Chapters 11 & 12: Intervention (Fundamentals & Adult Applications) Flashcards
What are the two main components of informed consent?
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
In what way are issues of consent age-related?
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
Why is ongoing monitoring of treatment important?
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
What is evidence-based practice in treatment?
best research evidence
clinical expertise
patient preferences & values
What is psychotherapy?
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
What is the APA resolution on effectiveness of psychotherapy?
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
What are the characteristics of psychotherapy?
within professional relationship
emphasis on psychological principles
broad: affect, behavior, cognition
acknowledges client/patient goals
but does not address whether services are evidence-based
What is an alternative definition to psychological treatment?
evidence based treatment of clinically significant emotional and behavioral problems
How is psychotherapy a controlled act?
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
What are some examples of discredited psychotherapies?
neurolinguistic programming
rebirthing
DARE
Scared Straight
How are evidence-based practice, empirically supported treatment, and randomized clinical trials related?
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
What if there is no evidence-based treatment that matches client needs exactly?
adopt the one that is closest
adapt if necessary
abandon if evidence it does not fit and replace with another EBP
What are the best supported therapies?
short-term psychodynamic therapies (STPP)
cognitive behavioral therapies (CBT)
process therapy (PT)
interpersonal therapy (IPT)
depends heavily on the disorders being treated
What are short-term psychodynamic psychotherapies?
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
What are the forms of feedback used in STPP?
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
What are the three phases of STPP?
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
What is the initial phase of interpersonal psychotherapy?
assessment and case formulation
What is the intermediate phase of interpersonal psychotherapy?
addressing interpersonal themes: grief, role disputes, role transitions, interpersonal deficits
What is the termination phase of interpersonal psychotherapy?
acknowledge feelings about termination
practice skills
anticipate challenges
What is the initial phase of interpersonal therapy used to treat depression?
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
What is the intermediate phase of interpersonal therapy used to treat depression?
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
What is the termination phase of interpersonal therapy used to treat depression?
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
What are process-experiential therapies?
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
What are the steps of process-experimental therapy?
therapeutic relationship + client self-determination + therapist empathy = exploring emotions & experiences
What are the two central premises of CBT?
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
What is CBT?
more focused on the present than other approaches
presenting concerns are reframed into behavioral descriptions: those, in turn, are used to define discrete goals
What are the steps of CBT?
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
What are the key activities of CBT?
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)
What are important characteristics of CBT?
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
What are the four steps of seeking psychotherapy proposed by Saunders (1993)?
acknowledging that there is a problem
deciding that treatment may be of benefit
making a formal decision to seek treatment
making an appointment
What is Prochaska and DiClemente’s (1984) “Stages of Change” model?
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)
What demographic that is most likely to pursue psychotherapy?
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
What are the rates of individuals that seek mental health treatment?
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
What are the alternatives to traditional psychotherapy?
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
What are the potential pitfalls in alternatives to psychotherapy?
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)
Why are some alternative psychotherapies attractive or use?
lowered stigma
cost effectiveness
serving individuals who wouldn’t otherwise seek assistance
What is stepped care?
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
What evidence is there that psychotherapy is effective?
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
What were the problems with the Hans Eysenck (1952) study that stated that psychotherapy was no more effective than no therapy?
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
What is the role of meta-analysis in treatment?
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
How is a common metric established in meta-analytic studies?
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
What are the criticisms of meta-analysis?
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
What are randomized control trials?
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
What are criticisms of randomized control trials?
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
Do we have options other than EBP and EST?
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
What are effectiveness trials?
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
What is the initial stage of CBT use in treatment of depression?
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
What is the intermediate stage of CBT use in treatment of depression?
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
What is the final stage of CBT use in treatment of depression?
relapse prevention strategies are employed which anticipate threats to the ongoing use of skills, and cope with those proactively
What is the initial stage of CBT use in treatment of PTSD?
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
What is the intermediate stage of CBT use in treatment of depression?
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
What is the final stage of CBT use in treatment of depression?
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
Short-Term Psychodynamic Therapies
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
Transference
the unconscious application of expectations and emotional experiences, based on important early relationships, to subsequent interpersonal relationships
Interpersonal Psychotherapy
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)
Process-Experimental Therapy
a treatment approach that emphasizes the importance of becoming aware of emotions, understanding and expressing emotions, and transforming maladaptive to adaptive emotions
Cognitive-Behavioral Therapies
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
Self-Efficacy
a person’s sense of competence to learn and perform new tasks
Self-Administered Treatment
treatment that the client engages in with no or minimal contact with a mental health professional
Telehealth
the delivery of health care services via telephone, videoconferencing, or computer-mediated communications
Stepped Care
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
Randomized Control Trial
an experiment in which research participants are randomly assigned to one of two or more treatment conditions
Meta-Analysis
a set of statistical procedures for quantitatively summarizing the results of a research domain
Effect Sizes
a standardized metric, typically expressed in standard deviation units or correlations, that allows the results of research studies to be combined and analyzed
Clinical Practice Guidelines
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
Empirically Supported Treatment
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
Open Trial
a type of initial exploratory treatment study in which no control group is used and, typically, few participant exclusion criteria are applied
Benchmarking Strategy
the use of data from empirical studies to provide a comparison against which the effectiveness of clinical services can be gauged
