Midterm 1

Question 1

What’s Zeitgeist and how does it apply to psychotherapy?

Answer 1

• German word
• ‘Spirit of the times’
• Application: dominant form of psychotherapy has changed over time and it has depended on what is going on at the time in the culture

Question 2

What are some contextual considerations to understand how the form of psychotherapy has changed overtime?

Answer 2

• What’s believed to be the cause of psychological problems? (etiology)
• Who is thought to be qualified to perform psychotherapy? (initially only psychiatrists performing psychotherapy, now usually a psychologist or another mental health professional)
• Can we use the scientific method to understand human behaviour? (resulted in major change in types of psychotherapies considered evidence-based -> have they been studied using research methods?)
• Can we study psychotherapy using the scientific method? (or is it too complex?)

Question 3

What were the early treatment traditions prior to the 19th century?

Answer 3

• Individuals with mental illness considered troublesome and were treated as they needed to be removed from society
• No hope that people especially with severe forms of mental illness would recover or be able to live a normal life
• Result: hospitals where people were treated no different than prisoners (animal tradition)
• Dark time in history with treatment of people with psychological conditions

Question 4

What’s the animal tradition?

Answer 4

• People with mental illness were seen as animals and put in hospitals where people could visit and pay a penny (the “penny show”) to watch them locked up
• Equivalent to today’s zoos

Question 5

What were the early treatment traditions during the 19th century?

Answer 5

• Moral treatment
• Realization that prior treatments were inhumane -> increase in moral treatments
• Moral treatments: “warm and trusting familial environment where patients could feel that their mental condition didn’t preclude participation in normal human activities”
• Idea that if you put people in relaxing environment and where they feel like they’re contributing something to the “mini society”, that this might help improve their mental health
• Led to development of a different type of asylum with large castle-like structures that had ballrooms for socializing, gardens where they could work (everyone had a job)
• Hope that this would allow patients to live a more normal life but still be treated within an in-patient environment
• Some of these were used for psychological treatment up until the 1980s (ex: Athens asylum in Ohio)

Question 6

What was the first formal psychotherapy?

Answer 6

• Psychoanalysis
• In all of the prior types of treatments, there wasn’t any psychotherapy involved
• People were being treated in locked units and mostly with medication

Question 7

Describe Sigmund Freud

Answer 7

• From Austria
• Trained as a neurologist because at that time there was no psychiatry
• Established 1st private psychotherapy practice (practicing out of an office rather than in a hospital setting)
• Published multiple books
• Early works: Hysteria (1895) & Interpretation of Dreams
  (1900)
• The way his work became publicized -> invited by G. Stanley Hall to US in 1908 where he discussed case of Anna O and as a result, lots of his work was translated into English and there became this interest in the US and in North America in terms of psychoanalysis becoming a dominant practice and it became more widespread than what was happening just in Europe
• Consequently, professional societies, journals, and training institutes on psychoanalysis developed in US

Question 8

Describe Freud’s work on Hysteria

Answer 8

His work was attributed to the wandering uterus and mostly as a result seen in females

Question 9

Describe the Anna O case

Answer 9

• Anna O was diagnosed with hysteria
• She thought she had some physical symptoms but it was decided that she had a psychological problem

Question 10

What were Freud’s major contributions with psychoanalysis?

Answer 10

• Drive Theory
• Levels of consciousness
• Personality structure
• Psychosexual stages of development
• Defense mechanisms
• Therapy techniques
• Therapy processes
• Most of these don’t really translate into current day psychotherapy and didn’t stick around

Question 11

Describe Freud’s Drive theory

Answer 11

• According to Freud, everything comes down to sexual instincts
• As he got older, he acknowledged that there’s also an instinct to avoid death and to do anything to avoid knowing about your mortality and facing your mortality

Question 12

Describe Freud’s Levels of Consciousness theory

Answer 12

• Unconscious, pre-conscious and conscious
• Psychoanalysis was trying to get to the unconscious (what people weren’t aware of)

Question 13

Describe Freud’s Personality Structure theory

Answer 13

• Id, Ego, Superego
• Relates to the Id and the Superego and the Ego in between trying to mediate

Question 14

Describe Freud’s Psychosexual Stages of Development theory

Answer 14

• Oral stage: toddlers putting everything in their mouths
• Anal stage: going through potty training
• Phallic stage: when kids become aware of their genitals
• Latency
• Genital stage: going through puberty and becoming aware of the opposite/same sex and of sexual instincts

Question 15

Describe Freud’s Defense Mechanisms

Answer 15

• Repression: preventing thoughts from coming into your consciousness
• Denial

Question 16

How much of Freud’s therapy techniques do we see in today’s psychotherapy practices?

Answer 16

• We see little of the types of techniques that Freud used in psychoanalysis in current psychotherapy
• Ex: free association (just saying what comes to your mind), dream analysis (asking people to describe their dreams, free form and try to find connections there)

Question 17

What types of techniques from Freud’s psychoanalysis have persisted in our thinking of psychotherapy?

Answer 17

• The discussion that Freud had about psychotherapy processes related to transference and counter-transference
• This is a pre-cursor to our modern day understanding of the psychotherapy relationship and how it’s an intimate relationship with another person and there can be feelings projected onto the other person in the form of transference and counter-transference
• This emphasized that we need to understand the relationship between these two people in this psychotherapy context

Question 18

What’s transference?

Answer 18

When the client feels a certain way about their therapist, perhaps based on past experiences, such as with their parents

Question 19

What’s counter-transference?

Answer 19

When the therapist develops feelings (non-romantic) about their client related to certain behaviours that they might engage in

Question 20

Who established the American Psychological Association (APA)?

Answer 20

• G. Stanley Hall (important figure)
• In 1892
• At the time the APA was dedicated towards research -> the science of psychology and not the practice of psychology
• The practice of psychology was under the purview of psychiatrists

Question 21

Who was the first to use the term “clinical psychology”and the one who established the first psychological training clinic at the University of Pennsylvania?

Answer 21

• Lightner Witmer
• In 1896
• The first person to describe the development of a training clinic within a university
• Psychology research was being done within universities and he had this training clinic that most likely was being used for research as well as treatment purposes
• The current training model that a lot of different university clinical psychology programs use, including McGill, where you have a clinic embedded within the university and that’s where the students who are undergoing their training first see their clients and get the first initial experiences with providing psychotherapy or assessment

Question 22

Psychologists were initially responsible for what instead of therapy?

Answer 22

• In the early 1900s, psychologists were initially doing things more related to assessment
• Ex: Intelligence testing -> intelligence assessments using the Wexler intelligence systems
• Ex: Personality testing
• They weren’t actually providing treatment
• Ex: during the wars, they were determining based on intelligence and personality, who would be a good candidate for a leadership position as opposed to a lower position in the army

Question 23

What caused this shift for psychologists focusing only on assessment to start focusing on psychotherapy?

Answer 23

• When WW2 happened and a lot of soldiers came back with what they referred to at the time as “shell shock” (modern day PTSD) and it created an additional need for people doing psychotherapy
• That’s when psychologists who were traditionally interested in academic and research transitioned to being involved/interested in more practice-based issues

Question 24

Describe Eysenck’s Critique of Psychotherapy

Answer 24

• Eysenck was a main academic psychologist involved in personality psychology
• In 1952, he published a paper called “The Effects of Psychotherapy: An Evaluation”
• He examined 19 studies
• All of these studies were either using psychoanalytic or eclectic psychotherapy
• All of the studies examined what they referred to as “neurotic” patients (equivalent to today’s depression/anxiety)
• They weren’t including studies where they were describing treatment of schizophrenia or psychosis or bipolar disorder
• A lot of limitations to this study when we think about it in terms of modern research methods -> but in 1952, it was a powerful study

Question 25

Describe the findings of Eysenck’s Critique of Psychotherapy

Answer 25

• In terms of recovery (defined by the practitioner at the time, not standardized), found that:
• 44% of the patients recovered when they were treated with psychoanalysis
• 64% recovered when they were treated with eclectic psychotherapy
• 72% recovered when they were just seeing a general practitioner and they weren’t necessarily receiving treatment for their neuroses

Question 26

Describe the conclusions from Eysenck’s Critique of Psychotherapy

Answer 26

• Eysenck concluded that there was an inverse correlation between the amount of psychotherapy received and the chances of recovery
• Because psychoanalysis is the most intensive therapy, eclectic psychotherapy would be in the middle and treatment from a general practitioner is the least intense (and those are the people who were most likely to get better according to this study)
• Also concluded that 2/3 of patients will recover regardless of whether they’re treated with psychotherapy or not -> because the 72% were the ones that didn’t receive any psychotherapy but still got better

Question 27

Describe the consequences of Eysenck’s Critique of Psychotherapy

Answer 27

• Inspired controlled research in terms of studying psychotherapy using research methods that were developed by academic psychologists
• Inspired the development of alternatives to psychoanalysis (of which there really weren’t any at the time) -> this study showed that in some ways psychoanalysis might be harmful because people were less likely to recover if they received psychoanalysis

Question 28

What’s eclectic psychotherapy?

Answer 28

• A mix of things
• Not sure what eclectic psychotherapy looked like in 1952 or before, because there wasn’t a whole lot beyond psychoanalysis
• Probably would have been a less intense version of psychoanalysis (ex: 1x a week instead of 3-5x a week)

Question 29

Describe client/person-centered therapy

Answer 29

• Developed by Carl Rogers
• Wrote a book: “Client-Centered Therapy” (1951)
• This therapy was focused on the therapeutic process and the relationship between the therapist and the client rather than techniques
• While Freud used techniques in psychoanalysis like dream analysis and free association, Rogers was focused on the person and the relationship with the therapist rather than the specific problems that the person presented with and rather than using techniques
• He believed that there were 3 core therapist qualities that were necessary for someone to get better in psychotherapy (genuineness, empathy, unconditional positive regard)
• Believed that everyone had this ability to get better and that everyone wanted to live a thriving life and that we just needed to mobilize this self-actualizing tendency in people through the psychotherapy for them to make improvements
• The first to conduct research on psychotherapy process (relationship between the therapist and the client) and how this related to the outcomes of the client (did they get better in treatment?) -> this was important and inspired by the Zeitgeist at the time which was that psychoanalysis was not doing that and was not working for everyone

Question 30

According to Carl Rogers, what are the 3 core therapist qualities necessary for someone to get better in psychotherapy?

Answer 30

• Genuineness
• Empathy
• Unconditional positive regard

Question 31

What are the 3 Waves of Behaviour Therapy?

Answer 31

• 1st wave: focus on observable behaviour and objective environment (behaviourism -> developed therapies based on theories of behaviourism that were studied in research contexts)
• 2nd wave: focus on cognitive representations of the environment (not just objective environment but also what’s happening in terms of interpretation of the environment -> things aren’t as simple as “change the environment and you’ll change the behaviour” )
• 3rd wave: focus on how internal processes are functionally related to the objective environment (sort of where we are now)

Question 32

Describe the origins of behaviour therapy

Answer 32

• Originated in British empiricism -> knowledge comes from experience
• We don’t come to this world with pre-existing knowledge
• We learn based on our experiences (one reason why early childhood experiences are important)
• Tabula rasa -> we come with this blank state
• Means that we can teach and shape people based on experience
• Ex: learning theory

Question 33

What are some examples of the learning theory?

Answer 33

• Ivan Pavlov and classical conditioning (idea that you can train a dog to salivate based on a bell after you pair the bell with some meat enough times)
• Edward Thorndike and the Law of Effect (relates to the cats and the puzzle boxes -> if the cat learns that their behaviour is going to produce a satisfying effect, they’re going to be more likely to repeat that behaviour)
• These provided the basis of behaviour therapy

Question 34

Describe behaviourism

Answer 34

• John B. Watson
• Wrote a poignant article: “Psychology as the Behaviorist Views It” (1913)
• In a famous quote from this article, he argues that there are no genes involved, no hereditary basis, it’s all behaviour, it’s all experience, it’s all environment (basically saying that we can shape behaviour)
• He conducted the Little Albert experiments where he conditioned Little Albert to be afraid of a white rat and then was able to generalize that fear to other things that were white and fuzzy, including a Santa beard

Question 35

Who wrote this famous quote: “Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors.”

Answer 35

John B. Watson

Question 36

Describe Mary Cover Jones (1924) behaviour therapy innovation

Answer 36

• Little Peter and deconditioning
• Jones was one of John Watson’s graduate students
• She did a very similar kind of experiment with Little Peter where she was able to decondition a fear
• This experiment showed that you can decondition a fear
• This was a pre-cursor to the treatment of phobias and anxiety disorders

Question 37

Describe Mowrer & Mowrer (1938) behaviour therapy innovation

Answer 37

• Bell and pad method for treating enuresis (bed wetting)
• Less psychological experiment for treating bed wetting where they developed this bell and pad method
• Once the pad that was underneath the mattress got wet from an accident, there would be a signal that would go off to indicate to the child that they peed and have to get up
• This was to train the child to know that they wet the bed with the bell

Question 38

Describe Skinner (1953) behaviour therapy innovation

Answer 38

• Skinner is thought of as a learning theorist and a research psychologist
• He applied some of his research on operant conditioning to try to increase social behaviour in patients with psychosis who often have very flat affect and who have a difficult time forming social relationships

Question 39

Describe Joseph Wolpe (1959) behaviour therapy innovation

Answer 39

• Developed systematic desensitization: based on classical conditioning and involved getting patients into a deeply relaxed state and then presenting them with a feared object
• The idea was that you couldn’t be both relaxed and afraid at the same time
• The relaxation was to try and reduce the likelihood of a fear response
• This was considered to be the first formal alternative treatment to psychoanalysis
• This was used mostly for anxiety and fear-related conditions

Question 40

What was considered to be the first formal alternative treatment to psychoanalysis?

Answer 40

Joseph Wolpe’s Systematic Desensitization

Question 41

Describe Albert Bandura’s contribution to cognitive therapy

Answer 41

• Albert Bandura was an important person for the development of cognitive therapy with his social learning theory
• Behaviour influenced by stimulus events, reinforcement, and cognitive processes
• Learning through modeling suggests direct reinforcement is unnecessary
• Ex: bobo dolls
• Even just observing something happening is important
• You don’t need to be conditioned yourself to learn something -> making connections without being reinforced
• Suggests there has to be something cognitively happening

Question 42

Describe Aaron Beck’s contribution to cognitive therapy

Answer 42

• Beck developed the cognitive theory
• This was more of his basic research
• He found that people respond to cognitive representations of the environment that are not always accurate and are not always based on objective reality but rather on their own interpretation
• Biased information processing: the way that we interact with the world and take information from the world can be biased
• Those biases and information processing are going to impact how we feel, think and behave (sort of the whole basis for cognitive behaviour therapy)

Question 43

Describe Mahoney’s (1974) contribution to cognitive therapy

Answer 43

• Mahoney was the inaugural editor of a journal called Cognitive Therapy and Research
• He felt like for things to generalize beyond a particular situation (ex: Watson’s work with Little Albert and seeing that the fear of the white object generalized to different things) this involves cognition
• You need to be able to know that this resembles this and therefore is also potentially a threat and/or will produce a fear response
• He developed the mediational approach
• He took things from a direct stimulus-response relationship (behaviourism approach) to the idea that there was stimulus mediated by the organism (the person is interpreting and/or making sense of things -> cognitive interpretation) to a response

Question 44

Describe Albert Ellis’ contribution to cognitive therapy

Answer 44

• Ellis is the author of Rational Emotive Behaviour Therapy
• Focused on beliefs as irrational and illogical
• Used logic and persuasion to help patients see their thinking errors and see that they were wrong in the way that they were interpreting things and adopt more “rational philosophies”
• Developed ABCDE model that he used to help patients do this

Question 45

Describe Albert Ellis

Answer 45

• Author of Rational Emotive Behaviour Therapy
• He gives his perspective on how things have changed over time and how cognitive therapy was developed
• He appeared at the same time as Aaron Beck who we often hear more about
• Both Ellis and Beck were trained as psychoanalysts but they were dissatisfied with the approach
• They didn’t feel like it fit with everyone and like the methods were always helpful for people
• They both went their own ways as a result of different experiences and developed more of this idea that cognitions are important
• He was a clinician and supervisor, not a researcher

Question 46

Why did Ellis’ influence not persist the same way as Beck’s?

Answer 46

• He was a clinician, he worked in private practice and supervised people who were learning his therapy that he wrote about but he was not a researcher
• He didn’t do any actual primary research on the therapy
• So it didn’t make its way into a lexicon as much as formal cognitive behaviour therapy

Question 47

Describe the ABCDE Model

Answer 47

A: Activating Event or Adversity
B: Beliefs about Event or Adversity
C: The emotional Consequences
D: Disputations to challenge irrational beliefs
E: Effective new beliefs replace the irrational ones
* We still use something very similar to this in current CBT
* There’s a situation that happens (A) and what’s really crucial is the belief about the event or adversity (B) -> the way that we interpret this situation and the way that we understand it
* That is going to determine the emotional consequences (C) -> if we change these beliefs the emotional consequences are going to be different
* Then the therapy works to dispute or challenge the irrational beliefs (D) and replace them with more rational beliefs and something that’ll make the person feel better that’s also based in reality (E)
* D & E are what’s done in the treatment

Question 48

Describe Aaron Beck

Answer 48

• Academic Psychiatrist at U Penn
• He was trained in psychoanalysis but he was based in the university unlike Ellis
• He did basic research on cognitions and information processing
• Most of his research and research on CBT was on depression
• Based on his research he concluded that depression is due to beliefs of being inadequate and unlovable
• Believed these were generalized beliefs that people had trouble seeing any kind of grey zone -> they believed this strongly and had trouble seeing instances where this wasn’t true
• Focus on beliefs as inaccurate, but not necessarily irrational -> he often talked about how it makes sense that people feel a certain way based on their childhood or previous experiences but it’s not true that they’re inadequate and unlovable in every single situation or that because they had these experiences that these experiences will repeat
• Used empirical disconfirmation (ex: with use of behavioural experiments) to test accuracy of beliefs
• Because he was a researcher, he believed in the power of evidence and of testing things out for yourself and seeing what the results are
• The first person to conduct RCTs of his cognitive therapy -> people had done some research on psychotherapy before but RCTs were only done in medicine at the time
• He was also comparing psychotherapy to medication -> medication was the leading treatment at the time and he was able to show that therapy was as effective as medication
• To disseminate his treatment, he developed treatment manuals -> he wrote everything down and made it useable which facilitated additional research and people practicing this

Question 49

What was a big difference between Beck and Ellis?

Answer 49

• Beck focused on beliefs as inaccurate but not necessarily irrational
• Ellis focused on beliefs as irrational and illogical
• Also, instead of challenging people and convincing them to see the other side of things in more of a talk therapy kind of way, Beck’s technique was to help people to see for themselves that things weren’t as black and white

Question 50

Describe the first trial of psychotherapy compared to medication

Answer 50

• First evidence that psychotherapy is at least as effective as medication came from a study by Rush, Beck, Kovacs, & Hollon (1977)
• Compared cognitive behavioural intervention to medication
• In both conditions people got better and maintained their improvement
• Looks like there might be a slight benefit for psychotherapy, but not significant -> they were comparable

Question 51

Describe Third wave Behaviour Therapy

Answer 51

• Distinct from traditional CBT (2nd wave) in emphasis on learning to accept emotions, cognitions, and behaviours, rather than trying to change
• Thoughts do not correspond to objective reality –> distance ourselves from our thoughts and our emotions rather than engaging with them
• Focus on valued living vs symptom reduction: reducing impairment from our symptoms rather than the symptoms themselves

Question 52

What are some examples of Third wave Behaviour Therapy

Answer 52

• Acceptance and Commitment Therapy
• Mindfulness-based cognitive therapy
• Dialectical Behavior Therapy

Question 53

What’s Acceptance and Commitment Therapy?

Answer 53

Idea that it’s not helpful to fight against our thoughts and give them more importance than they deserve and we should instead learn to accept that they’re just thoughts and we don’t have to act in accordance with them

Question 54

What’s the Canadian Psychological Association (CPA) Code of Ethics?

Answer 54

• Ethical principles, values, and standards for psychologists operating across various contexts
• They’re broad in the sense that they encompass those ethical guidelines for people providing psychotherapy but also psychologists who work in a research setting (ex: informed consent for research) and other contexts
• They apply to all types of psychologists, not just clinical psychologists or psychotherapists
• There are 4 ethical principles under which various statutes fall
• The code of ethics states that if there’s conflict between different statutes that fall under these different ethical principles, the earlier ethical principles (ex: 1 and 2) become prioritized over the later ethical principles

Question 55

What are the 4 ethical principles of the CPA Code of Ethics?

Answer 55

1. Respect for dignity of persons and peoples (in psychotherapy context, extremely important)
2. Responsible caring
3. Integrity in relationships
4. Responsibility to society

Question 56

What are the statutes present under the ethical principle of respect for dignity of persons and peoples in the psychotherapy context?

Answer 56

• Informed consent
• Privacy
• Confidentiality

Question 57

Describe the statute of informed consent under the ethical principle of respect for dignity of persons and peoples in the psychotherapy context

Answer 57

• Ensure client understands nature of therapy and has an
  opportunity to ask questions
• Ex: we want them to understand the limits of confidentiality
• We want them to go into this experience/relationship understanding what’s going to take place

Question 58

Describe the statute of privacy under the ethical principle of respect for dignity of persons and peoples in the psychotherapy context

Answer 58

• Collect minimal info necessary and keep all records secure
• We ask people a lot of personal info in psychotherapy, including past history, past experiences
• To the extent to which we take notes, we need to make sure we keep all of our records secure
• All data has to be encrypted or kept under a lock and key

Question 59

Describe the statute of confidentiality under the ethical principle of respect for dignity of persons and peoples in the psychotherapy context

Answer 59

• Don’t share client info with anyone unless required
  by law
• Everything that happens in therapy, stays in therapy
• Confidential relationship
• The therapist doesn’t tell their partner or friends about what their client says or share any info that could identify the clients
• Unless it’s required by law for the therapist to share something, then the info stays confidential -> part of the informed consent, client needs to know what specific situations where their therapist might need to disclose something to the authorities or someone else

Question 60

What are the statutes present under the ethical principle of responsible caring in the psychotherapy context?

Answer 60

• Competence and self-knowledge
• Maximize benefit
• Minimize harm

Question 61

Describe the statute of competence and self-knowledge under the ethical principle of responsible caring in the psychotherapy context

Answer 61

• Practice within areas of competence or seek
  consultation/supervision -> if you have a prospective client or a client with new problem and you don’t feel you have that competence, you need to seek some sort of consultation, supervision on the case, or some training on a particular psychotherapy method
• Engage in self-care and seek help if needed -> therapists are people and have their own struggles
• Important that if something is troubling the therapist and it’s getting in the way of their work, they need to try and seek help or engage in self-care and ensure that they’re stable and well enough to continue to treat their clients

Question 62

Describe the statute of maximize benefit under the ethical principle of responsible caring in the psychotherapy context

Answer 62

• Provide the best service possible
• Staying up to date with the literature and the different requirements that might change overtime

Question 63

Describe the statute of minimize harm under the ethical principle of responsible caring in the psychotherapy context

Answer 63

• Be aware that there’s a power differential in a psychotherapy relationship -> the therapist is an expert providing a service to a client and so the therapist has to make sure they’re protecting that person
• Don’t encourage or engage in sexual intimacy -> this can put the client in a very vulnerable position

Question 64

What are the statutes present under the ethical principle of integrity in relationships in the psychotherapy context?

Answer 64

• Accuracy/honesty
• Straightforwardness/ openness
• Avoidance of conflict of interest

Question 65

Describe the statute of accuracy/honesty under the ethical principle of integrity in relationships in the psychotherapy context

Answer 65

• Accurately represent your credentials and qualifications
• Making sure people are aware of what they’re getting into -> part of the informed consent

Question 66

Describe the statute of straightforwardness/openness under the ethical principle of integrity in relationships in the psychotherapy context

Answer 66

• Be clear about fees, policies, limits of confidentiality
• Fees: clients should know about the cost of psychotherapy right from the start, there should be no surprises
• Policies: ex -> cancellation policies
• Confidentiality: during the informed consent process, being very clear about the limits of confidentiality -> so that clients know if they disclose something that the therapist has told them might need to be shared outside of the therapy, it’s not a surprise to them when the therapist tells them that they need to contact someone about this

Question 67

Describe the statute of avoidance of conflict of interest under the ethical principle of integrity in relationships in the psychotherapy context

Answer 67

• Avoid multiple relationships
• In the psychotherapy context: your interest is in treating your client and helping them with whatever goals they have set out in therapy and so you want to avoid anything that could get in the way of that interest
• Ex: multiple relationships -> when you’re in a relationship with the client and there’s another relationship that’s in the mix that’s related to that
• Ex: could be that you know the client in another context, could be that you have an additional relationship with someone that the client knows (ex: family member or friend)
• This is a grey area
• There are times where multiple relationships can’t be avoided -> this is ok but you need to protect the client as much as possible because that’s your primary duty as the therapist

Question 68

What are the statutes present under the ethical principle of responsibility to society in the psychotherapy context?

Answer 68

• Respect for society
• Development of society
• These are more of the aspirational goals of therapists and why it falls on the last one of the list

Question 69

Describe the statute of respect for society under the ethical principle of responsibility to society in the psychotherapy context

Answer 69

• Familiarize self with laws and regulations in one’s
  jurisdiction
• Why it’s not the easiest thing to move between states or provinces with your psychotherapy permit
• It’s possible but you often have to take additional exams when you move because there are laws specific to that place

Question 70

Describe the statute of development of society under the ethical principle of responsibility to society in the psychotherapy context

Answer 70

• More the aspirational one
• Act to change aspects of the discipline that detract from beneficial societal change
• As a therapist, you’re an expert and a professional and you have to try and act in a way that can help change problematic aspects of the discipline that aren’t beneficial for societal change
• Ex: Canadian psychological association coming out with a statement that was against conversion therapy and that they regret the mistakes of the past and that they don’t endorse this moving forward
• Trying to make change within the context of therapy

Question 71

What are some common ethical issues in psychotherapy?

Answer 71

• Confidentiality and its limits
• Confidentiality and treating adolescents
• Multiple relationships
• Telepsychology

Question 72

Describe the ethical issue of confidentiality and its limits in psychotherapy

Answer 72

• (Almost) everything in psychotherapy remains
  confidential -> what’s said in the room remains in the room
• Confidentiality is very important
• Clients need to feel that they can be open and honest and that this is a safe environment
• Otherwise they may not be, they may not reveal things that are important and that are keeping them stuck -> this can lead to the therapist feeling there’s a mystery going on
• Not uncommon for clients to slowly open up overtime

Limits of confidentiality:
- Harm to self or someone else (ex: risk of suicide or risk of homicide)
- Harm or neglect of vulnerable person (ex: children, the elderly, people with disabilities, people who are dependent on others)
- Hard to navigate this with clients
- If someone reports that they have suicidal thoughts, not necessarily going to call the police on them since this is common for people in therapy -> more about the degree of risk
- Lots of training in clinical psych about how to conduct a risk assessment to figure out how likely it is that a certain person is at imminent risk (if they leave this office, there’s a good chance that they may harm themselves)
- Sometimes people think that this requirement of the therapist to have to report suicidality decreases the likelihood that this is going to be revealed in psychotherapy but this is something that often comes up and it becomes assessed but most times, it doesn’t lead to any need to contact the police
- The same goes with threats of harm to someone else but this is much less common and is associated with a particular presentation in psychotherapy (ex: people can have thoughts of suicide with many different diagnoses but thoughts of homicide/being at risk for homicide is more related to ASPD diagnosis or heavy substance use or psychosis, but people with psychosis tend to not be violent)
- Ex: Tarasoff vs. Board of Regents of University of California (1976)

Question 73

Describe Tarasoff vs. Board of Regents of University of California (1976)

Answer 73

• Duty to warn and protect is an important statute from the US
• Shows what are the duties of a psychologist
• This was a lawsuit
• Dr. Moore seems to have done what he was supposed to do, he assessed risk, he determined that there was a high likelihood that this client would harm someone else and he contacted the police and asked for the client to be committed to a hospital
• The police allegedly interrogated the client and found him rational, they concluded that he didn’t pose a danger and secured a promise that he would stay away from Ms. Tarasoff
• It was determined based on this case that Dr. Moore was liable for the death of Tarasoff, even though he did what he thought he was supposed to do which was contact the police
• What was determined from this case is that there’s a duty to warn and protect -> if there’s an identifiable victim of a potential crime, it’s the job of the psychologist to warn that person and somehow protect them
• Based on this ruling, Dr. Moore should have contacted Tarasoff and ensured that she had police protection
• In terms of confidentiality, therapists think to contact the police but not to contact other people and break the client’s confidentiality
• When it has to do with someone’s life, then that’s something that’s necessary
• This hasn’t come to court in Canada but we typically think that we have the same duty to warn and protect here

Question 74

Describe the video of the case related to the ethical issue of confidentiality and its limits

Answer 74

• Related to school shooting
• Psychiatrist had concerns about the threat one of her clients pose, she contacted his school’s threat assessment team, patient did not reach the threshold for a 72-hour hold for people who are an imminent threat to themselves or others and patient dropped out of school so they had no more control over him
• Predicting violence is a very difficult area in psychiatry -> best indicator is a past history of violence
• We see how difficult it is for psychologists to make these threat assessments
• In this case there was a concern, but no identified victim and not enough info
• HIPA -> US version of protecting patient’s medical info
• They didn’t have enough evidence to break that confidentiality and contact the police or have the person hospitalized

Question 75

Describe the ethical issue of confidentiality and treating adolescents in psychotherapy

Answer 75

• Specific area where confidentiality is very important and tricky
• Adolescents are complicated and are used to keeping information to themselves (ex: from their parents)
• When adolescents expect confidentiality, disclosure
  increases -> if you want true honest responses, an adolescent in therapy needs to feel that their info is going to be kept confidential
• Most times, guardians hold rights to records -> they’re providing the informed consent on the part of the adolescent
• They’re hence able to request info about their child from the therapist
• It’s up to the therapist to make rules/guidelines explicit from the beginning about what can be shared to the parents/guardians
• The parent/guardian and the adolescent need to know what kind of info is going to be shared
• Everyone needs to agree with this arrangement, otherwise there will be conflicts
• In Québec, 14 is the age of medical consent -> you can provide consent to attend your own psychotherapy starting this age (means there’s less that can be shared with parent or guardian)

When to disclose info to parents?
- No rigid rules on this -> comes down to the comfort of the therapist and what has been established as those ground rules
- Self-harm -> NSSI (cutting or burning) -> not necessarily disclosing this since the child isn’t necessarily putting themselves at risk of suicide
- Suicidal thoughts -> to what extent does the suicidal thinking have to have escalated in the risk assessment to then disclose this info to the parents
- Sexual activity: especially very early or unsafe sexual activity
- Violence: getting into fights, having urges to harm someone
- These are very tricky situations because if the therapist policy was that all of these types of things have to be disclosed to the parents, then they should be pretty sure that the adolescent is not going to be reporting a lot of these types of things that might be going on and that may be the reason that they’re in therapy

Question 76

What are some considerations when deciding when to disclose info to an adolescent’s guardian/parent?

Answer 76

• Immediate and future harm -> is this something that’s going to happen soon vs is this a pattern of behaviour that could potentially if it continues cause future harm and when in this pattern of behaviour would you want to disclose
• Parental reaction and client-parent relationship -> important to keep in mind the adolescent-parent relationship and how the parent would react to some of this info because that can also impact the overall dynamic
• Most likely if you’re working with an adolescent, the parent is involved in some way -> there are some sessions with the parent and the adolescent, some sessions with just the parent
• Have to consider what’s in the best interest of client and therapeutic relationship -> if the disclosure means that the client is no longer going to want to attend therapy and therefore the benefits of therapy are no longer going to be reached then that’s an important consideration
• If it’s determined on the part of the therapist that there’s a disclosure that needs to happen to the parent, then it’s important for the therapist not to do this on their own without involving the adolescent -> important to partner with the adolescent and provide them with some autonomy about how they want to handle this

Question 77

Describe the ethical issue of multiple relationships in psychotherapy

Answer 77

• There are many different types of multiple relationships
• No hard or fast rules about which ones are allowed and which ones aren’t -> except a sexual relationship with a current client is never allowed
• Multiple roles with the client or relationships with people that the client knows
• Not all multiple relationships are necessarily unethical -> sometimes can’t be avoided
• Ex: in a rural community where there’s one psychologist and one school and the psychologist’s kids go to school with all of the client’s kids and there’s bday parties and fairs where they’re seeing each other all the time -> not much that can be done in this situation
• Can create conflicts of interest -> can be tricky
• Ex: as a psychologist in a rural community who has a client and the client’s kid and your kid get in a fight and then you have to navigate that with the client as parents, while not letting it affect your therapeutic relationship
• Telepsychology would be a good alternative for this because it would allow people who live in rural communities to have access to a therapist that’s not part of their community

Question 78

What are some examples of violations of multiple relationships ethical issue in the psychotherapy context?

Answer 78

• Violations like having a sexual relationship with a current client are clear

Less clear examples:
- Dating your former client’s cousin -> as a therapist, your first duty is to think about the client and if the former client wants to return to therapy but by this point you’re dating their cousin, they may not want to do that anymore and it’s harming them because now they have to seek out a new therapist
- Treating one of your child’s classmates -> you may be one of the only child therapists and your child and their classmate may end up becoming best friends or may have a fight -> how do you handle this?
- Going to the same gym as your client -> generally not too big of a concern, but could be that the client has an eating disorder and you notice the exercise they’re doing may be too intense for them in the stage of their eating disorder

Question 79

What are some guiding questions for evaluating multiple relationships?

Answer 79

• Is the multiple relationship necessary? (Is there any other way around it?)
• Is the multiple relationship exploitative? (Your client shouldn’t be offering you things -> ex: they have a business and are offering you discounts. You don’t want to take advantage of the client in any way because of the power differential -> they’re always in somewhat of a more vulnerable position)
• Who does the multiple relationship benefit? (Should not benefit the therapist)
• Is there a risk that the multiple relationship could damage the client?
• Is there a risk that the multiple relationship could disrupt the therapeutic relationship?
• The easiest thing to do is simply to avoid it -> but there are some situations where you can’t avoid it and this is when you would ask these questions

Question 80

What are some benefits to telepsychology?

Answer 80

• Increased access, availability, and flexibility (for both therapist and client, to be able to just jump on a call and not have to commute to therapy for a while is a benefit for people)
• Ex: patients in rural communities -> there are communities like in Northern Quebec where there are no psychologists and so to be able to access those services without having to drive significant distances is important
• Ex: specialist care -> for conditions that not everyone feels comfortable treating (ex: eating disorders -> there are a lot of therapists that don’t want to see patients with eating disorders because on top of the psychological consequences to EDs, there are also medical consequences and therapists don’t feel comfortable having to manage all of that)
• Convenience, satisfaction, and increased demand (clients generally like the online format for therapy)
• Anonymity and privacy (disclosure may increase -> feels more private and more comfortable when you’re in your own environment)
• Issue for people who the idea of being seen in a therapist office is something that turns them away from therapy -> don’t want other people in the waiting room to see them

Question 81

What are some ethical concerns about telepsychology?

Answer 81

• Privacy, confidentiality, and security issues (ex: unencrypted tools)
• Ex: technology issues -> this is the case anytime we use anything online (ex: email -> often times if you’re a therapist, you have a statement at the end of your email that states that email is not a secure form of communication)
• Ex: concerns about how we are going to secure the relationship and the disclosures
• Ex: want to use encrypted tools -> during the pandemic software companies made their programs as secure as possible (ex: special version of zoom that’s especially secure where psychotherapy can take place)
• Therapist competence and training (technology and therapeutic competence)
• Ex: for younger therapists, doing this online is probably not too different from their regular technology use, but older therapists must have a harder time
• Ex: the relationship online is different -> but the data have been very encouraging about symptomatic outcomes of telepsychology
  (there’s been generally no differences between in-person and online therapy)
• Informed consent and emergency issues
• Ex: to get informed consent, you have to make sure the person in front of you is who they say they are (verify patient identity)
• Ex: you need to know where the person is located -> if there’s a concern of risk (imminent suicidal or homicidal risk), you need to be able to call the police and tell them where that person lives
• Practicing across borders -> very complicated
• Ex: if the client is located in a particular province, the therapist has to be licensed in that province -> this becomes an issue when clients move for school or work
• Ex: PSYPACT in US -> many states have come to an agreement that they recognize the license of therapists from numerous different states and they can practice across state borders
• This has opened up certain types of therapies to people from a much bigger area
• Prevents therapists from having to get licensed individually in multiple states, which requires multiple tests and payments

Question 82

What are some recommendations for using telepsychology?

Answer 82

• Comprehensive informed consent procedure that talks about things like the limits of the technology being used, the potential for some sort of technology breach
• Know emergency care options in client’s local area should you have to contact them
• Ensure both clinical (therapeutic relationship) and technological competence in types of technology being used
• Develop set of procedures for verifying client identity
• Ensure client and presenting problem is appropriate for telepsychology -> you don’t want the telepsychology option to be feeding into the person’s disorder
• Ex: this may be a good option for clients early on especially for those that have social anxiety disorder or agoraphobia, because they just can’t get themselves to the therapist’s office, but overtime, it would be good to bring that person into the office, as an exposure and as part of the therapy to get them to work on being able to get out of their house

Question 83

What are Randomized Controlled Trials (RCTs)?

Answer 83

• Main research method that we use to empirically evaluate whether a psychotherapy is effective or efficacious
• Used a lot in medicine
• Adopted from medicine where we study new medications and we compare them to placebo or sugar pills
• It’s a true experimental design (type of design where we can see a cause and effect relationship because we randomize people to different conditions and then look at the effect)

Question 84

What are the different methods to do research on/evaluate psychotherapy?

Answer 84

• Case studies
• Naturalistic studies
• Quasi-experiments
• Randomized controlled trials (RCTs)

Question 85

What sparked an interest in using research methods to evaluate psychotherapies?

Answer 85

• With increase in types of psychotherapy, the framework to evaluate psychotherapy developed
• People became increasingly interested in developing new forms of psychotherapy and with that became an interest in using research methods to evaluate these psychotherapies
• People wanted to see if there was a psychotherapy better than what was available before that
• Ex: Aaron Beck was comparing CBT to antidepressant medication
• There were no psychotherapies that were researched and evaluated prior to this and so medication was the gold standard at the time

Question 86

What are case studies of psychotherapy?

Answer 86

A series of cases that a psychologist has worked with for a particular presenting problem

Question 87

What are naturalistic studies of psychotherapy?

Answer 87

Having a practice and prior to a particular time point you were using a specific form of psychotherapy and you started getting trained in a new form of psychotherapy and you want to see how your clients after you started implementing this new kind of psychotherapy compare to how they did before

Question 88

What are quasi-experiments of psychotherapy?

Answer 88

• Comparing 2 different types of psychotherapy but clients aren’t randomly assigned
• You may have a particular practice where clients are given a choice (do you want to undergo CBT or interpersonal psychotherapy) and then outcomes are compared between those 2 groups
• Here we don’t have the random assignment that helps control for factors that would lead some people to choose one form of psychotherapy and others to choose another form of psychotherapy
• Those factors might then be related to the outcome that they have regardless of what kind of psychotherapy they receive
• This is why most studies in this area use a randomized controlled trial format

Question 89

What are the steps of a Randomized Controlled Trial?

Answer 89

• Step 1: Develop the protocol
• Step 2: Choose comparison to treatment of interest
• Step 3: Select participants of interest
• Step 4: Randomly assign participants to the different treatment conditions
• Step 5: Administer treatment and assess fidelity
• Step 6: Evaluate outcomes at end of treatment
• Step 7: Evaluate outcomes at follow-up time points

Question 90

Describe step 1 of the Randomized Controlled Trial

Answer 90

• Develop the protocol
• What’s actually being administered in this psychotherapy?
• What is the treatment?
• The treatment generally comes from some type of theoretical model that people think is important in the maintenance of some psychological problem and that’s what we want to change based on the treatment
• May come from arm-chair theorizing (traditionally would come from this), clinical observation, basic psychological research (common today)
• Treatment techniques -> what will you do in therapy to change problems specified in theoretical model?
• What we do in therapy will depend on what our theoretical model is, it’s directly going to follow from what we think is happening and then we’re going to develop treatment techniques to change these problems that we think are going to be maintaining the problem
• How will the treatment be administered?
• Need to have some standardization to have experimental control
• Most common thing that’s done when a treatment is being developed, tested, and researched is some type of treatment manual is being written
• This doesn’t mean you have to say specific things in specific sessions -> treatment manuals aren’t super strict, they just outline the kinds of things you’re going to cover with your client and suggest a general order that has flexibility
• There are probably going to be multiple people (clinicians) administering the treatment in the context of a treatment trial who will have to be trained and have to have ongoing supervision to ensure they’re doing the treatment correctly

Question 91

Describe step 2 of the Randomized Controlled Trial

Answer 91

• Choose comparison treatment -> to what will you compare the treatment of interest?
• Waitlist control (historically people used this)
• Supportive psychotherapy
• Gold standard treatment (CBT is often gold standard to which new treatments are compared)
• Much more difficult in the psychotherapy world then in the medication world because we don’t have placebo pills to give to people in terms of psychotherapy

Question 92

What are clinical observations?

Answer 92

• A lot of the early treatment traditions came from people watching their patients
• This is how Beck and Ellis came up with CBT because they didn’t feel like the instincts talked about in psychoanalysis were what was driving depression and they thought it was more about faulty beliefs

Question 93

What’s arm chair theorizing?

Answer 93

• When professors had more time on their hands and would sit around and think a lot
• Where theoretical models would traditionally come from

Question 94

What’s basic psychological research?

Answer 94

Conducting research in an experimental type of way and seeing if we can target some of the processes that have shown to be important in experimental studies in a treatment

Question 95

What’s a waitlist control?

Answer 95

• Historically people used waitlist controls
• They had a comparison where people would just wait and then eventually receive the treatment for ethical reasons because they’re participating in research and should receive a treatment that is thought to be promising
• Problem: this really isn’t equivalent to a placebo in pharmacotherapy trials because people know that they’re not receiving any treatment and are just waiting -> not like they’re taking a treatment or a pill everyday and aren’t sure what they’re receiving
• People have moved away from a waitlist control to a supportive psychotherapy

Question 96

What’s supportive psychotherapy?

Answer 96

• Psychotherapy where the clients/participants are meeting with a therapist
• This controls for the interaction with the therapist and common factors that are important in influencing psychotherapy outcomes
• Just having someone to talk to every week about your problems, expressing your emotions, receiving support and receiving validation
• Important thing for this comparison treatment is that it doesn’t contain the active ingredients or the things you think are important in the maintenance of the disorder -> what’s missing
• Both treatments have this supportive environment/aspect, but one contains the active ingredient -> like in a medicine trial where you’re taking a pill everyday and thinking this will help you get better but one pill has the active ingredients and one doesn’t (placebo)

Question 97

Describe the gold standard treatment

Answer 97

• Nowadays there has been enough research done to say that CBT for most conditions is considered the gold standard treatment
• It has the most research support
• Good first line treatment to try
• For people developing new treatments these days, they’re often comparing it to CBT
• Sometimes not looking to show that new treatment is better than CBT but instead looking to show that it’s equivalent to CBT
• Because we know CBT is quite effective so if treatment is equivalent then it provides people with another treatment option

Question 98

Describe step 3 of the Randomized Controlled Trial

Answer 98

• Select participants
• Who will your participants be?
• Who is our sample going to be and to whom do we want these results to generalize?
• You want to balance the concerns with internal vs external validity
• Ideally you want the participants in your treatment trial to be representative of the population to which your results would be generalized
• This relates to demographic factors (are you including people of all genders, are you including people of all races and ethnicities?) and comorbid diagnoses (historically a lot of treatment trials excluded people with a comorbid diagnosis -> although this increases internal validity (you can say your results aren’t due to people getting better from another disorder, really only due to the disorder you’re studying), this decreases external validity because most of these people who only have one disorder are not representative of people with depression in the real world -> comorbidity is the rule rather than the exception)
• This has changed, now we’re including people with comorbid diagnoses for the most part, at least diagnoses that don’t significantly interfere with completing the treatment

Question 99

What’s internal validity?

Answer 99

• Quality of experimental design and control for extraneous factors
• Refers to experimental control
• How tightly controlled is your experimental design and how able are you to rule out extraneous factors that might be related to the ultimate outcome of your treatment trial

Question 100

What’s external validity?

Answer 100

• Will results extend to other people and settings
• Related to generalizability
• How well are you able to extend your results to other people, other settings, individual people that were not included in the treatment trial

Question 101

Describe step 4 of the Randomized Controlled Trial

Answer 101

• Random assignment -> randomly assign participants to the different treatment conditions
• Always assess baseline characteristics of participants to see whether a random assignment actually worked
• Random assignment minimizes pre-existing differences between groups that could affect outcome (ex: gender, race, baseline levels of depression)
• We should ideally have an equal number of people from all genders, races, baseline levels in our experimental and our control group
• We want to do our best to blind to the extent that we can (single vs double)
• Double-blind not possible in psychotherapy trials
• No blinding is possible when you have a waitlist control design because the participant clearly knows that they’re not receiving any treatment, they’re just waiting
• When comparing an experimental treatment to a supportive psychotherapy, it’s possible that if you don’t give a lot of detail about the new psychotherapy to the participant prior to them starting the trial, they may not know whether they’re in the experimental or control group
• This would be a positive thing because they wouldn’t necessarily develop the expectation that one treatment is going to be better than the other
• But the clinician is always going to know because they’re delivering the treatment and have a treatment manual so they know what treatment is new and which one isn’t (limitation of RCTs of psychotherapy that we can’t overcome)

Question 102

What’s single-blinding in an RCT?

Answer 102

The participant doesn’t know what condition they’re in

Question 103

What’s double-blinding in an RCT?

Answer 103

Both the participant and the clinician don’t know what condition they’re in

Question 104

Describe step 5 of the Randomized Controlled Trial

Answer 104

• Administer treatment
• Who’s administering the treatment and are they doing it properly?
• Are the therapists administering the treatment as outlined?
• We can have treatment manuals but if people don’t use them and don’t adhere to what was initially developed by the treatment developers then are we really having a good test of the treatment?
• We do fidelity checks (how well are people doing the treatment as intended?): ongoing supervision of the therapist conducting the treatment and typically the sessions will be recorded and there will be coding of the sessions to ensure that they’re adhering to the format of the treatment manual or doing what they’re supposed to
• How well is the treatment being administered?
• Everyone could be using the same treatment manual but some therapists are better skilled than other therapists which in part comes down to general interpersonal factors
• Important to consider therapist factors and to think about how if you have particularly strong therapists administering the experimental treatment and not the control treatment then that may be a big confound -> have to work around this

Question 105

Describe step 6 of the Randomized Controlled Trial

Answer 105

• Evaluate treatment in terms of:
• What’s the outcome of interest?
• Statistical significance
• Effect size
• Therapist and site effects
• Drop-outs

Question 106

Describe evaluating the treatment (step 6 of RCT) in terms of what’s the outcome of interest

Answer 106

• One of the things we have to define and typically pre-define is what’s the outcome of interest -> what do we really care about in terms of change
• No longer meeting the DSM diagnostic criteria for the psychological disorder (ex: for depression you need to meet 5 of 9 criteria and someone started at 5 criteria but is now at 4 criteria, they technically wouldn’t meet the diagnosis anymore but is that a meaningful change?)
• A decrease in target symptoms -> often use a continuous measure such as the Beck Depression Inventory and look at a change in symptoms
  -> Often a question of how much change (ex: difference between statistical and clinical significance)
  -> How much change do we need to see on an outcome to say that the treatment was helpful?
• A decrease in comorbid symptoms (ex: decrease in anxiety in treatment for depression)
• May also care about comorbid symptoms especially for some of the new treatments that are being developed and considered to be transdiagnostic in nature (trying to target multiple disorders at the same time)
• An increase in functioning (ex: occupational, social)
• Most come to therapy because they aren’t functioning the way that they were and they want to get back to their normal self and their normal life
• These are things that patients care about and that we should also care about when testing our treatments

Question 107

Describe evaluating the treatment (step 6 of RCT) in terms of statistical significance

Answer 107

• Statistical significance is typically defined as a value of less than .05 (p < .05)
• Means in practice that there’s a 5% likelihood that the result that you obtained occurred by chance
• Most people are comfortable with that 5%
• Some people want it to be lower and rarely ever go higher than 5%
• Both the magnitude of effect (ex: the difference between 2 groups - experimental and control group) and the sample size influence statistical significance
• The sample size really influences whether a result is statistically significant
• Ex: you can have a really large sample and you can have lots of statistically significant results but they’re very small and not very meaningful
• RCTs are very hard to do, they require a lot of time and effort and so the sample sizes aren’t always huge and this is always a concern

Question 108

Describe evaluating the treatment (step 6 of RCT) in terms of effect size

Answer 108

• Effect size is the magnitude of the difference (ex: between the experimental and the control conditions)
• Independent of sample size (much more meaningful outcome because it allows us to compare across different studies that have different sample sizes)
• Formula: Mean difference between experimental and control group/standard deviation of control group
• Often represented by Cohen’s d (we also see Hedge’s g quite often which is just a slight difference)
• General way that we interpret those coefficients: value of 0.2 = small; 0.5 = medium; 0.8 = large
• Between .2 and .5 = small-medium, between .5 and .8 = medium-large
• Anything larger than .8 is large
• This doesn’t really address the question of how much change is needed for clinical significance
• This is something that we don’t have a standard for, but for measures that are often used, we often want people to move from being within one standard deviation of the average of a clinical group to moving towards being in one standard deviation of the average of a non-clinical group on a particular measure -> this would indicate that they’re switching groups and this is a clinically significant change
• But this needs to be determined for every single outcome measure and you need to have population norms, you need to have norms for those non-clinical and clinical groups to be able to make this distinction -> much harder

Question 109

Describe evaluating the treatment (step 6 of RCT) in terms of therapist and site effects

Answer 109

• Therapists can differ
• A lot of times with RCTs because it’s really hard to get the population of interest, there’s a lot of different university or medical hospital sites working on the same trial -> you have to control for that
• These are random factors that are unrelated to the particular treatment that need to be accounted for in some way, typically as controlled variables in the statistical analysis

Question 110

Describe evaluating the treatment (step 6 of RCT) in terms of drop-outs

Answer 110

• Drop-outs happen in treatment trials just like in therapy
• Motto: once they’re randomized, always analyze
• Once they’re put in a particular group, you need to account for them
• There are particular statistical ways to do that called intention-to-treat analyses -> where you don’t just ignore the people that dropped out, you include them and impute their data

Question 111

Describe step 7 of the Randomized Controlled Trial

Answer 111

• Follow-up -> to see whether the treatment and its benefits persist overtime
• What happens after treatment is withdrawn?
• Relapse and Sleeper effect
• Finding that psychological treatment
  more enduring than
  medication: common finding we see when looking at follow-up where when comparing antidepressant medication to a psychological treatment like CBT, they do equally well in the short-term but CBT maintains its improvements overtime better than the medication
• Idea that you’re learning skills (ex: problem-solving) and particular techniques that you can continue to use after the treatment is done whereas with antidepressant medication, you’re not really learning anything, you hope your brain is rewiring to some extent but sometimes that rewiring isn’t permanent and so it doesn’t necessarily help after the treatment

Question 112

What’s the sleeper effect?

Answer 112

• Phenomenon where during the treatment, it doesn’t seem like people are doing that well but they actually continue to get better after the treatment
• Interpersonal psychotherapy often shows this sleeper effect
• Could be because you’re working on interpersonal interactions and how you can do better in your relationships and sometimes in the course of a short treatment, you don’t have that many opportunities to practice these skills but you keep practicing them after the treatment is done and so you keep experiencing improvements as a result of having received that treatment

Question 113

Describe DeRubeis, Siegle, & Hollon’s (2008) study on antidepressant medications and cognitive therapy

Answer 113

• Groups were randomized
• Placebo group, antidepressant medication group (broken into those that were compliant with taking the medication and those who weren’t) and cognitive therapy group
• During the continuation phase, those who were on the medication continued on their medication and those who had cognitive therapy had a few booster sessions but it wasn’t necessarily that they were continuing once weekly psychotherapy
• Then all treatments stopped and they found that the medication group quickly continued on a downward trend towards relapse and the cognitive therapy group is the group that best retained their improvements as a result of treatment
• This is a really common finding

Question 114

What’s the CONSORT Flow Diagram?

Answer 114

• Reporting RCT Results
• Required to be included in any RCT empirical paper
• Helps you see how the flow of the treatment went
• Why were people being excluded? -> they were interested in the study but they were excluded for what reasons?
• How many people were randomized? -> these are the people that should be analyzed in the final sample
• How many people were allocated to each intervention?
• How many people were excluded and why? -> often with medications, here’s where you would see people who dropped out because of side effects
• We might want to see that same type of thing for psychotherapy

Question 115

What’s a meta-analysis?

Answer 115

• Meta-analysis answers the question of what does a particular body of research say about psychotherapy or about a particular treatment
• Effect sizes are helpful because they’re independent of sample size and it allows us to compare across studies where we have different sample sizes
• A meta-analysis is a statistical technique that pools effect size estimates: it’s taking a bunch of effect size estimates from a bunch of different studies and combining them to see what’s the strength of the evidence across all of these different studies
• It’s considering sample sizes in terms of the strength of that evidence (it’s always weighted to sample size when you combine effect size estimates)
• You can have some studies that show an effect, some studies that don’t show an effect, some studies that show the opposite effect
• You want to see what’s the overall picture
• The meta-analysis can examine moderators of treatment efficacy
• It’s possible that a new treatment is particularly helpful for a particular group of participants
• Ex: are the effects larger for a particular group of participants, maybe when using a particular outcome measure such as a participant-reported scale vs a clinician-rated scale? Is it better if the practitioners are PhD-level psychologists vs masters-level social workers?
• What’s explaining why across different studies we see different effect sizes
• That’s why we would do a moderator analysis in a meta-analysis

Question 116

What’s a moderator?

Answer 116

A variable that determines the strength or the direction of a relationship

Question 117

Describe the first meta-analysis of psychotherapy research

Answer 117

• Smith & Glass (1977)
• Meta-analysis of 375 controlled therapy studies
• Findings: the typical therapy client ends up better than 75% of untreated clients (those who don’t go to therapy) -> different conclusion than Eysenck who thought that you could get worse if you went to therapy or that there was an inverse correlation between the amount of therapy received and tendency to recover
• Found a combined effect size across the therapies = 0.68 (medium-large effect size)
• Effects sizes similar across different treatments -> across different types of therapy, there wasn’t a lot of difference between the treatments
• All of them had average effect sizes that were generally in the medium-large range, with a few exceptions (ex: Gestalt being 0.26 but also having the lowest number of studies)

Question 118

Describe Chambless & Hollon (1998) description of empirically supported treatment (EST)

Answer 118

• Chambless & Hollon (1998) Journal of Consulting and Clinical Psychology
• This was the big paper that came out and said this is what we want to see to be able to call a treatment empirically supported (it has research support)
• There were only 2 categories in this paper: well-established treatments and probably efficacious treatments
• They have a description of what “good” means
• Probably efficacious treatments mean that we need some more evidence but it’s looking promising
• This was our definition of empirically supported treatment for a very long time
• Despite the fact that so much research was being done on psychotherapy, we still had this bar of having 2 studies showing an effect
• There was no consideration of what to do if there’s a bunch of studies that don’t show the effects that the others do or what to do if there’s mixed findings
• Wasn’t clear how we were supposed to use that definition that was developed in a time where research was only just getting started compared to now

Question 119

What are Chambless & Hollon’s (1998) criteria for well-established treatments?

Answer 119

• At least 2 “good” between-group design experiments that show the treatment is better to a medication, a psychotherapy placebo (ex: supportive psychotherapy), or other treatment OR is equivalent to an established treatment (ex: comparing treatment to CBT) OR (if you don’t have this, could also be…)
• A large series of single-case design experiments with good experimental design and comparison to another treatment AND
• Must be conducted with treatment manuals or other clear description (because it needs to be clear what was actually done in the treatment)
• Characteristics of samples must be clearly defined
• Effects must be demonstrated by at least 2 different investigators or teams (important at the time) -> tends to happen that when a treatment is developed, the people who develop it are especially interested/motivated in showing that it works and sometimes they’re the only people doing research on the treatment, so then there’s concern about if it’s only the people who developed the treatment that are able to deliver it successfully then that’s not going to be a helpful treatment because it’s not generalizable (we can’t give it to people working in the clinic and expect them to use it)
• We need to see that this is something that other people can successfully use and show that it works

Question 120

What are Chambless & Hollon’s (1998) criteria for probably efficacious treatments?

Answer 120

• 2 experiments show treatment is better to waitlist control (no comparison to a medication or a psychotherapy placebo or another treatment) OR
• One or more experiments meet criteria above but have not been replicated by independent investigators OR
• A small series of single case design experiments have been conducted

Question 121

Describe Tolin et al. (2015) description of empirically supported treatment (EST)

Answer 121

• Tolin et al. (2015); Clinical Psychology: Science and Practice
• Almost 20 years after Chambless & Hollon, Tolin wrote with a bunch of other clinical psychologists an article to try and update the guidelines of what an EST is
• Made the argument that this evaluation based on 2 studies showing significant findings is an unreasonably low bar given the number of RCTs
• Said we have to focus on systematic reviews and meta-analyses that synthesize the literature as a whole (to know across all studies, what the picture is here) -> we can’t just focus on 2 studies, which are the only 2 that show significant effects
• We also have to take into account that studies vary in their quality and risk of bias and incorporate this into our systematic reviews and meta-analyses (most of these knowledge syntheses do that now) -> keeping in mind that studies from 20 yrs ago are probably going to be less rigorous and well-designed than some of our current trials
• Other criticism was that the focus had been on symptom reduction (showing a decrease in target symptoms) -> argues that it’s much more important to measure functional impairment and quality of life as this is what’s most relevant to patients
• Based on Chambless & Hollon’s guidelines for ESTs, the APA came out with a list of ESTs for different conditions
• Ex: for depression because it receives the most research, the list was ~20 treatments long
• Tolin argued that when we have 20 treatments to choose from, how do clinicians know which treatment to choose from the list
• No guidance on which EST to choose from list
• We want to include info on the strength of the treatment (ex: the effect size from meta-analyses) and evaluate both clinical and statistical significance because it’s not enough to rely on just statistical significance

Question 122

What are common factors?

Answer 122

• Factors that characterize psychotherapy, in general
• Ex: therapeutic alliance, empathy, expectation for
  improvement that the client normally has when they start treatment, therapist skills
• Contrast with factors that are specific or unique to a particular form of therapy
• Ex: Dream analysis in Psychoanalysis (you don’t really see other psychotherapies talking about dreams in that same way); Exposure in Behaviour Therapy; Cognitive restructuring in CBT

Question 123

What’s the Dodo bird verdict and how does it relate to common factors in psychotherapy?

Answer 123

• Saul Rosenzweig (1936) talked about the Dodo bird verdict
• Comes from Alice in Wonderland -> book refers to the dodo bird
• Idea that the dodo bird says in the book is “all have one and all must have prizes”
• Saul adopted this phrase to talk about how all therapies have been shown to be helpful and all must be recognized
• Not sure what else was around at this time other than psychoanalysis
• This continued and we see reference to the dodo bird verdict in relation to psychotherapy in more contemporary days

Question 124

Describe Jerome & Julia Frank’s contribution to common factors perspective of psychotherapy

Answer 124

• Jerome & Julia Frank: Persuasion and Healing (1963)
• In this book, they come out strongly for the common factors model
• They say that the healing and persuasive power of therapy depends on features of psychotherapy that are shared by all schools/models of psychotherapy
• Goal of therapist, regardless of the therapy practice, is to:
• Clarify symptoms and problems
• Inspire hope (important that the client feels they can get better so that they’re able to make changes that need to be made)
• Facilitate experiences of success and mastery (so that they notice some improvement and that they continue to build on that)
• Stir patient’s emotions (to really get to those core emotions that people are often avoiding)
• As a result of these actions, patient becomes “remoralized” and they have an increased sense that they can change something within themselves or their environment)
• Therapy really is on the part of the client themselves to make the changes -> the therapist’s job is to facilitate that and so by providing these different parameters, such as clarifying the symptoms, the client feels like they have now the tools and that they can implement these outside of therapy

Question 125

Describe Bruce Wampold’s Contextual Model (common factors model)

Answer 125

• There are different pathways through which psychotherapy exerts its effects
• Initial therapeutic relationship: “First impression”
• 1st pathway: “Real” relationship
• 2nd pathway: Expectations
• 3rd pathway: treatment that elicits healthy patient actions will be effective
• This is the model of common factors in the sense that whatever the client is doing in therapy, as long as it has been shown to be beneficial, it’s going to be an effective therapy

Question 126

Describe the initial therapeutic relationship part of Bruce Wampold’s Contextual Model

Answer 126

• “First impression”
• Recognizing the importance of that initial contact
• More clients drop out of therapy after first session than any other time
  point
• If they go to therapy, which sometimes takes a lot of motivation and sometimes people are hesitant to start therapy, and find that they’re not connecting on that first session with their therapist, then they often drop-out and sometimes they don’t necessarily go and find another therapist they may decide that’s not for them
• That first initial impression is very important for retaining clients in therapy

Question 127

Describe the 1st pathway of Bruce Wampold’s Contextual Model

Answer 127

• “Real” relationship
• Personal relationship marked by genuineness (one of Carl Rogers’ necessary factors in therapy) and a perception that befits
  the other
• Even though the therapist is not doing the same thing as the client in terms of talking about their life and revealing a lot of personal details, you really are getting to know the other person in terms of their personality
• The therapist is being genuine with their clients

Question 128

Describe the 2nd pathway of Bruce Wampold’s Contextual Model

Answer 128

• Expectations -> there’s an expectation on the part of the client that therapy is going to be helpful or else, unless they’re mandated to treatment for some reason, there would be no reason that they would be in therapy
• “Remoralization” that clients are hoping for in the course of therapy
• The idea is that participating in therapy is going to provide some sort of benefit
• Participating in psychotherapy will help the person in their current situation and that motivates the client themselves to take action that will further contribute to their expectation that they’re going to get better and then eventually that they themselves have the tools to be able to get better

Question 129

Describe the 3rd pathway of Bruce Wampold’s Contextual Model

Answer 129

• Treatment that elicits healthy patient actions will be effective
• This is where the specific factors come in
• Depending on what the therapy is, what’s being asked of the client in terms of what they should be doing either in treatment or outside of the sessions is going to differ
• But Wampold says that regardless of what the clients are being asked, as long as they’re engaging in actions that are healthy and helping them to make improvement, the therapy is going to be effective

Question 130

What’s the evidence for common factors?

Answer 130

• Therapeutic alliance
• Empathy
• Expectations
• Therapist effects
• Facilitative interpersonal skills (FIS)

Question 131

Describe the therapeutic alliance evidence for common factors

Answer 131

• Most studied common factor
• Typically divided into 3 categories:
• Affective bond: the real part of the relationship (ex: you like the other person, you respect the other person, you feel positively in their company)
• Agreement on end goals of therapy: what’s the therapy trying to achieve at the end?
• Ex: common question we might ask clients at the beginning of therapy is how would we know when therapy is over? How would we know when there’s been sufficient improvement? What are the goals of this course of therapy?
• Agreement on in session tasks: what’s the therapy going to look like from session to session? What are we going to do together?
• These things can be measured using Working Alliance Inventory
• Ex: clients may complete the measures of the WAI after every session and then therapists can see how the alliance improved overtime
• Often times people rate these things very highly, they’re very connected with their therapists, but sometimes you can see a drop based on a difficult session and then what you want to see is that there’s a recovery in the alliance in subsequent sessions
• Relationship (correlation) between early therapeutic alliance (in the first few sessions) and therapy outcome: r = .27 (medium effect)
• These are different from Cohen’s d, because Cohen’s d is when you’re comparing 2 different things and here we only have one therapy
• We want to focus on the early part of therapy in terms of measuring the alliance because as someone gets better in therapy, the alliance tends to improve -> they tend to be confounded with one another as therapy goes on

Question 132

Describe the empathy evidence for common factors

Answer 132

• One of Carl Rogers’ important factors of therapy
• Empathy: process by which an individual can be affected by and share emotional state of another, understand or assess reasons for the other’s state, and identify with them by adopting their perspective
• Related constructs (sometimes studied alongside empathy):
• Positive regard/affirmation
• Congruence/genuineness
• Empathy, rated by clients, therapists, and outside observers (ex: by using videotaped sessions), correlates with therapy outcome (rs = .32, .25, and .20, respectively)
• Strongest correlation being with the clients’ rating of the empathy -> shows how it’s most important how the client perceives the therapist because that’s the person who’s making the changes in terms of getting better
• Less important for the therapist to think they’re empathic if the client doesn’t agree

Question 133

Describe the expectations evidence for common factors

Answer 133

• Wampold thinks that this is very important
• Relates to the explanation of the patient disorder (diagnosis or model of how disorder developed and is maintained), rationale for
  treatment, that client understands why they’re participating in particular therapeutic actions
• Expectations are basis of placebo effect (when you show up in therapy, you most likely have the expectation that this is going to be helpful and that’s part of why therapy ends up being helpful)
• Relationship between patient expectations and outcome, r = .12 (small effect)

Question 134

Describe the therapist effects evidence for common factors

Answer 134

• Do some therapists produce better outcomes (ex: in terms of client recovery), regardless of
  nature of patients and treatments delivered?
• Some believe that a therapist could use any type of treatment with a client and that it’s more in the therapist rather than in the treatment that the client’s going to get better
• Within a treatment, we have to control for the fact that some therapists will be more skillful than others, and we might have more skilled therapists on our experimental treatment than our controlled treatment and that would be an important confound to consider
• In clinical trials, therapist effects are small-to-moderate (d = .35) -> more control over treatment delivery (more training, supervision and more checks of fidelity -> kind of equating some of the therapist factors)
• In naturalistic settings (ex: in private practice), therapist effects are moderate (d =
  .55) -> much larger because therapists are going by their typical routine and aren’t being supervised in the same way so we see more individual differences

Question 135

Describe the facilitative interpersonal skills (FIS) evidence for common factors

Answer 135

• One way of conceptualizing therapist effects
• 8 skill domains: verbal fluency, emotional expression, persuasiveness, warmth/positive regard, hopefulness, empathy, alliance bond capacity, alliance-rupture-repair responsiveness
• Thought to be pre-existing skills that predict client outcome
• Some new research shows that some of this that can be trained early-on in a graduate program but that a lot of it people come to a graduate program with and it’s an important selection factor for students in a helping career graduate program
• Self-report assessments can be biased -> if we ask new therapists about these, they’re probably going to rate themselves highly because they have the expectation that they’re going to be helpful to their clients and if we tell them these are important things that help their clients and generate good outcomes, then they’re probably going to rate themselves highly
• Performance-based assessment involves therapists responding to standard client scenarios and then are asked how they would respond and their responses are coded for FIS domains -> more objective than self-report assessment

Question 136

What are the 8 facilitative interpersonal skills (FIS) domains?

Answer 136

• Verbal fluency (how well are you able to carry a conversation)
• Emotional expression (on the part of the therapist)
• Persuasiveness (how persuasive are they in terms of talking about the reason for the person’s problems or the rationale for the treatment)
• Warmth/positive regard
• Hopefulness (are they hopeful that the client is going to get better? Are they helpful in instilling that in the client?)
• Empathy
• Alliance bond capacity (particular part of the alliance, are they able to develop that relationship part with the client?)
• Alliance-rupture-repair responsiveness (important -> when there’s a problem in the therapy how well is the therapist able to recognize that problem, talk about it and repair the problem so that the therapy continues on the right track)

Question 137

Describe Anderson et al. (2016) study on therapist effects

Answer 137

• Journal of Consulting and Clinical Psychology
• Longitudinal study
• 44 Clinical Psychology PhD students as the participants
• Within the university there was an in-house clinic
• These were all of the entering PhD students
• In their first semester of their PhD program, they self-reported social skills and completed FIS performance task in the first 2 weeks of program (meaning this is presumably not influenced by what they’re learning in the program and any kind of practice that they’re having in some of these skills)
• Then they complete their 1st year, don’t start seeing clients in therapy until their 2nd year (typically do this in 2nd, 3rd and 4th year)
• The PhD students saw 117 clients in the university clinic
• The clients were receiving treatments corresponding to a variety of theoretical orientations (ex: general CBT, eclectic approach, emotion-focused therapy)
• Students began seeing clients in 2nd year of program
• The clients at the beginning of each session before they went in to see their therapist completed measures reporting on their general symptoms and their functioning each session (how they tracked outcome)

Question 138

Describe the findings of Anderson et al. (2016) study on therapist effects

Answer 138

• Results showed that the higher FIS therapists, as determined at beginning of program, had clients with better outcomes in years 2, 3, and 4 of program
• Effect was present for therapies of shorter duration (< 8 sessions), but not longer (> 16 sessions) durations
• Figure shows a large difference between the high FIS and low FIS therapists for the 4 sessions, 8 sessions, 12 sessions but then once we get to 16 sessions, the difference is much smaller and by 20 sessions, you don’t see a difference at all
• This suggests that therapist FIS may contribute to sudden gains early in therapy so that people get better quicker and therefore may not need to continue in therapy for as long
• Also suggests that if the lower FIS therapists can form a strong relationship with their client early in therapy and retain the client for longer, then those differences go away
• What’s probably happening in some of the early sessions is that clients are dropping out because they’re not feeling like the therapists are as skilled

Question 139

What’s the evidence that favours common over specific factors?

Answer 139

• Any therapy is better than no therapy (almost universally the case that a therapy outperforms a waitlist -> why we don’t use waitlist controls anymore as control conditions in RCTs)
• Therapies often don’t differ when pitted against one another (ex: compare CBT to another therapy)
• Differences that do exist often reduced when controlling for investigator allegiance (when the person who developed the therapy is also the person testing the therapy and they therefore have a vested interest in seeing that the therapy works) -> presence of bias among the investigator and among the team members carrying out the trial
• Therapist adherence to specific therapy techniques or to the manual unrelated to outcome in their clients
• Null correlation between therapist fidelity measures and patient response
• However, because of the nature of common factors, there are no controlled studies to demonstrate that common factors are sufficient for causing therapeutic change (all of the research in this area is correlational in nature -> we can’t manipulate a therapist’s empathy or a therapist’s alliance, because what is therapy without those things and is it ethical to assign clients to a therapist who isn’t empathic at all?)

Question 140

Describe the debate between common vs specific factors in psychotherapy

Answer 140

• What’s driving change in therapy?
• Is it empathy, alliance, the therapist being skilled regardless of the therapy?
• OR is it what the client is doing in therapy? (ex: doing cognitive restructuring, doing exposure) -> would they have the same outcomes if they weren’t doing those things
• In some ways, this debate partly comes down to what one considers to be strong evidence
• Ex: if someone thinks that RCTs are the only evidence that should be considered because it’s a controlled experimental type of design, then they’re never going to be convinced by the common factors evidence because it’s never going to look like that

Question 141

Describe Lubrosky et al. (2002) study on the common vs specific factors debate

Answer 141

• Clinical Psychology: Science and Practice
• “The Dodo Bird Verdict is Alive and Well – Mostly”
• Examination of 17 meta-analyses comparing different forms of psychotherapy to one another
• Meta-analyses where they tried to answer the question about how do different therapies compare to one another and is there support for the common factors approach
• Using data from RCTs that support the common factors model
• No waitlist control comparison
• Mean effect size across all of these meta-analyses: d = .21 (small)
• Controlling for investigator allegiance reduces effect: d = .12 (even smaller -> negligeable effect size)

Question 142

What’s the problem with psychotherapy research?

Answer 142

• Research takes a nomothetic approach (how well does a therapy work, on average, for a population of
  people or what makes a therapy work on average)
• With research, we’re always talking about a group of participants that we hope is generally representative of the larger population but we’re averaging across that group of participants
• Therapy is idiographic (conducted one-on-one with a person who may or may not be well represented in research studies)
• Generally people who are of racial or ethnic minority status or of lower SES don’t necessarily participate in research and therefore aren’t well represented
• Problem: we’re trying to generalize from this nomothetic data to individual situations
• Evidence-based practice tries to account for that

Question 143

What’s evidence-based practice?

Answer 143

• Evidence-based practice combines what we know from research with information about the therapy process and client characteristics and preferences
• A comprehensive concept
• Not equivalent to empirically-supported treatment
• Empirically-supported treatment is only one component of what we consider evidence-based practice
• Ways to depict this:
  1) We have 3 different components of evidence-based practice and we’re looking at the intersection of the 3 (what we would consider evidence-based practice)
  2) 3 legs of the stool (triad of evidence-based practice) -> published in the APA report

Question 144

What are the 3 legs of the stool (triad of evidence-based practice)?

Answer 144

1. The best scientific evidence
2. The clinical experience of the therapist
3. The patient preferences or characteristics

Question 145

Describe leg 1 of evidence-based practice

Answer 145

• Best available research evidence
• Not all research evidence is equivalent
• Common depiction of research evidence is a pyramid and the upper levels of the pyramid are those that minimize the sources of error and they’re the ones we want to turn to first (ex: systematic reviews or meta-analyses and RCTs)
• When available, you go to the highest level of the pyramid to search for your evidence and when there’s nothing available for the question you have, then you go down the levels of the pyramid
• Consider sources of evidence (ex: treatment efficacy vs treatment effectiveness/clinical utility and info about how therapies work through research on basic psychological processes that might be relevant to treatment)
• Research studies must also move beyond what treatment has best outcome and consider patient diversity, mode of delivery, feasibility of delivery in real world settings, treatment costs, therapeutic relationships

Question 146

What are the different levels of the pyramid of research evidence

Answer 146

1. Systematic reviews (highest level)
2. RCTs
3. Cohort studies
4. Case-control studies
5. Case series and case reports
6. Editorials and expert opinion (lowest level)

Question 147

What’s treatment efficacy?

Answer 147

• Strength of the evidence pertaining to causal relationships between administering an intervention and improvement in a disorder
• Treatment efficacy evidence comes from RCTs because we’re talking about carefully designed studies where we’re prioritizing internal validity and therefore having a lot of controls around other explanations for why someone might get better in the treatment trial
• Comes from rigorously designed studies in research settings

Question 148

What’s treatment effectiveness/clinical utility?

Answer 148

• How well does the therapy work in “real world” clinical settings
• Seeing if the therapy works in a real-world setting, such as a CLSC, where a lot of the treatment is being done by social workers or masters level psychotherapists who have less training in research and they’re taking people as they come and are not considering to control for extraneous factors
• Ex: generalizability (do the treatments that we’ve seen work in RCTs work in the real-world?), feasibility (are they feasible to be delivered by individuals with less training), costs and benefits of intervention (specifically financial costs -> big concern in public health systems for the government or private systems for insurance companies)

Question 149

What are the basic psychological processes relevant to treatment?

Answer 149

• Memory
• Attention
• Problem-solving
• Emotion
• Personality
• All of these basic psychological things are relevant to psychotherapy and can characterize people with psychological disorders
• Ex: are these things improving in the course of a treatment?

Question 150

What are the different types of behaviour modification?

Answer 150

• Classical conditioning
• Operant conditioning
• Observational learning
• Rational behaviourism

Question 151

What’s classical conditioning?

Answer 151

• Reflexive responses (something that’s already included in the organism’s repertoire) elicited by a new stimulus
• The classic experiments that were done to show classical conditioning are those of Pavlov and his dogs
• The dogs were used to salivating (response that they had that was reflexive) in response to food
• Pavlov was able to condition the dogs to respond also to a bell by pairing the sound of the bell with the presentation of steaks
• Eventually, just the bell on its own was able to elicit the unconditioned response, which was the salivation
• We see some classical conditioning, especially in terms of fear-based responses, such as those that characterize phobias and other anxiety disorders

Question 152

What’s operant conditioning?

Answer 152

• A lot of what we’re talking about in psychotherapy is operant conditioning
• Behaviours that are influenced by consequences
• Reinforcement or punishment -> these serve to change behaviour
• The classic studies were those done by Skinner and his pigeons
• He found that if you reinforce the pigeons for pecking with food pellets, they were more likely to continue to do that
• He also tried different schedules of reinforcement

Question 153

What’s observational learning?

Answer 153

• Learning through observation of another’s behaviour without any direct reinforcement
• Bandura and the bobo dolls experiment
• It was found that children were able to model aggressive behaviour if they just saw other people engaging in aggressive behaviour towards these blow up dolls, even if they weren’t directly reinforced for that behaviour

Question 154

What’s rational behaviourism?

Answer 154

• Learning and performance of responses that have not been directly trained
• The idea that organisms look for cause-and-effect relationships in their environment and learn through their own behaviour
• It doesn’t mean that there needs to be someone, like a trainer, out there doing reinforcement or punishment, but that organisms can learn just based on cause-and-effect relationships in the natural environment

Question 155

What’s reinforcement?

Answer 155

• Anything that you do to increase the behaviour
• Doesn’t necessarily have to do with the positive or negative nature of the behaviour or of what’s being done to reinforce the behaviour

Question 156

What’s punishment?

Answer 156

• Anything that you do to decrease the behaviour
• Can be positive or negative

Question 157

What does positive and negative refer to with operant conditioning?

Answer 157

• Positive and negative comes to whether you’re adding or taking something away from the environment
• Positive: you’re adding something to the environment
• Negative: you’re taking something away from the environment

Question 158

Describe the different types of reinforcement and punishment

Answer 158

• Positive reinforcement: increase behaviour and add to environment
• Negative reinforcement: increase behaviour and remove from environment
• Positive punishment: decrease behaviour and add to environment
• Negative punishment: decrease behaviour and remove from environment

Question 159

What should we focus on when trying to understand whether it’s reinforcement or punishment?

Answer 159

The consequence

Question 160

What’s escape conditioning?

Answer 160

• Negative reinforcement
• Immediate, response contingent removal of aversive condition that increases frequency of future behaviour
• When you’re in a situation and start feeling anxiety or fear or some sort of negative emotion and to remove that fear, you end up escaping (leaving the situation)
• Consequence: more likely to take that action of leaving the situation in the future
• This applies to anxiety disorders in the sense that you won’t have the opportunity to learn that if you stayed in the situation for long enough your anxiety or your fear will decrease (whole basis of exposure therapy)
• Ex: you start studying for an upcoming exam and looking at the material is making you very anxious about how you’re going to perform on the exam, so you stop studying and watch Netflix instead

Question 161

What’s avoidance conditioning?

Answer 161

• Negative reinforcement
• Immediate, response-contingent prevention of aversive condition that increases frequency of future behaviour
• Very similar to escape conditioning (sort of like the 2nd step) except that you don’t even put yourself in a situation that is going to cause you anxiety or fear because you’ve taken it out of your repertoire and that would continue
• Therefore you’re never able to learn that that anxiety and fear won’t stay forever
• Ex: you’re anxious about studying, so you don’t even bother to go home and open your book, instead you go straight to watching Netflix, rather than have those negative thoughts and feelings come up

Question 162

What type of reinforcement is especially relevant for psychopathology?

Answer 162

• Negative reinforcement
• It’s the way in which anxiety tends to be maintained

Question 163

What’s extinction?

Answer 163

• When you stop reinforcing the behaviour and presumably it’s going to get better overtime
• If there’s no reinforcement then there’s not going to be any pairing of the reinforcement and the behaviour and the behaviour is going to decrease overtime

Question 164

What’s differential reinforcement?

Answer 164

• Reinforce some behaviours and not others, or reinforce
  behaviours under some conditions but not others
• Ex: if you’re parenting, you have some behaviours that your child does that you don’t want them to continue so you try very hard to not reinforce those behaviours, whereas you have some behaviours like politeness that you do want to continue so you try to reinforce those behaviours

Question 165

What are the schedules of reinforcement?

Answer 165

• Fixed vs variable
• Ratio vs interval
• Could be on a fixed schedule vs more random
• Could be after a certain number of times
• Fixed is often referred to as time-based whereas ratio is often referred to as the number of times an event has to happen
• Often we think about this with gambling where the reason why gambling can become so addictive to people is because it has the perfect schedule of reinforcement (variable and interval)
• You can’t predict when you might hit the jackpot so every time that you pull the lever on a slot machine, there’s a possibility that it could happen -> it’s not based on how many times you pull it or how long since the last jackpot
• There’s no real way to predict when you might win

Question 166

What’s shaping?

Answer 166

• Reinforcement of successive approximations of final response
• In this case, the organism doesn’t have the final response in their repertoire so you can’t reinforce the final response you have to reinforce little parts that are getting closer and closer to the final response
• Ex: a baby starting to say mom, they’re not able to say the whole word right away so they often start with babbling, pronouncing the m sound, and then they put the 2 ma ma’s together which leads to this final response

Question 167

What’s chaining?

Answer 167

• Create a series of behaviours from distinct behaviours
• Each individual behaviour is in the organism’s repertoire and what you’re teaching them is to put them in order and do them together
• Ex: how to do your laundry -> you have to put the clothes in the clothes basket first, you have to sort your clothes, put your clothes in the washer, put in the soap, turn it on
• These are all distinct behaviours that if the person knows how to do each one of them individually then it’s just about what order to do them in
• Ex: toilet training

Question 168

What’s discrimination?

Answer 168

• Different responses under different stimulus conditions
• Ex: we’re different with our friends than we are when in a professional setting (ex: work)
• We learn to discriminate our different environments and then respond differently in those environments

Question 169

What are the 2 types of generalization?

Answer 169

• Stimulus generalization
• Response generalization

Question 170

What’s stimulus generalization?

Answer 170

• When you have the same response to different stimuli
• Ex: Little Albert experiments where Watson conditioned him to have the same fear response to different white furry things

Question 171

What’s response generalization?

Answer 171

• When you have different responses to the same stimulus
• Ex: you might teach your child that when they’re around other adults it’s important to be polite and say please and thank you

Question 172

What are the ABCs of Behaviour?

Answer 172

• Antecedents: stimuli, settings, and context that occur before and influence behaviours
• Anything that’s setting up the behaviour of interest
• Could be a particular event but it could be just generally describing the context and the people that are around
• Behaviour: behaviours that individuals do or don’t do
• Often the focus of Functional Behavioural Assessment
• Sometimes you’re trying to stop a negative behaviour or increase a behaviour that’s positive that isn’t happening
• Ex: in a classroom setting, a behaviour that you’re trying to decrease is the child that’s constantly getting out of their seat whereas a behaviour that you’re trying to increase could be the child raising their hand
• Consequences: events that follow behaviour and may or may not influence future behaviour
• When you’re doing a functional behavioural assessment, you want to fully assess the consequences because you don’t know when you start what’s going to be relevant and what’s not going to be relevant
• Important to take note of anything that follows the behaviour because it might be important in the maintenance process, which is what you need to stop because it’s maintaining the negative behaviour or it’s interfering with the behaviour that you want to increase

Question 173

Describe the Functional Behavioural Assessment

Answer 173

• Application of scientific experimental approach to human behaviour
• What behaviour do you want to change? (operational definition: Objectivity, clarity, completeness)
• Assess behaviour at baseline (frequency or Yes/No; Duration; Latency; Intensity)
• Determine function(s) of behaviour (what’s the purpose of the behaviour? What are the maintaining contingencies?) -> main thing we’re doing in a functional behavioural assessment
• Use all of the info from this functional behavioural assessment to develop some sort of intervention

Question 174

What are the key steps of Functional Behavioural Assessment?

Answer 174

1. Systematically collect information: gather info about the behaviour and antecedents, consequences, and context using one of the methods of assessment
2. Generate hypotheses: propose hypotheses about what purposes the behaviour might serve (what consequences or reactions in the environment are generalized by that behaviour)
   - Generating hypotheses about what the potential functions of the behaviour might be
3. Test the hypotheses: set up the conditions so that the different influences that are proposed can be evaluated to see if one of these in fact supports the proposed influence
   - Need to be able to isolate -> if you have multiple hypothesized functions of a behaviour, your test of the hypotheses needs to be able to isolate each potential function so that when you finish testing your hypotheses, you can clearly say yes this function is important or no this function isn’t important
4. Devise an intervention: on the assumption that one of the hypothesized conditions influenced behaviour, now move from what might have been a brief, experimental demonstration to an intervention that uses that info to change behaviour in an everyday setting

Question 175

What are the different methods of assessment for ABC relations?

Answer 175

• Indirect assessments: self-report, interview
• Direct assessments: naturalistic, analog

Question 176

What’s functional analysis?

Answer 176

• Testing of the hypotheses
• Testing, through experimental manipulation, the consequences that control the behaviour
• Each hypothesized function is tested one by one

Question 177

Describe Leg 2 of Evidence-Based Practice

Answer 177

• Clinical Expertise
• Competence attained by psychologists through education, training, and experience that results in effective treatment (mixed evidence about whether years of experience relates to outcome of therapy for the clients)
• Specific areas of clinical expertise:
• Clinical case conceptualization (how to make sense of the case)
• Treatment planning (based on case conceptualization)
• Treatment implementation
• Interpersonal expertise (ex: facilitative interpersonal skills)
• Self-reflection (ability to self-reflect to know if there’s an issue in personal life that might be interfering with therapy)
• Knowledge and use of research literature (staying up to date with research literature and knowing how to search for new research using databases)
• Understanding influence of diversity and culture on treatment
• Seeking consultation and resources (knowing when you don’t have the answers and when to ask for help)
• Research evidence not available to dictate every decision in a therapy session -> make use of clinical judgment, clinical expertise and past experience
• But with evidence-based practice you should always start with the research evidence when planning a treatment

Question 178

Describe Leg 3 of Evidence-Based Practice

Answer 178

• Patient Characteristics, Culture, and Preferences
• We have the research that’s done on the general people/public and then we have the 2 people in the room (the therapist and the patient)
• “What works for whom”
• Research can examine patient moderators of treatment effects
• There are a lot of different patient characteristics that could moderate treatment effects
• Do treatments tested on majority groups generalize to minority groups?
• How do comorbid conditions affect efficacy of treatment?
• Back when RCTs excluded people with comorbid conditions -> might be less confident that the results from those studies would apply to the person sitting in front of you who has 3-4 psychological disorders
• Phenotypically similar symptoms can have different etiological and maintenance factors
• People who have the same sets of symptoms or the same diagnosis may have come to that diagnosis via different pathways

Question 179

Describe the CPA Report on Evidence-Based Practice

Answer 179

• Evidence for recommending or providing treatment should stem from treatment outcome research (ex: RCTs), treatment process research, and basic psychological research
• Before providing treatment, psychologists should first consider the hierarchy of evidence available for the treatment options under consideration
• Psychologists should utilize the best available evidence (evidence highest on the hierarchy) which includes findings that are replicated across studies and that have used methodologies that address threats to validity (ex: RCTs to address threats to internal validity, naturalistic studies to address threats to external validity)
• In cases where there may be little or no relevant treatment research, practice guidelines may be available that are based on consensus among experts and have been determined by formalized methods
• Psychologists should frequently and systematically monitor clients’ reactions, symptoms and functioning during treatment
• Psychologists should be prepared to alter the treatment based on data from ongoing treatment monitoring discussions with the client and reconsideration of the relevant hierarchy of evidence

Question 180

What was one thing about the CPA Report on Evidence-Based Practice that was quite different from the APA Report

Answer 180

• They focused more on treatment process research
• Treatment process research is often the research that’s done related to common factors (ex: the therapeutic relationship, the alliance, empathy, etc.)
• They recognize that there was an important role for this type of research because it informs how the therapy unfolds and what can be done to boost therapy outcomes

Question 181

What are the 3 types of research that should be prioritized according to the CPA Report on Evidence-Based Practice?

Answer 181

• Treatment outcome research
• Treatment process research
• Basic psychological research (that can be applied to clinical practice)

Question 182

Describe the treatment process with the pyramid of evidence according to the CPA Report on Evidence-Based Practice

Answer 182

The evidence informs treatment decision-making (especially at the beginning of treatment), then you’re giving the treatment and you’re conducting treatment monitoring and outcome evaluation

Question 183

What are the advantages of evidence-based practice?

Answer 183

• Improve quality and cost-effectiveness of treatment -> a lot of treatments that have been shown to be empirically-supported are more brief, so the idea is that being in treatment for shorter lengths of time is going to be associated with fewer costs
• Enhance accountability -> if the public knows that there are certain treatments that are recommended for certain disorders then they can make sure that they’re receiving those treatments as opposed to being unaware of how there are some treatments that have been shown to work in research and some that have not, which would lead to them not being informed consumers

Question 184

What are the criticisms of evidence-based practice?

Answer 184

• Treatments amenable to research are more likely to be included in the list of empirically-supported treatments
• Ex: CBT tends to be shorter than psychodynamic therapy meaning it’s easier to look at in a research study because the research study doesn’t have to be as long and it’s more amenable to a manual and to training therapists in treatment techniques
• Because it’s studied more, more likely to be included in lists of empirically supported treatments whereas psychodynamic psychotherapy is studied less in research and is less likely to appear on these lists of empirically supported treatments
• Not necessarily that it doesn’t work, it’s more of an open question because there’s not as much research on it
• Could inappropriately restrict access to certain treatments
• If these treatments don’t appear on a list of empirically supported treatments, funders might decide they don’t want to pay for them, when really it’s not that these don’t work, it’s more that we don’t know
• Should we really be restricting access to those treatments especially if there’s a strong preference on the part of the patient?

Question 185

What do we want moving forward with Evidence-based practice?

Answer 185

• What we want, from a research perspective, is that there’s a clear relationship between the theory behind the treatment, the more theoretical research (ex: research on basic psychological processes) and the treatment outcome (treatment and its outcomes)
  1. Proposed mechanisms of change (what we think is happening in the treatment to help people get better) should be validated in basic research to be shown to be related to the techniques that are being used
  2. Proposed mechanisms of change in the therapy should be related to proposed mechanisms of disorder
• Ex: if we think that there’s a problem of emotion and we want to target it in treatment, we should be only using that treatment for psychopathologies that we think have problems with emotion
  3. Change in proposed mechanisms should relate to change in symptoms in treatment studies
• We should see that if our treatment is changing problems with emotion or emotion-regulation, that those changes in problems with emotion-regulation are then associated with changes in the symptoms of the disorder

Question 186

What’s the difference between unvalidated treatments and invalidated treatments?

Answer 186

• Unvalidated: not been examined sufficiently in controlled study
• Not listed as evidence-based, but doesn’t mean that it might not
  work, it may just be brand new treatment that doesn’t have enough data yet
• Invalidated treatment: things that have been shown not to work and in some cases have even been shown to be harmful
• There’s a suggestion to make a list of invalidated treatments for the public and for therapists to know what is clear not to do and when it’s clear to find a new therapist if your therapist is suggesting these types of treatments

Question 187

What’s the only treatment with strong research support for Panic
Disorder and Generalized Anxiety Disorder?

Answer 187

• CBT (because of its emphasis on exposure and actually confronting the feared stimuli)
• CBT for Panic Disorder: cognitive techniques to modify catastrophic thinking related to bodily sensations, and
  interoceptive (bodily) exposures
• CBT for Generalized Anxiety Disorder: cognitive techniques to modify catastrophic thinking related to likelihood of negative outcomes as well as the adaptive function of worry
  -Behavioural techniques including worry time, relaxation training

Question 188

What are things we assess in terms of a patient’s psychosocial history?

Answer 188

• Family
• Education
• Occupation
• Peers/romantic relationships

Question 189

Describe Barth et al. (2013) study on Common vs Specific Factors

Answer 189

• PLOS One
• Meta-analysis of 198 studies of 7 psychotherapies for depression
• Each intervention was more effective than waitlist control: ds = .62-.92 (large effect sizes)
• Effect sizes similar for different interventions
• With one exception: the effect size for interpersonal psychotherapy of 0.92 was significantly larger than the effect size of supportive psychotherapy of 0.62
• Supportive psychotherapy is almost like the psychotherapy placebo, but even there we see an effect size of 0.62 compared to a waitlist but there’s this one difference where IPT outperformed

Question 190

Describe Tolin (2010) study on Common vs Specific Factors

Answer 190

• Clinical Psychology Review
• CBT vs other psychotherapies (interpersonal, psychodynamic, supportive)
• Only comparisons considered “bona fide” treatments versus “intent-to-fail” conditions
• He only wanted to consider the control condition if it was a bona fide treatment
• He didn’t include studies where supportive psychotherapy was set up as the control condition and just to control for common factors, it was only if the supportive psychotherapy was considered to potentially be helpful for people
• 26 studies
• CBT superior to psychodynamic therapy: d = .28 (small-to-moderate effect size) -> not superior to the others
• CBT only significantly superior than other therapies for depression and anxiety and not for the other conditions that they examined
• Investigator allegiance to CBT correlated with strength of study effect, but CBT remained superior after controlling for the investigator allegiance
• Tolin has an allegiance to CBT
• This study shows a bit more support for CBT compared to the other treatments

Question 191

Describe Mulder, Murray, & Ruckledge (2017) study on Common vs Specific Factors

Answer 191

• Article discussing this debate and how we should move on from the debate
• These authors talk about how there’s more similarities than differences in terms of the positions of common vs specific factor theorists
• Specific factor theorists agree that common factors are important and therapeutic relationship is necessary (but not sufficient)
• Common factors theorists have tightened definition of “bona fide” treatments
• There needs to be some sort of actions on the part of the client that are going to elicit potential for change, they can’t just be passive recipients of the therapy
• Common factors theorists acknowledge that some specific techniques are more effective than others for particular conditions (ex: exposure for anxiety disorders -> agreed among most people and is included in almost all treatments for anxiety)

Question 192

What are Mulder, Murray, & Ruckledge (2017) recommendations moving forward, with regard to Common vs Specific Factors

Answer 192

• Prioritize treatment process research over treatment outcome research -> focus not just on what works, but how it works
• Evidence for efficacy (coming from RCTs) does not necessarily mean that the treatment is valid or that it’s going to be helpful in all different situations -> remain skeptical even if it’s an RCT
• Train students in therapeutic principles of CBT or the principles of another treatment -> focus on specific techniques when evidence shows therapeutic benefit or those techniques vs other techniques that maybe the evidence is more mixed or not very strong in terms of showing benefits

Question 193

Describe the debate between Wampold and Fonagy

Answer 193

• Question: are some psychological treatments more effective than others?
• Fonagy:
• Argues it’s important/our responsibility to our patients to figure out what works and for whom
• He considers any attempt to hinder that process to be both unethical and unacceptable intellectually
• He thinks it’s unacceptable to offer a therapy that we don’t know works
• Wampold:
• Argues that some are more effective than others
• Argues what really makes a difference is the therapist
• Argues the key to success is that some therapists have the skills to be able to help patients regardless of the treatment
• Argues that in clinical trials, if you compare 2 treatments given by people who have allegiance to them and who have cogent rationale and ways for patients to work on the problems that bother them are just about exactly equally effective, if there’s a difference, it’s so small and does not have a practical significance
• What doesn’t work as well in trials, although it works better than no treatment at all, is just sitting with the patient and being empathic and understanding
• Treatment without structure and without some way for the patient to work hard to overcome their difficulties don’t work as well as focused treatments
• Unstructured treatments (ex: psychoanalysis) where therapists just sit there and ask how the client’s day was don’t get the same outcomes than the people that are doing mentalization or CBT or behavioral therapy for eating disorders

Question 194

Who’s Peter Fonagy?

Answer 194

Creator of Mentalization-Based Therapy, a psychodynamic treatment for borderline personality disorder