Chapters 11 & 12: Intervention (Fundamentals & Adult Applications)

Question 1

What are the two main components of informed consent?

Answer 1

two main elements are comprehension and agreement

comprehension depends on verbal and cognitive flexibility which may be compromised by psychological disorders and/or age

incumbent upon the psychologist to ensure the client understands treatment options, anticipated outcome, alternatives, timelines, potential side effects, and costs

Question 2

In what way are issues of consent age-related?

Answer 2

even children and cognitively impaired adults can expect these issues to be explained in understandable terms

issues of consent are also age-related

usually means age 18

psychologist may accept consent from individuals between 16 and 18 if satisfied that they are competent

important to document evidence

Question 3

Why is ongoing monitoring of treatment important?

Answer 3

ongoing monitoring of treatment effectiveness is necessary

inherently unethical to continue a course of treatment which is not working: new strategies should be implemented as needed

dilemma may arise if working with mandated clients, e.g., under probation order

Question 4

What is evidence-based practice in treatment?

Answer 4

best research evidence

clinical expertise

patient preferences & values

Question 5

What is psychotherapy?

Answer 5

psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable

Question 6

What is the APA resolution on effectiveness of psychotherapy?

Answer 6

be it resolved that as a healing practice and professional service, psychotherapy is effective and highly cost-effective

consequently, psychotherapy should be included in the healthcare system as an evidence-based practice

Question 7

What are the characteristics of psychotherapy?

Answer 7

within professional relationship

emphasis on psychological principles

broad: affect, behavior, cognition

acknowledges client/patient goals

but does not address whether services are evidence-based

Question 8

What is an alternative definition to psychological treatment?

Answer 8

evidence based treatment of clinically significant emotional and behavioral problems

Question 9

How is psychotherapy a controlled act?

Answer 9

not adequately controlled in many jurisdictions: there is significant potential to do harm

HPA: psychosocial intervention (dangerous acts, scope of practice, qualifications)

referred to by CAP as interventions: activities based on psychological knowledge, skills, and judgment that promote, restore, sustain, and/or enhance positive functioning and a sense of well-being in clients through preventive, developmental, and/or remedial services

Question 10

What are some examples of discredited psychotherapies?

Answer 10

neurolinguistic programming

rebirthing

DARE

Scared Straight

Question 11

How are evidence-based practice, empirically supported treatment, and randomized clinical trials related?

Answer 11

recall, evidence-based practice (EBT) implies selection of interventions on the basis of the best available evidence

not the same as empirically supported treatment (EST) which implies randomized clinical trials (RCT)

treatment for conditions for which there is little available evidence must begin with disclosure of limitations to client, and careful monitoring for the emergence of harmful side effects

Question 12

What if there is no evidence-based treatment that matches client needs exactly?

Answer 12

adopt the one that is closest

adapt if necessary

abandon if evidence it does not fit and replace with another EBP

Question 13

What are the best supported therapies?

Answer 13

short-term psychodynamic therapies (STPP)

cognitive behavioral therapies (CBT)

process therapy (PT)

interpersonal therapy (IPT)

depends heavily on the disorders being treated

Question 14

What are short-term psychodynamic psychotherapies?

Answer 14

based on neo-Freudian models

premise is that some aspect of development was negatively impacted by a harmful event, or improper resolution of a developmental stage/task: subsequently manifests as one or more disorders

role of therapist is to capitalize on transference and act as a vehicle by which the patient can return to an earlier conflict, or stage, and addressed the basis of their presenting concerns

approach depends heavily on insight regarding the origin of conflicts, their effects, and developing the psychological maturity to overcome them

individual therapy is most common: may last several months (usually 16 to 30 weeks)

there is empirical support for the use of STPP with depression, some substance abuse concerns, panic disorder, and (possibly) Borderline Personality Disorder

therapists are relatively active, compared to traditional psychoanalysts, often providing feedback

Question 15

What are the forms of feedback used in STPP?

Answer 15

reflection: paraphrasing client comments

clarification: bringing patterns to the attention of client

confrontation: prompting the patient to deliberately set aside a maladaptive tendency that likely highlights the action of a defense mechanisms

interpretation: reframing patient experiences and comments in terms of conflicts and defenses

Question 16

What are the three phases of STPP?

Answer 16

phase 1: identifying issues and developing a therapeutic alliance (transference relationship)

phase 2: using the transference relationship as a model of the client’s patterns of interacting

phase 3: preparing to terminate therapy, including severing the professional relationship and using that process as a working model for healthy coping with subsequent losses

Question 17

What is the initial phase of interpersonal psychotherapy?

Answer 17

assessment and case formulation

Question 18

What is the intermediate phase of interpersonal psychotherapy?

Answer 18

addressing interpersonal themes: grief, role disputes, role transitions, interpersonal deficits

Question 19

What is the termination phase of interpersonal psychotherapy?

Answer 19

acknowledge feelings about termination

practice skills

anticipate challenges

Question 20

What is the initial phase of interpersonal therapy used to treat depression?

Answer 20

based on the assumption that mental disorders are rooted in relational difficulty which, in turn, may be based in communication deficiencies

treatment typically lasts several months; begins with assessment of symptoms and discussion of patient’s personal relationships: results in a relationship inventory, patient is encouraged to accept themselves for who they are, and not self-blame for past relational failures

in the case of treatment for depression, the psychologist explains the link between ill relationships and low mood

Question 21

What is the intermediate phase of interpersonal therapy used to treat depression?

Answer 21

in the intermediate stages, patient is assisted in coming to terms with loss relationships, expressing negative affect appropriately, and concentrating on new endeavors and forming new relationships

practical advice is provided concerning resolution of social conflicts and clear direction is given to foster increased social engagement

communication patterns are re-visited and care is taken to monitor for the re-emergence of old patterns in novel social contexts

Question 22

What is the termination phase of interpersonal therapy used to treat depression?

Answer 22

in the final (termination) phase, the patient prepares to end the therapeutic relationship

concerns and negative affect are acknowledged

advice given concerning the practice of skills

encouragement is given to seek out new opportunities to exercise the recently gained skills

it is well known that significant alternations in personal roles and circumstances may result in heightened psychological vulnerability

Question 23

What are process-experiential therapies?

Answer 23

very much an outgrowth of the humanistic/existential school

central premise: humans are intrinsically motivated to grow, learn, seek choice, and “self-actualize”: heavy emphasis placed on identification and integration of emotions

much time spent in reflective listening (as with STPP)

psychologists of this orientation tend to avoid quantitative research and prefer single subject, qualitative studies: has discouraged outcome studies

Question 24

What are the steps of process-experimental therapy?

Answer 24

therapeutic relationship + client self-determination + therapist empathy = exploring emotions & experiences

Question 25

What are the two central premises of CBT?

Answer 25

behaviors (mental and overt, adaptive and maladaptive) are learned, and can be unlearned according to scientifically established principles

one’s evaluation of their circumstances is often more harmful or distressing than the situation itself

Question 26

What is CBT?

Answer 26

more focused on the present than other approaches

presenting concerns are reframed into behavioral descriptions: those, in turn, are used to define discrete goals

Question 27

What are the steps of CBT?

Answer 27

assessment to develop case formulation and client goals

cognitive and behavioral skills modeled and practiced in session and generalized through homework tasks

review goals & skills; anticipate challenges; booster sessions as required

Question 28

What are the key activities of CBT?

Answer 28

problem identification

examining automatic thoughts and core beliefs

challenging interpretations and formulating alternatives

ongoing monitoring and evaluation

learning to generate and correctly choose options for solving practical problems (pros and cons)

Question 29

What are important characteristics of CBT?

Answer 29

homework assignments are give routinely: belief is that most change occurs outside of the office

reality testing and Socratic questioning emphasized

collaborative empiricism: concrete tests of dysfunctional beliefs are designed and implemented

CBT treatments tend to be slightly shorter than the others

termination occurs when goals have been met: skills are reviewed, discussion of possible challenges and stumbling blocks

return to booster sessions

Question 30

What are the four steps of seeking psychotherapy proposed by Saunders (1993)?

Answer 30

acknowledging that there is a problem

deciding that treatment may be of benefit

making a formal decision to seek treatment

making an appointment

Question 31

What is Prochaska and DiClemente’s (1984) “Stages of Change” model?

Answer 31

not specific to receiving professional interventions

pre-contemplative: given no thought to making a change of any kind

contemplation: no committing to make a change, but can recognize a potential problem

preparation: determining that something needs to be done

action: patient’s participation

maintenance: after therapy is terminated

relapse: extremely common, two processes (inattention, apparently irrelevant decisions)

Question 32

What demographic that is most likely to pursue psychotherapy?

Answer 32

despite strong evidence for the efficacy of psychotherapy in a broad range of mental disorders, a minority of individuals actually seek these interventions out

individuals most likely to pursue psychotherapy are female, have post-secondary educations and are young to middle-aged adults: in some respects, the lest likely to need help

Question 33

What are the rates of individuals that seek mental health treatment?

Answer 33

treatment is not uniformly available in all parts of Canada

while rates of mental illness are just as prevalent in rural areas, mental health practitioners of most types are far less accessible

most individuals who pursue therapy attend to 5 to 13 sessions

treatment may not complete in that time, and that may contribute to unfavorable outcome data

some individuals will receive non-EBT which may further deflate apparent success rates

Question 34

What are the alternatives to traditional psychotherapy?

Answer 34

usually means face-to-face, individual sessions with a therapist

self-help books

manualized, self-administered treatment (usually work books and tapes/CDs/DVDs)

computer-based interventions

group therapy

family therapy

telehealth

with the exception of self-help books, all of these have a demonstrated value for some disorders and clients

Question 35

What are the potential pitfalls in alternatives to psychotherapy?

Answer 35

early termination, when no professional is involved

not being able to meet needs of high-severity patients (e.g., telehealth with someone who turns out to be suicidal)

other screening failures

cross-jurisdictional licensure

relative difficulty making clinical observations (e.g., signal delays over telehealth)

Question 36

Why are some alternative psychotherapies attractive or use?

Answer 36

lowered stigma

cost effectiveness

serving individuals who wouldn’t otherwise seek assistance

Question 37

What is stepped care?

Answer 37

purely to address costs, we can consider arranging stepped care

beginning with least-intrusive and expensive measures and only offering more specialized, expensive services subsequently as needed

widely used in other areas of health care, but little empirical support in psychology

Question 38

What evidence is there that psychotherapy is effective?

Answer 38

Hunsley and Lee point out that little literature on therapy outcomes was available prior to 1950

rapid increase of work in that area ensued after that point

Question 39

What were the problems with the Hans Eysenck (1952) study that stated that psychotherapy was no more effective than no therapy?

Answer 39

lack of control groups

using essentially untreated individuals as examples of psychotherapy patients, and individuals in residential treatment settings as no-treatment controls

failing to control for other variables influencing changes in psychological functioning

Question 40

What is the role of meta-analysis in treatment?

Answer 40

more modern research has shown overwhelmingly strong evidence for successful treatment of several conditions

problem: comparing research reports by different investigators, using different approaches, with different patients is inherently problematic

difficult to establish a common metric

Question 41

How is a common metric established in meta-analytic studies?

Answer 41

express differences between treatment and control groups in terms of effect size, reflected by Cohen’s d

calculate the correlation between group membership and some measure of symptom reduction or severity

calculate the percentage of individuals in the treatment group who score above the mean value of the control group to quantify relative chances of improvement

Question 42

What are the criticisms of meta-analysis?

Answer 42

by themselves, these figures provide little guidance in determining which patients are most likely to profit

meta-analysis quality cannot exceed that of their component studies

despite these objections, this has become the method of choice for reporting large-scale treatment outcome inquiries

Question 43

What are randomized control trials?

Answer 43

both treatment and no-treatment controls

statistically significant outcomes, according to accepted quantitative analysis

manualized treatment (for replicability)

reliable and valid outcome measures

careful subject inclusion/exclusion criteria

these conditions are often difficult to meet in real-world clinical settings: in addition, some practitioners may feel threatened by challenges to their existing practices

almost certainly, a number of practices currently in use (but not yet adequately tested) will have proven efficacy in the future: others will be dismissed, or even identified as dangerous

Question 44

What are criticisms of randomized control trials?

Answer 44

strict inclusion/exclusion criteria defend internal validity, but may inaccurately portray real-world patients

many mental disorders show high comorbidity; more severe patients may be excluded from RCT to reduce confounds

RCT participants may therefore be highly atypical of real-world patients

research has concluded that RCT participants tend to be more severe symptomatically than the average patient receiving mental health services

Question 45

Do we have options other than EBP and EST?

Answer 45

while psychologists should always prefer treatment approaches for which there is good support, the reality is that nothing works for everybody

it is inevitable that one will have to consider alternatives

doesn’t grant use free license to do whatever we want

should start with the best-supported approaches and only resort to less established methods as necessary

always monitor for side effects

Question 46

What are effectiveness trials?

Answer 46

recall that effectiveness is contrasted with efficacy on the basis of differences in effect size between contrived research conditions, and real-world clinical outcomes

encouragingly, the disparity between the two is often not great

much of that success depends on:
delivering treatment in the most realistic and natural surroundings possible
making careful efforts to generalize treatment gains to the operational environment

Question 47

What is the initial stage of CBT use in treatment of depression?

Answer 47

in CBT, depression is conceptualized as a joint product of self-effacing beliefs and a withdrawn, inactive lifestyle

efforts are made early to encourage patient to “get off the couch”, participate in social activities

monitoring of activity (an inactivity) is required

can include exercise, pursuing recreational activities, re-engaging with friends, sitting idle

Question 48

What is the intermediate stage of CBT use in treatment of depression?

Answer 48

attempts are also made to monitor thoughts using tracking sheets

depressive thinking is negative in nature, reflects feelings of worthlessness, incapacity, and hopelessness

those thoughts are challenged, and careful consideration is given by the psychologist and patient to how those beliefs have influenced both mood and behavior

antidote thoughts or alternative interpretations are formulated and practiced

steps are taken to locate those thoughts in broader schema

involves building a new worldview and encouraging more optimistic forethought

personal experiments are encouraged along the way

Question 49

What is the final stage of CBT use in treatment of depression?

Answer 49

relapse prevention strategies are employed which anticipate threats to the ongoing use of skills, and cope with those proactively

Question 50

What is the initial stage of CBT use in treatment of PTSD?

Answer 50

capitalized jointly on exposure and response prevention

patient is trained in the use of relaxation skills to combat stress and feelings of anxiety that arise from re-experiencing trauma through imagery

client is encouraged to actively visualize a traumatic event while providing a present-tense narrative of their mental imagery

their descriptions should be vivid, detailed, and can include any sensory modalities

without the relaxation skills, this can be distressing enough to cause therapy termination

Question 51

What is the intermediate stage of CBT use in treatment of depression?

Answer 51

feelings of distress in response to imagery will extinguish if they can be consistently paired with feelings of relaxation, rather than panic

response prevention addresses tendency to discontinue, or flee, which will only negatively reinforce avoidant behavior if allowed to continue

often enough just to encourage continuation and remind them they are in no present danger

Question 52

What is the final stage of CBT use in treatment of depression?

Answer 52

there may be an element of systematic desensitization involving the construction of a hierarchy of fear-inducing stimuli, if the full recall is too threatening at the beginning

in vivo exposure is the final phase, patient confronts aspects of, or a situation similar to, the one in which they were traumatized

obviously, care must be taken at they are not re-traumatized or physically harmed

Question 53

Short-Term Psychodynamic Therapies

Answer 53

a treatment approach that emphasizes bringing to awareness unconscious process, especially as they are expressed in interpersonal relationships, and helping the client to understand and alter these processes

Question 54

Transference

Answer 54

the unconscious application of expectations and emotional experiences, based on important early relationships, to subsequent interpersonal relationships

Question 55

Interpersonal Psychotherapy

Answer 55

a treatment approach that emphasizes interpersonal elements in the development, maintenance, and alteration of psychological problems (especially grief, role disputes, role transitions, and interpersonal deficits)

Question 56

Process-Experimental Therapy

Answer 56

a treatment approach that emphasizes the importance of becoming aware of emotions, understanding and expressing emotions, and transforming maladaptive to adaptive emotions

Question 57

Cognitive-Behavioral Therapies

Answer 57

a treatment approach that emphasizes the roles of thoughts and behavior in psychological problems and, therefore, focuses on altering beliefs, expectations, and behaviors in order to improve the client’s functioning

Question 58

Self-Efficacy

Answer 58

a person’s sense of competence to learn and perform new tasks

Question 59

Self-Administered Treatment

Answer 59

treatment that the client engages in with no or minimal contact with a mental health professional

Question 60

Telehealth

Answer 60

the delivery of health care services via telephone, videoconferencing, or computer-mediated communications

Question 61

Stepped Care

Answer 61

an approach to health care service delivery in which lower-cost interventions are offered first, with more intensive and more costly interventions being provided only to those for whom the first-line intervention was insufficient

Question 62

Randomized Control Trial

Answer 62

an experiment in which research participants are randomly assigned to one of two or more treatment conditions

Question 63

Meta-Analysis

Answer 63

a set of statistical procedures for quantitatively summarizing the results of a research domain

Question 64

Effect Sizes

Answer 64

a standardized metric, typically expressed in standard deviation units or correlations, that allows the results of research studies to be combined and analyzed

Question 65

Clinical Practice Guidelines

Answer 65

a summary of scientific research (dealing with the diagnosis, assessment, and/or treatment of a disorder) designed to provide guidance to clinicians providing services to patients with the disorder

Question 66

Empirically Supported Treatment

Answer 66

a psychotherapy that has been found, in a series of randomized controlled trials or single-participant designs, to be efficacious in the treatment of a specific condition

Question 67

Open Trial

Answer 67

a type of initial exploratory treatment study in which no control group is used and, typically, few participant exclusion criteria are applied

Question 68

Benchmarking Strategy

Answer 68

the use of data from empirical studies to provide a comparison against which the effectiveness of clinical services can be gauged