Psychological Intervention Chapter 17 Outcomes and Issues in Psychological Intervention

Chapter Outline Client Factors → Psychotherapy Outcomes Therapist Factors → Psychotherapy Outcomes Client-Therapist Factors → Psychotherapy Outcomes General Issues in Evaluating Psychotherapy Behavioural and Cognitive Therapies Psychoanalytic Therapies Client-Centered Therapy Couples and Family Therapies Psychotherapy Integration Contemporary developments in treatment and intervention Source: page 2

Client Factors Influencing Psychotherapy Outcomes Therapy Expectations Demoralization hypothesis - people seek help not just because of symptoms but because of ↓ self-esteem etc. Instilling hope can lead to better outcomes Client personality Attachment styles are predictors of therapy outcome Goals and motivation to change Motivation Interviewing to overcome resistance to change Type and severity of dysfunction Complex clinical presentations (including comorbidity) pose more challenges for therapists

Therapist Factors Influencing Psychotherapy Outcomes Personal qualities Convey warmth, sense of stability Experience, training, competence Collaboration Understanding Interpersonal effectiveness Cultural competencies to work with diverse populations Core competencies – ability to engage in relationships and communicate

Client-Therapist Factors Influencing Psychotherapy Outcomes Working alliance Sometimes called therapeutic alliance Build on initial rapport Establish trust and develop mutually agreed-upon goals Client commitment to therapy

General Issues in Evaluating Psychotherapy Research Therapy as Researched vs. Therapy as Practiced Adherence to Treatment manuals Defines the ‘independent variable’ in outcome research Controlled research studies need specific diagnoses Individuals are excluded from treatment unless meet strict disorder criteria (for example, comorbidity results in exclusion) Gap between research and clinical practice Research does not capture complexities of practice Research procedures disrupt or distort typical therapy process Research participants are not representative of typical therapy clients Qualitative research and single case studies are under-valued while Randomized Controlled Trials (RCT) are over-emphasized Overemphasize treatment techniques not relationship process

Treatment Efficacy versus Treatment Effectiveness Efficacy – determined by controlled research study of therapy outcome Effectiveness – refers to outcomes in the ‘real world’ Dodo bird effect – ‘everyone has won’, tendency for various therapies to achieve similar results 75% of people who undergo psychotherapy achieve some improvement People change more because of ‘common’ factors rather than ‘specific’ factors or techniques Specific therapies are more effective for certain diagnoses

Evidence-Based Treatment Also termed empirically supported therapies (EST) Outcome studies that use randomized designs, appropriate comparison (control group) and follow-up Need for future EST research studies that: use multiple locations (multi-site) follow participants over long periods of time (longitudinal) consider processes of change, client factors, chronicity (severity) of condition investigate non-dominant clinical therapeutic approaches

Stepped Care Models

Review of Behavioural and Cognitive Therapies Core assumption is that way people construe their world is a major determinant of their feelings and behaviour Evaluation of Counter-conditioning and Exposure Methods Some empirical support Evaluation of Operant Methods Proved successful with a wide range of behavioural problems Generalization and Maintenance of Treatment Effects

Generalization and Maintenance of Treatment Effects Importance of sustaining the immediate benefits of therapy over time Approaches include: Intermittent and naturalistic reinforcement Environmental modification Eliminating secondary gain Attribution to self

Rational Emotive Behaviour Therapy Ellis’s Rational-Emotive Behaviour Therapy (REBT) Emotional suffering is due primarily to unverbalized assumptions (for example: ‘I must be approved by everyone’) REBT therapist challenges these assumptions (reduce need to try and achieve unattainable demands on themselves) Evidence for REBT  general anxiety, speech anxiety, and test anxiety. Improves self-reports and behaviour for social anxiety Inferior to exposure-based treatments for agoraphobia. May be useful in treating excessive anger, depression, and anti-social behaviour. Useful only as part of more comprehensive behavioural programs for sexual dysfunction. Useful as a preventive measure for untroubled people Appears to achieve effects through  irrationality of thought

Cognitive Therapy Beck’s Cognitive Therapy (CT) Evidence like REBT, emotional distress is considered to be caused by cognitive assumptions (termed schemas) Compared to REBT, CT is more collaborative and helps client examine the evidence for beliefs. Emphasis on challenging evidence for cognitive ‘biases’ (such as selective abstraction, overgeneralization) that filter experience. Evidence Effectiveness of CT under intensive study for more than 30 yrs. Works for depression, anxiety disorders and other conditions but may not be demonstrably better than other treatments. More research is needed to determine which components and ingredients of CT lead to improvements

Schema-Focused Therapy Young’s Schema-Focused Therapy Emphasis on identifying a person’s ‘deep’ maladaptive schemas, which are core themes or constructs that are developed early and are long-standing Relevant to personality disorders Uses CT techniques as well as methods borrowed from interpersonal therapies Some evidence that schema-focused therapy leads to clinical improvements Most existing research has examined schema-focused treatment of borderline personality disorder

Psychoanalytic Therapies Key concepts in psychoanalysis Remove repressions that block ego development Psychoanalytic techniques include: free association and dream interpretation to uncover ‘unconscious’ or buried fears Analysis of transference (distorted/unrealistic) view of therapist to help better understand client’s view of important childhood figures Classical Psychoanalysis has been modified Psychodynamic psychotherapy is more oriented to present, towards better understanding of current real-life problems still emphasizes unconscious motivation and hidden reasons for behaviour

Psychoanalytic Therapies (cont.) Compared with cognitive therapies, psychoanalytic therapies have greater emphasis on: emotional expression exploration of attempts to avoid thoughts that cause distress identification of recurring themes past experiences as they relate to the present interpersonal relationships therapeutic relationship wishes, dreams, fantasies

Evidence - Psychoanalytic therapies Relatively few studies Difficult to research because the therapy is so long-term psychoanalytic psychotherapy: Meta-analysis of few available studies showed limited and conflicting support brief psychodynamic psychotherapy: Meta-analysis of many studies showed evidence of effectiveness

Client-Centred Therapy Roger’s Client-Centred therapy Regarded as humanistic therapy Emphasis on freedom to make own choices taking responsibility for choices that have been made Therapist is accepting and non-judgmental, is empathic not directive, shows genuineness, unconditional positive regard Compassion-focused therapy is an extension of client-centred therapy, designed for self-critical people to develop self-acceptance Evidence Rogers originated the scientific study of psychotherapy through research Emphasis on client self-reports (phenomenology) Meta-analysis of studies (1978 to 1992) found that clients were better off after intervention than about 80% of non-treated people

Review of Couples and Family Therapy Basic Concepts and Techniques Rooted in established approaches (such as REBT) that were then applied to couples ‘Normality’ of Conflict – help couples who avoid dealing with disagreements Problems occur when there is a split alliance (therapist has stronger alliance with one member of the couple) Various Approaches to Couples and Family Therapy Mental Research Institute Tradition Cognitive-Behavioural Approaches Integrative Behavioural Couples Therapy Emotion-Focused Therapy

Principles of Emotional Change in Emotion Focused Therapy

Evidence Couples and Family Therapy Meta-analysis shows that couples therapy can improve many relationship problems Predictors of poor outcome: Poor communication of feelings Low sexual activity Rigidly held traditional gender roles One partner is clinically depressed

Psychotherapy Integration Eclecticism and theoretical integration in psychotherapy Three types of psychotherapy integration Technical eclecticism Therapist from one orientation uses techniques from other ‘brand’ Common factorism Strategies common to all approaches Theoretical integration Synthesis of theories, not just techniques

Contemporary developments Psychotechnologies Use of virtual reality technology (such as in treatment of PTSD) Internet-based delivery of psychotherapy Tele-mental health delivery Use of video conferencing for rural and remote geographic locations Computerized therapy use of cCBT for depressed and anxious students

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