Chap 17: Clinical Approaches to Disorders

Question 1

What are client factors?

Answer 1

therapy outcome beliefs, client personality, motivation for change, type and severity of dysfunction. Therapist must be aware of unique features to structure and frame treatment.

Question 2

What are therapist factors?

Answer 2

personal qualities of the therapist, therapist experience + training + competence. Clients will have more positive reactions to some therapists than others - function of personal qualities among these people. A warm therapist brought sense of stability in relationship. Also, whether the therapist has a secure attachment style lead to more positive outcomes. Also, their orientation - those more psychosocial than biological.

Question 3

What are client-therapist relationship factors?

Answer 3

match between client and therapist, therapeutic working alliance. Therapeutic/working alliance - rapport and trust and to a sense that the therapist and client are working together to achieve mutually agreed upon goals. Stronger alliance = better outcome. Might make therapists interpretations more effective or have direct therapeutic effect. The alliance is multi-faceted and one of more of its aspects may be involved. There are 3 components: 1) bond 2) agreement on goals and 3) agreement on tasks of therapy.

Question 4

What did Frank and Frank advance?

Answer 4

Frank and Frank advanced demoralization hypothesis - as explanation for when clients will seek therapy. They suggested clients seek help not just because of their symptoms - symptoms are accompanied by state of demoralization including feelings of alienation, helplessness, hopelessness, loss of self-esteem and subjective feelings of incompetence. Therapeutic task - restore sense of morale by instilling new sense of mastery.

Question 5

What is Snyder et al two-factor theory of hope?

Answer 5

Snyder et all - two-factor theory of hope -hope is key to success of CBT interventions - agency (will to change) and pathways (plans and procedures). However, in medicine, it is not ethical to provide hope if it does not warrant it - no false hope. Psychiatric care is exception as it may lead to better outcomes. Link between hope and outcome is strongly supported.

Question 6

What are Swift and Derthick’s 5 techniques for increasing treatment expectancies?

Answer 6

1. Present a strong treatment rationale early on in therapy. 2. Increase clients belief in skills and competencies of therapist. 3. Express confidence in clients ability to complete the therapy. 4. Share research outcomes. 5. Review progress and compare it with expectations.

Question 7

What role do personality factors play in treatment?

Answer 7

certain personality disorders have negative impact on treatment outcome. Personality attributes of client may account for 40% of variability in therapy outcomes. Attachment style impacts treatment outcomes.

Question 8

How is motivation linked to treatment?

Answer 8

Clients who are highly motivated and ready to change will actually be more likely to improve due to treatment. Motivational interviewing (MI) reflects fact some people are highly threatened by change and are ambivalent about engaging in therapy. Helps clients develop readiness for change by exploring and incorporating own personal motives.

Question 9

How is degree of clinical dysfunction and impairment a client factor?

Answer 9

Generally accepted people with complex clinical presentations, even best therapist will be highly challenged. Those with more extreme levels of dysfunction may demonstrate significant clinical improvement but are likely to have residual symptoms. Complexity of dysfunction, with elevated levels of comorbidity linked with less positive outcomes.

Question 10

How is the experience of the therapist a factor? What are core competencies? What is the Cognitive Therapy Scale?

Answer 10

The extent to which therapist is experienced is factor. Therapists with more experience lead to better outcomes. Therapists also differ in quality and competence. Some are more capable in terms of core competencies- ability to engage in relationships and communicate, cultural competencies etc. Competency is assessed by Cognitive Therapy Scale - grouped into three general therapeutic skills - collaboration, understanding and interpersonal effectiveness and three cognitive therapy skills - focusing on key cognitions, strategy for change and use of cognitive-behavioural techniques.

Question 11

What is the gap between research and clinical practice?

Answer 11

Gap Between Research and Clinical Practice - Does not capture complexities of practice, procedures disrupt or distort typical therapy, participants are not representative of typical therapy clients, qualitative and single case studies are undervalued, Randomized Control Trials (RCTs) are overemphasized, overemphasize treatment techniques not relationship process.

Question 12

What is treatment efficacy vs. treatment effectiveness? Dodo bird effect?

Answer 12

efficacy - intervention is impact as determined from controlled outcome study, typically conducted in an academic research setting. Effectiveness of intervention is its impact when offered to and received by people in everyday world. Efficacy researchers emphasize maximizing internal validity and effectiveness researchers hope to optimize external validity or generalizability of intervention. Efficacy is well-established but evidence of effectiveness lags well behind. Dodo bird effect - tendency for various therapies to achieve similar results. 75% of people who undergo psychotherapy achieve some improvement, change more because of common factors rather than specific factors or techniques. Specific therapies are more effective for certain diagnosis.

Question 13

What is the consensus of psychotherapy research?

Answer 13

1. Therapy is helpful to majority of clients. 2. Most people achieve some change relatively quickly in therapy. 3. In general, therapies achieve similar outcomes. 4. People change more because of common factors than specific ones. 5. Client-therapist relationship is best predictor of treatment change. 6. Most therapists learn more about effective therapy techniques from their experience than from research. 7. About 10% of clients get worse as a result of therapy. 75% achieve some improvement

Question 14

What is stepped care?

Answer 14

notion clinicians should match level of required treatment to seriousness of adjustment problem being addressed but should begin with less involved and less costly interventions, followed by more complex if initial are not successful. May be benefits but more research is needed.

Question 15

What is the challenge of managed care?

Answer 15

for most part by business people rather than by HCPs - managed-care organization (MCOs) have brought down costs of care - demanded increased accountability from providers. Look to scientific evidence to justify procedures used by HCPs. Has been applied to treatments of mental disorders. Different in Canada - universal health care - has been pressure to increase efficiency of our system, to reduce costs.

Question 16

What are evidence-based/empirically supported therapies (ESTs)?

Answer 16

demonstrated to be effective in research studies with appropriate scientific controls in specific population.

Question 17

What are some concerns about RCTs and ESTs?

Answer 17

ESTs are well suited to treating some disorders but are poorly suited to treating other disorders - issued call for empirically informed therapies that are more focused on intervention strategies and for change processes that are guided by clinicians insights rather than rigidly invoked manualized approach that may not take into account important factors such as personality characteristics, comorbidities etc.

Question 18

What does the Canadian Psychological Association Task Force focus on promoting?

Answer 18

evidence-based practice - promoting collaboration among stakeholders and providing info about limitations of current empirical knowledge. Their most recent update - provided definition of evidence-based practice “Evidence based practice of psychological treatments involves conscientious, explicit and judicious use of best available research evidence to inform each stage of clinical decision-making and service delivery”.

Question 19

What are some pros and cons of counterconditioning and exposure methods?

Answer 19

For anxiety related problems it leads to marked reductions in their unrealistic fears - benefitted people with many anxiety disorders but behavior change can be difficult to sustain. It is rarely used exclusively.

Question 20

What are some pros and cons of operant methods? (reward and punishment)

Answer 20

Proved successful with wide range of behavioural problems. Treatment of childhood problems - altering reinforcement changes childs behaviour. Generalizing to real life and maintaining gains is difficult. Insight therapists assume therapeutic effects are enduring because of personality restructuring. Behaviour therapists wonder how the changes can be maintained. Several approaches to generalizing treatment effects: 1. Intermittent and naturalistic reinforcement 2. Environmental modification. 3. Eliminating secondary gain. 4. Attribution to self.
intermittent and naturalistic reinforcement - rewarding only some of time or remove artificial reinforcers. Environmental modification - manipulate surroundings to support change. Eliminating secondary gain - assign homework. People sometimes act as though they wish to keep symptoms - may have to examine interpersonal relationships for clues as to why this occurs. Attribution to self - person who has terminated therapy may attribute improvement to external cause. May be more helpful for therapists to help clients feel more responsible - I did it.

Question 21

What are some pros and cons of Ellis’s Rational-Emotive Behaviour Therapy?

Answer 21

emotional suffering due to unverbalized assumptions, REBT therapist challenges these, achieve therapy effects through reduction in irrationality of thought, is typically integrated with other CBT interventions ie. Beck’s CT and exposure therapy.
Research supporting effectiveness of this for psychopathology and helping emotionally healthy people cope better with everyday stress - been few empirical attempts to compare REBT with other forms of treatment. REBT did form basis of resilience boosting intervention for soldiers. REBT achieves its effects through a reduction in irrationality of thought. It is typically integrated with other CBT interventions.

Question 22

What are some pros and cons of cognitive therapy?

Answer 22

emotional distress caused by cognitive assumptions (schemas), CT is more collaborative than REBT and helps clients examine evidence for beliefs, emphasis on challenging evidence for cognitive biases that filter experience. Effectiveness of CT under intensive study for more than 30 years, works for depression anxiety disorders and other conditions but may not be better than other treatments, therapeutic alliance is important to success, more research needed to determine which components lead to improvements, studies should examine whether strategies aimed at reducing catastrophic thinking are those that lead to symptom change.
Studies attest to favourable impact on depression. May be better than drug treatment at preventing future episodes. Acquire useful skills they can use following termination of therapy. National Institute of Mental Health did not find CT superior to drug therapy or IPT but supported this approach in treatment of depression. Effective for panic disorder, GAD, social phobia, chronic pain, IBS and bulimia nervosa - fairing better than medications alone. CT helps clients change cognitions and predictable changes in them occur - found as well in drug treatment. Research shows brain-related changes. No evidence CBT is superior. Is not established that CBT is effective in addressing certain deeply ingrained personality styles unless treatment is tailored specifically to key themes. Need to focus on effectiveness in real world.

Question 23

What are some pros and cons of Young’s Schema-Focused Therapy?

Answer 23

emphasis on identifying persons deep maladaptive schemas, relevant to PDs, uses CT techniques as well as interpersonal techniques, leads to clinical improvements, most research has examined it for BPD.
Research focused on use in treating BPD - existing data suggest it is promising.

Question 24

What are some distinguishing features of psychoanalytic therapies?

Answer 24

Brief therapy focuses more on practical, real-life problems: assessment is rapid and early, made clear therapy will be limited and improvement expected within 6-25 sessions, goals concrete and focused on worst symptoms, interpretations directed towards present, development of transference not encouraged, general understanding psychotherapy does not cure. Distinguishing features from CBT: focus on affect and emotion expression, exploration of attempts to avoid thoughts + feelings that create distress, identification of recurring themes and patterns expressed in thoughts feelings experiences or relationships, emphasis on past experiences relating to current, focus on interpersonal relationships, emphasis on therapy relationship and exploration of clients wishes dreams and fantasies. Contemporary psychodynamic treatment of personality disorders has 3 emphases: 1) defensive restructuring to address hidden/repressed themes, 2) affective restructuring to facilitate tolerance of distress and 3) cognitive restructuring of beliefs and schemas while bolstering coping skills.

Question 25

What are some pros and cons of psychodynamic psychotherapy?

Answer 25

remove repressions that block ego development, techniques: free association + dream interpretation + transference, classical psychoanalysis has been modified to psychodynamic psychotherapy (oriented to present toward better understanding of current, real-life problems), still emphasizes unconscious motivation and hidden reasons for behaviour. Compared with CT, has greater emphasis on emotional expression , exploration of attempts to avoid distressing thoughts, identification of recurring themes, past experiences as they relate to present, interpersonal relationships, therapeutic relationship, wishes + dreams + fantasies.
Few outcome studies. 60% of clients with anxiety, depression or both improved but no differences between psychoanalysis and short-term psychodynamic psychotherapy. Mean number of sessions for long term psychoanalysis - 500 over 3.6 years. For psychotherapy - 150 over 2.5 years. Long term was quite effective but greater effectiveness was found for symptom reduction rather than personality change. Rate of recovery following long-term is relatively equal to other interventions. There is little benefit to long-term approach. ½ of clients in short-term groups and ⅓ in long term sought out other therapies in follow-up period. Brief psychodynamic psychotherapy is effective - large changes in depression level maintained at 1 year follow up. Other forms of treatment are slightly more effective post-treatment, this was not maintained at 1 year follow up.

Question 26

What are some pros and cons of Roger’s client-centred therapy?

Answer 26

humanistic psychotherapy, emphasis on freedom of choice, taking responsibility for choices made, therapist is accepting and non-judgemental - empathic not directive (shows unconditional positive regard), compassion-focused therapy is extension of client-centred therapy designed for self-critical people to develop self-acceptance. Evidence - meta-analysis of studies found clients were better off after intervention than about 80% of non-treated people.
No better outcome achieved by comparison therapies. Therapist empathy is a moderately strong predictor of positive therapy outcomes - held across diff orientations. Importance of enhancing therapists understanding of client experiences and that clients are their own agents of change. Clients perception of therapists behaviour is more important in predicting therapy outcome than therapists actual behaviour in therapeutic relationship - clients cognitive appraisals are important. Validity is issue - Rogers relied on what client said but asserted they can be unaware of true feelings. Exclusive use of self-descriptive measures of outcome was later supplemented with direct assessment of functioning. They only focused on mildly disturbed people also.

Question 27

What are some pros and cons of Gilbert’s compassion-focused therapy?

Answer 27

Non-judgemental safe space. Self-compassion can elicit same responses that people experience when have been treated in warm and supportive ways by others. Increases spontaneous self-compassionate thoughts, resulting in overall improvement. Case studies show it can result in gains among those previously treated unsuccessfully with CBT. Showed it was effective in reducing smoking. Can be incorporated into existing treatment programs.

Question 28

How does psychodymanic psych approach relationship problems?

Answer 28

focuses on how person seeks or avoids partner who resembles to the unconscious the opposite-sexed parent. Transference is explored but between two partners.

Question 29

What is the Mental Research Institute Tradition for relationship problems?

Answer 29

focus on faulty communication patterns, uneasy relationships and inflexibility. Shown how behaviour affects relations with others - persuaded to make changes. Not concerned with history - family systems approach.

Question 30

What are cognitive-behavioural approaches to relationship problems?

Answer 30

distressed couples do not react positively toward each other. One strategy - “caring days” - Stuart - applies operant strategy to couples conflict. This breaks cycle of distance, suspicion and aversive control of each other, it also shows giving partner that he or she is able to affect spouse in positive way. Behavioural marital therapy shares with other approaches a focus on enhancing communication skills between partners - emphasis more on increasing the ability of pleasing each other. Generally adopt Thibaur and Kelleys exchange theory of interaction - people value others if they receive from them a high ratio of benefits to costs. Therapists try encourage mutual dispensing of rewards. Spouses in distressed marriages view negative behaviour on part of partners as global and stable whereas they construe positive behaviour as less so.

Question 31

What is integrative behavioural couples therapy?

Answer 31

Christensen and Jacobsen - reinforcement principles as well as behavioural exchange and communication training strategies and incorporates Rogerian notion of acceptance and provides series of procedures to foster emotional acceptance in couples. IBCT recognizes that the actions and inactions of partners are important but emotional reactivity is more important.

Question 32

What is emotion-focused couples therapy?

Answer 32

EFT has psychodynamic elements but humanistic emphasis. Marital distress stems from maladaptive and distressed forms of emotion in marital context and destructive interactions that follow. The emotional processing is associated with improvements in psychological functioning. Focus on adult attachment styles in relationships - distress occurs when attachment needs are not met. Involves 12-15 sessions. Process of change 3 phases spanning 9 steps. First phase: de-escalate maladaptive cycle 1) assess current conflicts 2) identify problematic interaction cycle 3) access underlying emotions 4) try reframe problem in terms of emotions and attachment needs. Second phase: change interactional positions 1) help couple identify needs and aspects of self that have been denied and incorporate into relationship 2) learn to accept partners new emotional experience and related responses 3) learn to express specific needs and develop sense of positive emotional engagement. Third phase: consolidation and integration 1) attempts made to arrive at new solutions 2) new positions and cycles of attachment behaviour must be consolidated. It is effective - 70-73% recover. Also helps foster forgiveness where on is emotionally injured by other. Greenberg - point that emotional experience often occurs prior to and independent of cognition - cognitive processing is not likely to produce lasting emotional change. He has 6 empirically based principles of emotional change: emotional awareness, expression, regulation, reflection, transformation and corrective experience.

Question 33

What are some general features of couples therapy?

Answer 33

partner is trained to listen empathetically to other and state clearly what they understand is being said and what feelings underlie those remarks. Focus on improving communication so needs are met. Demand-withdraw cycle is destructive for couples - one partner attempts to discuss problem and other avoids. Give couples homework.

Question 34

What are some ethical issues with couples therapy?

Answer 34

couples therapy is complicated by degree of dysfunction, abuse, how to deal with disclosure of secretes, one member may be motivated and other is not - split alliance - therapist has stronger alliance with one member than other.

Question 35

What are some pros and cons to couples therapy?

Answer 35

beneficial effects for many relationship problems. ½ improve so they no longer have clinical problems. 1.5 have no improvement and 30% show improvement but still have significant problems. Is less effective for couples with severe relationship distress and dissatisfaction and where one member has a psychological disorder. Couples therapy can be used by a partner as a scapegoat instead of individual therapy. Can be effective for alcohol abuse and drug dependence.

Question 36

Which field is dominating clinical training programs?

Answer 36

Cognitive behavioural

Question 37

What are the four modes of psychotherapy integration?

Answer 37

technical eclecticism - therapist works within particular theoretical framework but sometimes imports from other orientations effective techniques - “using whatever works”. Common factorism - strategies that all therapy schools might share ie. empathy, hope, positive regard. Theoretical integration - tries to synthesize techniques and theories where the result is a blend of orientations. Assimilative integration - psych stays primarily within one orientation but uses concepts and techniques from others in a cohesive manner. Assimilative and theoretical are favoured followed by common factors, technical eclecticism and then others.

Question 38

What are psychotechnologies?

Answer 38

Psychotechnologies - delivery of psychotherapy and related services, social medias, telehealth apps, assessments, text reminders, etc. Can also be used for prevention. Internet-based delivery shows promise. This may also prove helpful to reach more children with mental health problems. Caution is warned ie. for social anxiety disorders or clients with high level of severity. Computerized CBT (cCBT) involves developing standardized program that can be used in conjunction with treatment. Also internet-based CBT and virtual reality exposure therapy. virtual reality technology (used for PTSD), interned-based delivery of psychotherapy (research growing, not recommended for high severity), tele-mental health delivery (video conferencing for remote areas), computerized therapy (cCBT for depressed and anxious students), evidence-review by Aboujaoude et al - most support for cCBT and iCBT but concluded VRET and mobile therapy were promising.