreases, and cohesiveness ^ w/trust of others and therapist. may reveal the real reason why they have come to therapy and show concern when a member is absent or drops. The dev of cohesiveness marks the begin of a mature group that can deal with the concerns of members.

Extended Family Systems Therapy: Differentiation:

intra- and interpersonal. intrapersonal: ability to distinguish between own feelings and thoughts interpersonal aspect of differentiation allows separation of emotional and intellectual Fx others. low level of differentiation = "emotionally fused" with other family members.

Cybernetic theory (family/group Tx)

is concerned with the mechanisms that regulate a system's functioning and distinguishes between negative and positive feedback loops: Negative feedback loops resist change and help a system maintain the status quo, while positive feedback loops amplify change and disrupt the status quo.

Extended Family Systems Therapy: Family Projection Process:

parents' projection of their emotional immaturity onto their children, which causes the children to have lower levels of differentiation.

Person-Centered Therapy:

people have an innate drive toward self-actualization, achieve their full potential. thwarted w/incongruence between self-concept and experience. Conditions of worth are one source of incongruence. react to incongruence defensively by distorting/denying their experiences=> psych maladjustment. help become a "fully functioning person" who is not defensive, open to new experiences, engaged in the process of self-actu. three facilitative (core) conditions: empathy, unconditional positive regard, and congruence. Empathy involves understanding the client's perspective and communicating that understanding to the client, unconditional positive regard involves valuing and accepting the client as a person, and congruence involves being genuine, authentic, and honest.

Adler's Individual Psychology:

replaced Freud's sexual instincts with an innate social interest and desire for connectedness and adopted a teleological approach that emphasizes the effects of future goals on current behavior. feelings of inferiority arise during childhood in response to real or imagined inadequacies. striving for superiority to overcome inferiority feelings. style of life how strive for superiority=> style of life develops during early childhood. people have adopted a healthy style of life when their goals reflect personal achievement AND well-being of others. In contrast, they've adopted a mistaken (unhealthy) style of life when their goals focus on overcompensating for feelings of inferiority. neurosis, psychosis, addiction, and other problems are manifestations of a mistaken style of life. Ix: replace the client's mistaken style of life with a healthier, by overcomomg feelings of inferiority and develop a stronger social interest. identifying early recollections, dream analysis, and having clients act "as if" they're already the people they want to be.

Solution-Focused Therapy: (brief therapy)

solutions to problems vs etiology and nature of probs. goal-directed collaborative; several types of Qs to ID Tx goals and personal strengths/resources to achieve goals: (a)miracle question establish the focus of Tx as the future (rather than the past or present) and ID Tx goals. Example: If a miracle happened during the night and your problem was solved, how would you know that a miracle occurred? (b) Exception questions ID when probs did't exist or were less intense. Example: Can you think of a time in the past two weeks when you and your partner did not argue? (c) Scaling questions help clients evaluate their current status or their progress toward achieving their goals. sessions structured w/Qs, providing feedback, and task before next session.

TELE- Anxiety Disorders:

tele effective for ind anx and also comorbid anxiety and mood Dx. studies found significant improvement in anxiety Sx following tele, with controlled studies finding no sig diff btw tele and in-person. found tele CBT to in-person CBT to be similarly effective for reducing comorbid anx and dep and improving quality of life.

Diagnostic Overshadowing:

tendency of MHPSs to attribute all of the problems of people who have received a Dx of intellectual dis to that Dx and overlook other problems. Since, term has been applied to other client characteristics. Ie: they assume that the presenting problems of gay clients are due to the clients' sexual orientation without considering other explanations.

Transdiagnostic Treatments: address a range of Dx that not only share Sx but also bio, psych, and env.

the commonalities across Dx outweigh diff w/important benefits compared to Dx-specific approaches" can reduce cost/time to deliver numerous diagnosis Ix and better for comorbidities. Some combine evidence-based strategies, while others combine strategies that are applicable to disorders from different categories.

Group Therapy Characteristics:

the recommended size for an adult outpatient group ranges from 7 to 10 members. less than 7, interactions are limited; more than 10 members, hard to involve everyone. larger the size, lower cohesiveness and ^ dropout rate. Closed groups begin with the desired number of members, usually specific goals and predet # of sessions. Advantages: associated with greater group cohesiveness. open groups maintain the same # of for duration by replacing members, usually broader goals and meet indefinitely. they benefit from the energy and new input of new members.

TELE- Posttraumatic Stress Disorder (PTSD):

when two versions compared of a brief beh Ix: tele and in-person. both versions reduced anx, dep, and PTSD Sx, with no sig diff btw them on any of the outcome measures. not entirely consistent: found that tele exposure therapy reduced veterans' PTSD Sx but that it was somewhat less effective than exposure therapy delivered in person.

The Working Alliance: consisting of three components:

working alliance, real relationship, and transference-countertransference. working alliance has been studied most extensively: core common factor across all Tx and sig predictor of successful Tx. for adult therapy clients, "the positive relation of the alliance and outcome remains across assessor perspectives, alliance and outcome measures, treatment approaches