Clinical Chap. 11 and 14

psychotherapy
emotional component;
– treatment for emotional problems
– affect changes in the individual (e.g. reduce symptoms)
– professionally established relationship
intervention
– inducing change (or acceptance) via professional relationship
– solve or prevent probs
– achieve latent potential
efficacy
– person receiving treatment must show significant reduction in the levels of dysfunction
— is it psychotherapy that’s causing the reduction/change?
– focus on internal validity
– does it work? is treatment responsible for change?
effectiveness
– treatment option must be representative
– emphasize external validity
— can we use this treatment on other ppl– older/younger/diff pops?
– effective beyond target population?
effect size
change relative to a comparison group that does not receive the treatment
– amount of change matters in comparison to control group
efficacy studies
– standardized studies
– selected, more homogenous participants to control for more extraneous variables
effectiveness studies
– more “real-world” testing
– may or may not include a control group
– surveyed 4000 readers who had sought treatment for a psychological problem and summarized
– most respondents were well-educated
– median age was 46
– half were women
– a wide variety of psychological probs reported
What did the 1995 study done by Consumer Reports magazine say about ppl seeking psychotherapy?
– majority reported SOME improvement
– those who felt the worst before treatment reported the MOST improvement
– all types of mental health professionals appeared to be EQUALLY effective
– respondents who received psychotherapy alone improved as much as those who received psychotherapy plus MEDICATION
– longer treatment (MORE sessions) was related to more improvement
What were the results of 1995 Consumer Reports study?
Evidence Based Treatments (EBTs)
– question of efficacy vs other treatments
– THESE have produced significant change in trials
– APA established criteria for THESE in 1995
– combined trials of THESE through use of meta-analysis
Evidence Based Practice (EBP)
– broader, contains non-controlled trials (i.e. no control/comparison group)
– question of whether one can scientifically measure effect without a comparison group
– rise in use w/ healthcare reforms
– not a direct match w/ research literature
1. evidence based treatment knowledge
2. clinical expertise
3. patient characteristics, values, preferences
What should be included in evidence-based practice approach?
supportive,
learning,
action
– involved in all effective psychotherapies
What are 3 common factors/features common to many therapies?
therapeutic alliance
– relation b/w client/therapist
– unique in importance
– not necessarily curative
– must be: non-judgmental, objective, insightful, professional
expert role
– expert knowledge about psychological probs
– competency/training
– maintaining equal respect
become a therapist
– educates, promotes self-efficacy, facilitate mastery experiences
non-specific factors
– influence of immeasureables: hope, belief
– placebo effect of therapist?
How do you build competency?
– degree of distrass
– intelligence
– age
– motivation
– openness
– gender
– race, ethnicity, social class
– reactions to patient
What are different therapeutic variables of the patient/client?
– age, sex, ethnicity
– personality
– empathy, warmness, genuineness
– emotional well-being
– experience
— professionals vs paraprofessionals
What are some therapeautic variables of a therapist?
1. initial contact
2. assessment
3. goals of treatment established (negotiated)
4. implementing treatment
5. termination, evaluation, follow-up
What is the course of clinical intervention?
pre-contemplation
no intention to alter behavior, outside pressure to change
contemplation
ware of problem, but not committed to changing
preparation
intention to change present
action
actively changing bad behaviors
maintenance
prevent relapses, further gains
termination
necessary changes made, relapse not a threat
– pre-contemplation
– contemplation
– preparation
– action
– maintenance
– termination
What are the 6 stages of change?
1. groups
– some receive treatment and some do not
– waiting list control
– attention only control
2. assessment of patient functioning
– conducted in parallel fashion for experimental and control groups
– before and after study
What are 2 issues w/ psychotherapy research?
waiting list control
when the treatment is delayed until after study
attention only control
when someone meets with a clinician, but no “active” treatment is given
– sample: is it representative?
– patient variables may influence outcome
– outcome measures: are they identical for every patient?
– nature of the study?
What are 4 other considerations about psychotherapy research?
studied behavior therapy vs psychdynamic therapy vs waiting list control
FOUND: BT and PT groups are better at termination and follow-up
Describe the Temple University study.
Smith, Glass, Miller (1977)
Who did the meta-analysis on 475 studies, 25,000 patients, 78 therapies, and an average of 16 sessions?
Non-RET cogntive therapies
cog-behavioral therapy
What had the 2 biggest effect sizes of the meta-analysis of 1977?
1. competence and adherence tied to positive outcomes
2. client emotionally processing session material tied to outcome
3. degree of cooperative and positive affect in session positively tied to outcome
What 3 events occur during therapy?
– efficacy and effectiveness
– factors related to higher efficacy and effectiveness
What does psychotherapy research focus on?
practice guidelines
recommend specific form of treatment for specific problems
common goal to achieve effective treatment
manualized treatment
involves a prescribed treatment method, encourages innovation, a therapeutic alliance, and managed care
behavioral approach
– clinical work that aligns itself with the study of human behavior
– highly diversified field
– scientific emphasis
– de-emphasis of inferred variables
– classical conditioning
– learning theory
– systematic desensitization
– operant tradition (antecendents, triggering)
kind of mechanistic– breaking down
for methodically oriented therapists
origins of the behavioral approach
– relationship b/w therapist and client
– use of multiple techniques
— broad spectrum behavioral therapy
– detailed analysis
— SORC
important techniques of behavior therapy
muscle tensing then release
possible use of hypnosis
breathing exercises
Name 3 relaxation techniques for systematic desensitization.
History of problem
Determining treatment
Assessing appropriateness
Briefing the patient
Relaxation training
Development of anxiety hierarchy (measured by SUDS)
procedure of systematic desensitization?
1. difficulties identified
2. ordered by anxiety level
3. low to moderate to extreme
4. relaxation practiced at each level of hierarchy
List the 4 steps of the anxiety hierarchy.
counterconditioning
the substitution of relaxation for anxiety
extinction of behaviors
when the patient repeatedly visualizes anxiety-generating situations but without ensuing bad experiences, the anxiety responses are eventually extinguished
– counterconditioning
– extinction of behaviors– don’t allow them to run away, wears down
– habituation
– positive reinforcements
Name 4 of the rationale behind systematic desensitization
exposure therapy
when the client is placed into anxiety causing situations
– external cues
– interoceptive cues for panic
– exposure and response prevention
– long durations (90-120 min)
– repetition to extinction
– graduated process
– interaction w/ stimuli
– exposure MUST provoke anxiety
Requirements for exposure therapy
behavioral rehearsal
a technique to expand a patient’s repertoire of coping behaviors
– practice the behavior for eventual integration into real life
– origins in psychodrama
– fixed role playing
— therapeutic emotional release
— altering cog structuresah
1. prepare the patient
2. target specific situations
3. actual rehearsal
4. patient’s utilization of skills in real-life situation
What are the 4 stages of behavioral rehearsal?
assertiveness training
part of behavioral rehearsal
– One application of behavioral rehearsal
– Stems from anxiety due to timid coping
– Sexual issues, depression, marital conflicts
– Cognitive self statements enhance effects of training
– Aim is not to teach aggression, but rather how to express one’s feelings without trampling on the rights of others
contingency management
– changing behavior by manipulating consequence
– common w/ children and adolescents
– forms
— shaping/successive approximation
— time out
— contingency contracting
— premack principle/Grandma’s rule
— token economies
– works best if you tell them what you’re doing
shaping/successive approximation
attempts at a desired behavior are rewarded until it is achieved
time out
removal of patient from environment/reinforcement in which unwanted behavior is reinforced;
i.e. kid has to want to be back in the family room, kitchen, etc. a reinforcing environment they want to return to TO somewhere not where they want to go;
removed from genuinely reinforcing environment
contingency contracting
agreement b/w patient and therapist specifying consequences of behavior
premack principle/Grandma’s rule
desired activity reinforced by allowing the individual to engage in a more desireable activity
i.e. homework done before you play outside
token economy
– children and residential care patients
– considerations:
— clear and specific definition of expected behavior
— clearly established reinforcer
— back up reinforcer
– requires:
— committed supervision
— detailed record keeping
aversion therapy
– controversial/ethical concerns
– series of treatments
– negative stimuli applied to cause change
— electroshock
— emetic drugs
– covert sensitization
cog-behavioral therapy
– modification of thought pattersn
– empirically supported
– social learning theory
– sense of self-efficacy
– active process
– general approach to therapy
*bandura
depressed
the higher your self-efficacy, the less likely you are to become ____________;
strength of your belief to emit a certain behavior
self-efficacy
keep going when first obstacle hit
you can do it and keep going
realistic sense of what they can do
modeling
– observational learning
– used often to eliminate unwarranted fears
– videotape modeling
– written instructions
when:
– subject attends/pays attention to model
– if patient retains the info provided by the model
– patient performs modeled behavior
– motivation to use behavior
When is modeling best and most efficient?
rational restructuring
– relabeling of situations, more realistically
– modification of the internal “self-talk”
– rational emotive therapy (RET)
–> REBT (rational emotive behavior therapy)
— B- beliefs
— A- activating events
— C- consequences
— therapist as a teacher; corrects illogical thinking
stress inoculation testing (SIT)
– exposure to a little bit of stress but how to deal w/ it
– prevents probs by inoculating clients to ongoing and future stressors
usages:
– rape/assault traumas
– PTSD
– anger issues
stages:
1. conceptualizations
2. skill acquisition and rehearsal
3. application
1. conceptualiztion
2. skill acquisition and rehearsal
3. application
What are the 3 stages of SIT?
Beck’s Cog. Theory
– utilizes cog and behavioral methodology
– modify dysfunctional patterns (of thoughts and behavior)
– cog therapy
– some techniques:
— increasing pleasurable activities
— cog rehearsal (practice certain kinds of thoughts)
— assertiveness training/role playing
— identify maladaptive, automatic thoughts
— challenge these
— search for alternative solutions of ways of coping
dialectical behavior therapy (DBT)
big since 2000
– used primarily w/ Borderline Personality Disorder (and those self-harm-ers) but can be applied in a lot
– 4 skills training models
1. mindfulness
2. emotional regulation
3. distress tolerance
4. interpersonal effectiveness
1. mindfulness
2. emotional regulation
3. distress tolerance
4. interpersonal effectiveness
What are the 4 training modules of DBT?
mindfulness
to be aware of the moment, focused, nonjudgmental
emotional regulation
identifying and dealing with emotions
distress tolerance
learning to cope with stress
interpersonal effectiveness
how to deal with conflict, get needs met, say no to unwanted demands
– efficacy
– efficiency
– evidence-based
– no evidence for symptom substitution
– breadth of application
– scientist practitioner/clinical scientist model
What are 6 strengths of CBT?
– hard to link practice to science sometimes when don’t have research base
– dehumanizing– to say change can be fixed that simply
– inner growth
– manipulation and control (exposure based stuff– but informed consent)
– do these effects generalize to real-world clients?
– lacks a unifying theory
What are 6 limitations to CBT?
attention only control group
a control group whose members meet regularly with a clinician but receive no “active” treatment
catharsis
the release of emotions
common factors
a set of features that characterize many therapy orientations and that may be the source of positive changes effected by psychological treatment
control group
in psychotherapy research, the group that does not receive the treatment under investigation
depth of a problem
the changeability of a condition or behavior
– the deeper the condition, the less changeable it is perceived to be
effect size
the size of the treatment effect
– determined statistically
effectiveness studies
studies that emphasize external validty and the representativeness of the treatment that is administered; it is considered effective to the extend that clients report clinically sig benefit from the treatment
efficacy studies
studies that place a premium on internal validity by controlling the types of clients in the study, by standardizing the treatments, and by randomly assigning patients to treatment or no treatment groups;
a treatment is considered ___________ to the extend that the average person receiving the treatment in clinical trials is demonstrated to be significantly less dysfunctional than the average person not receiving any treatment
empirically supported treatments (ESTs)
treatments for various psychological conditions taht have been shown through careful empirical study to be either “well established” or “probably efficacious”; a list of these is updated and published periodically by the APA’s Division of Clinical Psych
evidence-based treatments (EBTs)
those interventions or techniques that have produced sig change in clients and patients in controlled trials
evidence-based practice (EBP)
those interventions or techniques that have produced sig change in clients and patients in controlled trials
expert role
the therapist’s demonstration of competence (knowledge and experience)
insight
the achievement of understanding the nature and origins of one’s problems
interpretation
the therapist’s conceptualization of the meaning behind the patient’s experiences or behaviors
manualized treatment
psychotherapeutic treatment that is presented and described in a standardized, manual format (outlining the rationales, goals, and techniques that correspond to each phase of the treatment)
mastery
the acquisition of a high level of knowledge or skill; one goal of psychotherapy may be for a patient to develop competence or THIS in a particular area
meta-analysis
a method of research in which one compiles all studies relevant to a topic or question and combines the results statistically
nonspecific factors
factors that are not specific to any particular therapy orientation yet contribute to a positive treatment outcome (the expectation that you will improve)
outcome measures
indicators of patient functioning following treatment, used to gauge the treatment effectiveness
paraprofessionals
individuals without advanced education in psychology who have been trained to assist professional mental health workers
patient functioning
how well a patient is getting along across a number of domains (psychological, social/interpersonal, occupational)
process research
research that investigates the specific events that occur in the same course of the interaction b/w therapist and patient; some therapy processes have been shown to relate to treatment outcome
psychological intervention
a method of inducing changes in a person’s behavior, thoughts, or feelings
stages of change
a series of stages that represent a given client’s readiness for change in psychotherapy; including: precontemplation, contemplation, preparation, action, maintenance, and termination
treatment group
the group that receives the treatment under investigation
waiting list control group
a control group whose members receive treatment only after the study is completed
anxiety hierarchy
in systematic desensitization, a list of situations that precipitate anxiety rxns, ordered from lowest to highest severity. often, items may be organized according to their spatial or temporal distance from the feared stimulus
assertiveness training
using behavioral rehearsal and other techniques to train ppl and to express their needs effectively without infringing on the rights of others
aversion therapy
a controversial type of treatment in which an undesired behavior is followed consistently by an unpleasant consequence, thus decreasing the strength of the behavior over time
behavioral rehearsal
a general technique for expanding the patient’s repertoire of coping behaviors; successful THIS involves explaining to the patient the necessity of acquiring the new behaviors, selecting the target situations, conducting the rehearsal and providing feedback, and having the patient apply the newly acquired skills in real-life situations
behavior therapy
a framework for treating disorders that is based on the principles of conditioning or learning; this approach is scientific in nature and deemphasizes the role of inferred (unobservable) variables on behavior
cognitive therapy
a model of therapy pioneered by Aaron Beck that focuses on the connection b/w thinking patterns, emotions, and behavior that uses both cog and behavioral techniques to modify the dysfunctional thinking patterns that characterize a disorder. THIS is active, structured, and time limited and has been adapted for the treatment of several disorders
contingency contracting
a contingency management technique in which the therapist and patient draw up a contract that specifies the behaviors that are desired and undesired as well as the consequences of engaging or failing to engage in these behaviors
contingency management
any one of a variety of operant conditioning techniques that attempts to control a behavior by manipulating its consequences
counterconditioning
the principle of substituting relaxation for an anxiety response
covert sensitization
a form of aversion therapy in which patients are directed to imagine themselves engaging in an undesired behavior and then are instructed to imagine extremely aversive events occurring once they have the undesired behavior clearly in mind
exposure plus response prevention
a behavioral technique often used for the treatment of OCD. in this technique, the patient is exposed to the situation that spurs his/her obsession (touching a doorknob) and is prevented from engaging in the compulsive behavior that relieves the obsession; ultimately, the patient will habituate to his/her obsession and the compulsive behavior will be extinguished
exposure therapy
a behavioral technique for reducing anxiety in which patients expose themselves (in real life or fantasy) to stimuli or situations that are feared or avoided; to be effective, this exposure must provoke anxiety, must be of sufficient duration, and must be repeated until all anxiety is eliminated
extinction
the elimination of an undesired response
habituation
the elimination of a response that comes from the repeated and/or prolonged presentation of the provoking stimulus
interoceptive cues
internal physiological stimuli (dizziness, nausea)
modeling
aka observational learning;
the learning of a new skill or set of behaviors by ovserving another person perform these skills/behaviors
overcorrection
a form of aversion therapy in which the client is made to “overcorrect” for the consequences of his/her undesired behavior
Premack principle
“grandma’s rule”;
the contingency management technique in which a behavior is reinforced by allowing the individual to engage in a more attractive activity once the target behavior is completed
rational-emotive therapy (RET)
a therapy pioneered by Albert Ellis in which patients are forced to confront and correct their own illogical thinking. in this system, a person’s beliefs about events, rather than the events themselves, determine the problematic emotional or behavioral consequences
rational restructuring
an excectic set of techniques that teaches individuals to examine their assumptions about situations or the world in general and alter their ideas to be more realistic/rational
relaxation
a state of lowered anxiety, stress, and physiological arousal; this may be induced by tensing and then relaxing various muscle groups or via breathing exercises, imagery exercises, or hypnosis
response cost
a form of aversion therapy in which positive reinforcers are removed following an undesired behavior
shaping
a contingency management technique in which a behavior is developed by first rewarding any behavior that approximates it and then by selectively reinforcing behaviors that more and more resemble the target behavior
stress inoculation training (SIT)
a technique developed by Donald Meichenbaum that attempts to prevent problems by inoculating patients to ongoing and future stressors; this involves educating patients about how certain appraisal patterns lead to stress, teaching them to identify and cope w/ potential stressors, rehearsing these coping skills in the therapy setting, and consolidating these skills by applying them across a range of real-life stressful situations
successive approximation
another term for shaping
symptom substitution
the notion that if a symptom is removed without attending to the underlying pathology of an illness, another symptom will emerge to take its place
systematic desensitization
a behavioral technique for reducing anxiety in which patients practice relaxation while visualizing anxiety-provoking situaitons of increasing intensity; patient becomes used to the feared stimulus
time-out
a contingency management technique in which a person is removed temporarily from the situation that is reinforcing the undesired behavior
token economy
a system in which desired behaviors are promoted through the strict control of reinforcements; establishing such a system requires specifying the immediate reinforcers for each behavior as well as the backup reinforcers for which patients can exchange their immediate reinforcers