1. Psychological Intervention
Chapter 17
Outcomes and Issues in
Psychological Intervention

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Stepped Care Models

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Principles of Emotional Change in Emotion Focused Therapy

21. 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

22. 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

23. 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

24. Copyright
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