Chapter 12 - Intervention for Adults

Question 1

How do we know that psychotherapy works?

Answer 1

• Randomized control trials (comparing outcomes of different treatment groups to control group)
• Meta-analyses to review the overall effects of the psychotherapy
• Meta-analyses of treatments for specific disorders and populations (subgroups)

Question 2

Task Forces on Evidence-Based Practice

Answer 2

A team of experts who look at the research for evidence (to inform practice)
- integration of the best available research evidence and clinical expertise within the context of patient values and preferences (APA)
- emphasis on (a) published, peer reviewed research to inform treatment options and (b) use of ongoing monitoring of treatment effects (CPA)

Question 3

How do researchers search for evidence for best treatment?

Answer 3

Build a synthesis of knowledge through finding information through the following reputable resources
-Research databases (i.e., PsycINFO)
- High quality research syntheses (i.e., Cochrane reviews)
- Treatment guidelines
- Government healthcare research agencies

Question 4

What makes a treatment “Efficacious”

Answer 4

Evidence-based treatments that are developed in a controlled research study/ lab setting. Has nothing to do with if it actually works in real life settings (effectiveness)

Question 5

Effectiveness Trials

Answer 5

Used to determine whether an efficacious, evidence-based treatment works in routine clinical settings (i.e., IRL)
- Evidence indicates effectiveness for CBT, most strongly for treating anxiety and depression
- Shown to work across ethnicities

Question 6

Cochrane Reviews

Answer 6

Gold-standard (high quality) reviews by the Cochrane Collaboration that synthesize and comment on a body of literature (i.e., a type of psychotherapy)

Question 7

Phase 1 of CBT for Depression

Answer 7

Information gathering phase:
- Assessment
- Providing info about depression to client
- Case formulation
- Treatment options (i.e., CBT, meds, or both)

Question 8

What does Assessment during Phase 1 of CBT for Depression entail?

Answer 8

• Making a diagnosis and looking for comorbidities
• Life circumstances: interpersonal relationships and functioning (i.e., social support)
• Resources and strengths (i.e., protective factors)
• Precipitating events and stressors
• Risk assessment

Question 9

Phase 2 of CBT for Depression

Answer 9

Working on the treatment plan
- Behavioural activation
- Altering negative automatic thoughts
- Altering dysfunctional beliefs

Question 10

Behavioural Activation

Answer 10

Getting the client to re-engage in the activities that brought them joy prior to the depressive episode.
- goal setting: increasing their daily involvement in pleasurable activities (i.e., activity-scheduling, start small then add on)
- don’t need to feel motivated in order to do it, motivation (and alleviation of depressive feelings) comes from doing the thing

Question 11

How does CBT try to alter Negative Automatic Thoughts and Dysfunctional Beliefs for people with depression?

Answer 11

Challenging the client’s tendency to automatically focus on the negative aspects of their experiences and their negative beliefs about the self, the future, and the world (cognitive triad)
- Cognitive restructuring: asking questions like “how does this belief serve you?”, “is there evidence for the negative thought/belief?”
- Assigning a “thought record” for client to track their negative thoughts and how they make them feel and behave (outside of therapy)

Question 12

Phase 3 of CBT for Depression

Answer 12

Relapse Prevention: Creating a plan for when life happens (to prevent relapse back into depressive episode)
- Reviewing client’s gains and new skills
- Anticipating future stressors: discussing adaptive ways to respond to challenging events in future
- Identifying risk factors for potential relapse

Question 13

What are the stages of the “Vicious Cycle” of OCD?

Answer 13

1. Obsessive thought
2. Anxiety/fear/discomfort
3. Compulsion
4. Temporary Relief

Question 14

Obsessive Thoughts (OCD)

Answer 14

Also called “intrusive thoughts” where the content of the thought causes feelings of distress/anxiety. Thought can be frequent and intense.
- e.g., “I am going to cause harm to a child”, “all my plugged in appliances are going to cause a fire if I don’t unplug them”, “the bacteria on this counter is going to get me sick

Question 15

How do obsessive thoughts cause anxiety?

Answer 15

Thought Appraisal: the individual will interpret their obsessive thoughts to be more meaningful/powerful than it actually is.
- i.e., if they think it, it’s going to actually happen/ it is a reflection of them as a person
- e.g., having an intrusive thought about harming a child whenever you’re near a school. You don’t actually have the intentions to, but because you thought it, you worry that you might actually want to do it and that you’re a danger to children… and thus a horrible person

Question 16

How does one relieve their anxiety from an obsessive thought?

Answer 16

Compulsions (which is a form of avoidance)

Question 17

Compulsions

Answer 17

Maladaptive coping mechanism for when obsessive thoughts occur, through performing ritualistic behaviours to relieve feelings of distress/anxiety caused by the thought.
-e.g., excessive hand washing, avoiding certain things, checking, etc
- some compulsions are not always logically related to the thought content (i.e., “just right” compulsions. e.g., flicking light switch on and off 5 times before leaving house or else something bad will happen)

Question 18

Why are compulsions maladaptive?

Answer 18

They only provide temporary relief from the anxiety caused by the obsessive thought, which negatively reinforces the compulsion.
- When the thought comes back again, they will use the compulsion again because they know that it helps relieve distress, to the point where it becomes habitual
- Prevents facing what is making them anxious, which only prolongs the anxiety and makes it worse (avoidance)
- Compulsions may increase in intensity over time with increasing anxiety from intrusive thoughts (e.g., washing hands for a longer time, more times a day, causing dry skin and irritation)

Question 19

The Avoidance Peak

Answer 19

Graph where anxiety level is on the Y axis and time is on the X axis
- refers to when we are feeling anxious about something (i.e., have an obsessive thought), anxiety starts to climb up and will reach its peak at a certain point
- Those who tolerate their anxiety will see their anxious feelings start to decline after it reaches its peak

Question 20

How is the Avoidance Peak affected by OCD

Answer 20

When anxiety reaches its peak, the person with OCD will have the urge to perform a compulsion in order to relieve their anxious feelings
- when the compulsion used, feelings of anxiety quickly drop but the person fails to habituate to their anxiety (teaching themselves that they can’t tolerate their anxiety)
- therefore when the anxiety returns again, the same loop occurs and the time it takes before they perform the compulsion gets shorter and shorter

Question 21

What side of the avoidance peak does ERP focus on?

Answer 21

Teaches people with OCD/anxiety that anxiety can be tolerated by looking at the half of the graph where anxiety is tolerated and declines after the peak
- for OCD, the side after the peak is ignored because they are using a compulsion
- discomfort/anxiety caused by therapy does not mean harm (in this context)

Question 22

What does “ERP” stand for and what is it used to treat?

Answer 22

ERP = “Exposure and Response Prevention”
- Mainly used to treat OCD and as well as disorders with an anxiety/avoidance component

Question 23

What are the rules of ERP

Answer 23

EVERYTHING but also NOTHING

1. You do EVERYTHING with the client when you are doing an exposure
   - i.e., participating in every step of the exposure with them, modelling that doing hard things is possible
2. You do NOTHING when you are doing response prevention
   - i.e., doing nothing about client’s anxious feelings after the exposure, just sitting there and experiencing it with them
   - Providing reassurance feeds the cycle

Question 24

How many sessions are in the Introduction Gathering and Introduction Phase of ERP

Answer 24

The first 2 sessions
- Session 1: Intake and introduction
- Session 2: Introducing ERP

Question 25

What does the first session of ERP entail?

Answer 25

Intake and introduction
- Gathering relevant info (i.e., history, medical info, risk assessment)
- Determine obsessive thought content and compulsions
- Psychoeducation about CBT model
- Homework to self-monitor obsessions, compulsions, and time spent using daily tracking sheet

Question 26

Dose Response Relationship (ERP homework)

Answer 26

Dose (the homework) = Response
- i.e., a high dose of ERP homework (actually doing it) will result in a high response to the therapy

Question 27

What does the second session of ERP entail?

Answer 27

Introducing ERP
- Looking over the homework done by client: identifying where the anxiety and compulsions are taking place
- Developing a partial exposure hierarchy
- Discuss the vicious cycle and the ERP rationale
- Discuss treatment commitment needed in order to see results from therapy
- Determine the 1st in-session exposure (done together next week, don’t do alone because it often fails if done before therapy)
- Homework: add to the hierarchy (incase anything was missed)

Question 28

Exposure Hierarchy (ERP)

Answer 28

Identifying exposures to be done in therapy and ordering them by how much distress it causes the client (scale of 0-100)
- Want to start with the exposures at the low end of the hierarchy (distress ~20-30) to show client that they are capable of tolerating their anxiety

Question 29

How many sessions are in the Active Intervention Phase of ERP?

Answer 29

First exposure at the 3rd session, sessions 4-9 ascend up the exposure hierarchy (so 7 sessions total)

Question 30

What does the first exposure session (session 3) of ERP entail?

Answer 30

• Review the hierarchy and if anything was added by client during the week; and the purpose of ERP (i.e., why they have to do hard things in therapy and how it helps)
• Complete exposure using everything and nothing rules
• Reinforce tolerating vs removing emotions (i.e., by doing compulsions)
• Choose next exposure
• Ask at end: “what did you think was going to happen vs what actually happened?”
• Homework: continue the 1st exposure at home everyday and track distress levels (to see if it goes down throughout the week)

Question 31

Sessions 4-9 of ERP

Answer 31

Continued exposures, ascending up the hierarchy every session
- Same as session 3 structure per exposure
- adjust the number of sessions as needed based on treatment response and ability to generalize skills (i.e., spreading out sessions as they are able to do the exposures on their own, from every week to every other week)

Question 32

How many sessions are in the Relapse and Termination Phase of ERP?

Answer 32

The last 3 sessions
- Sessions 10 & 11: relapse prevention
- Session 12: Termination

Question 33

What do sessions 10 and 11 of ERP entail?

Answer 33

Relapse prevention
- Reviewing progress and begin relapse prevention planning (i.e., its common to want to relapse into compulsions when things get tough)
- Motivators and barriers, how to address them
- Helpful people and professionals
- Useful skills (i.e., knowing where you’re at and what needs to be done (red/yellow/green zones))
- How to make own exposures and respond to unplanned exposures
- Exposure as a lifelong “lifestyle skill”

Question 34

What does the last (12th) session of ERP entail?

Answer 34

Termination
- Providing at home/self-help supports
- review treatment and congratulate client for their hard work (reinforcing the role of therapy in healing)
- Plan for long-term follow-up if needed as booster/check-up to brush up on skills

Question 35

What are the phases and session goals of ERP (say the phase, session number, and its overall goal)

Answer 35

Information gathering and introduction phase
- Session 1: intake and introduction
- Session 2: introduce ERP
Active intervention phase
- Session 3: first exposure
- Sessions 4-9: continued exposure up the hierarchy
Relapse prevention and termination phase
- Sessions 10&11: relapse prevention
- Session 12: termination

Question 36

What is Prolonged Exposure therapy for PTSD

Answer 36

Sorta like ERP, avoidance gives power to trauma, want to disempower the trauma narrative
- Client repeats/recalls traumatic event to therapist
- Client initially feels anxious when recalling trauma, but it becomes just a memory after repeated recounting
- Practicing facing stimuli that reminds them of traumatic event and cause distress (i.e., environments, sounds, etc.)