1. Chapter 14 Intervention: Identifying Key Elements of Change INTRODUCTION TO CLINICAL PSYCHOLOGY 2E HUNSLEY & LEE PREPARED BY DR. CATHY CHOVAZ, KING’S COLLEGE, UNIVERSITY OF WESTERN ONTARIO

2. Topics 2  What Works for Whom, and When?  Process and Process-Outcome Research  Common Factors in Psychotherapy  The Therapeutic Alliance  Psychotherapy Equivalence  Empirically Supported Therapy Relationships

3. Process research and process-outcome research:  Understanding what specifically causes effective outcomes within psychotherapy  Note that not all therapy is effective for all people  Effective therapy does not always indicate how it was effective  Research can look at any time frame: seconds, minutes, days, weeks, etc. What Works for Whom, and When?

4. Example – Viewpoint Box 14.1  Looking closely at client outcome, Tang & DeRubeis (1999) noted that many patients make sudden gains around sessions 4-6  Important to consider:  Client factors (aspects about each specific client)  Therapist factors (aspects about the specific therapist)  Treatment factors (aspects about the treatment given) Process and Process-Outcome Research

5. Higher SES is associated with a greater likelihood of engaging and staying in treatment Socioeconomic Status Similarity in client and therapist ethnicity is associated with a greater likelihood of clients staying in Tx and making therapeutic change Ethnicity Women are more likely to seek therapy than men but there is no gender difference in premature termination of services Matching of client/therapist Gender Client age is unrelated to Tx outcome Age Client Factors that Influence Treatment: Sociodemographic Characteristics

6. Greater severity of psych. Symptoms is related to poorer Tx outcome Symptom Severity Greater overall impairment in functioning is related to poorer Tx outcome Functional Impairment Client Factors: Psychological Functioning

7. Presence of an Axis II Dx is associated with premature termination, problems in therapy and less therapeutic change Personality Disorders Related to positive Tx outcome Ego Strength Related to positive Tx outcome Psychological Mindfulness Clients low in reactance tend to experience greater therapeutic gains Clients high in reactance tend to experience greater therapeutic gains in less directive Tx Psychological Reactance Positive expectations for Tx are associated with remaining in Tx and greater therapeutic gains Treatment Expectations Client Factors: Personality Characteristics

8.  Therapist Factors – Findings  Limited findings on effect of ethnicity of therapist on outcome  Age, gender unrelated to outcome  Therapists trained in mental health have better outcomes than general health practitioners  Inconclusive differences on sub-mental health fields (clinical psych, social work, marriage and family counsellors, etc.) Process and Process-Outcome Research

9. Very little systematic research No consistent pattern of effects Ethnicity Therapist gender has no consistent effect on Tx outcome Gender Therapist age is unrelated to Tx outcome Similarity in therapist/client age does not contribute to Tx outcome Age Therapist Factors that Influence Treatment: Sociodemographic Characteristics

10. Therapists trained in mental health tend to have better Tx outcomes than those trained in a health discipline Inconclusive research re: type of mental health training Professional Discipline Considerable variability, but overall more therapist experience is positively related to Tx outcome Professional Experience Therapist Factors that Influence Treatment: Professional Background

11. Therapist personality traits have little association with Tx outcome Personality Traits Therapist emotional well-being is consistently positively associated with Tx outcome Emotional Well-being No consistent pattern of results Values, Attitudes, and Beliefs Self-disclosure has a small but positive effect on Tx outcome Use of Self-disclosure Therapist Factors that Influence Treatment: Personality Characteristics

12. in dynamic therapies not consistently related to outcome and best for people with strong interpersonal skills Interpretation likely depends on the reactance of the client Directiveness likely most helpful for introverted clients Insight likely best for extroverted or impulsive clients Symptom Reduction Examining Treatment Factors

13.  Treatment Factors – Findings  Note that when all patients are grouped together there are not differences in directiveness, insight, or symptom reduction  Between-session assignments do not increase the effectiveness of therapy, but for treatments that require them (e.g., CBT) whether a client does the homework is predictive of success Treatment Factors

14.  Several ways to define common factors  Jerome Frank’s (1973) model of role of a healer in society  Weinberger (1995) factors noted:  Therapeutic relationship  Client expectations  Confronting problems in therapy  Client’s sense of mastery  Client’s attribution for outcome Common Factors in Psychotherapy

15.  Lambert and Ogles’ three factors (support, learning and action)  Support Factors  Reducing isolation  Providing reassurance  Therapeutic alliance  Therapist expertise  Therapist respect, empathy  Acceptance, warmth  Catharsis Common Factors in Psychotherapy

16.  Lambert and Ogles’ three factors (support, learning, and action)  Learning Factors  Advice  Cognitive learning  Emotional experiencing  Insight  Feedback  Exploration of assumptions  Beliefs, expectations Common Factors in Psychotherapy

17.  Lambert and Ogles’ three factors (support, learning, and action)  Action Factors  Practice  Modeling  Reality testing  Facing fears  Working through issues  Development of mastery  Behavioral regulation Common Factors in Psychotherapy

18.  Integrative treatment models have developed from this research  One factor has been most consistently linked to positive outcome: therapeutic alliance – the quality and strength of the therapist-client relationship Common Factors in Psychotherapy

19.  Positively related to treatment outcome for adults and adolescents  Can be assessed by client, therapist or an independent rater  Importance of understanding correlation does not equal causation The Therapeutic Alliance

20.  Dodo Bird Effect: term used when psychotherapy orientations are systematically compared there are no clear differences  Some differences exist in some studies (particularly meta- analyses when certain studies are grouped), or when looking at client or therapist differences Psychotherapy Equivalence

21.  Important concepts:  Alliance and cohesion: importance of a good working relationship  Empathy: the ability to understand another person’s experience  Goal consensus and collaboration: importance of patient and therapist agreeing upon treatment goals  Reactance/resistance and impairment: changing the directiveness and frequency based on the client Empirically Supported Therapy Relationships

22.  Some important concepts  Client variables that might decrease benefits: impairment, Axis II, unfavourable expectations  Helpful relational conditions: the formation of a therapeutic alliance  Helpful therapist behaviours: empathy, collaboration, authenticity, skillful  Intervention targets: interpersonal issues, problematic cognitions, maladaptive emotions & behaviours Empirically Based Principles of Change

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