Chapter 6: Treatment, Intervention, Prevention, And Supervision

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matching characteristics btw clients/therapists

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results on gender and ethnicity matching are mixed and more extensive research is needed

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The Transtheoretical Model

(Assessing readiness for change)

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Based on the idea that behavior change is more successful when it based on individuals preparedness for change, which occurs in stages

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Stages of Change

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1. Precotemplation: might not recognize his or her behavior or issue as being problematic and that change has not occurred to them

2. Contemplation: he or she might have some ambivalence toward change but recognizes that a problem exists

3. Decision making : makes commitment to change

4. Action: the person actively changes behavior that has been deemed problematic.

5. Maintenance phase: the person continues in the maintenance change where change has been established and ongoing effort is made to progress and avoid relapse

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Psychoanalysis/Psychodynamic Theory

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thoughts, beliefs, and awareness work in levels: conscious, preconscious, and unconscious. Behavior and mental health are largely determined by childhood experience and progression through stages of development. Reactions to stress are called defense mechanisms, which are methods that manifest into actions that are meant to protect the individual from incoming threats

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The Psychoanalytic Defense Mechanisms

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Rationalization: tries to adopt a more acceptable motive than an otherwise unacceptable one, akin to intellectulization

projection: is a defense that happens when a person who finds certain motives that or she possesses unnacceptable, places them on others

also repression

reaction formation: used as an expression of repressed desires in a contrasting form to those desires

regression: a response to frustration and is used to reduce tension by reverting to ego to an earlier stage of development

Sublimination: allows unacceptable impulses or thoughts to transform into socially acceptable expression

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Psychoanalytic treatment

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involves exploration of past experiences as the present is determined by the past. Allows the client to engage in free association. Considers transference and dream interpretation to be significant tools. Process of therapy inolves 3 stages; the opening phase, which involves identifying the presenting problem and severity, the middle phase, which entails therapeutic treatment, and the final phase, termination

*has been shown to be most effective in treating dramatic and eccentric clusters of personality

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Adlerian Psychotherapy

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also referred to as individual psychology, a model of tx that views dreams, thoughts, emotions, and physical health as working together holistically as opposed to working as distinct entities. Emphasizes the child's perception of his or her role in family dynamics.

postulated that mental health was contingent on the child perceived himself and ideal self. When not synchronized, the individual would develop an inferiority complex, whereas healthy individuals, these feelings would be managed using appropriate coping mechanisms.

TX; utilizes future oriented strategies that emphasize how goals determine individuals' course of life

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Aims of Adlerian Psychotherapy

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Establishing and maintaining a a healthy relationship with the patient, discovering the patient's way of life, including reaction to stimuli, relationships, and goals, and their effects on life; building significant insight in therapy; and reorientation of the individual

therapist's role is to provide an ideal persona of a healthy person for the patient to imitate and model to enable change and growth.

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Analytical Psychotherapy

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Also known as Jungian psychotherapy; considers the patient-therapist relationship as a prototype of the general structure of the patient's relationship pattern.

Based on four tenets: the self-regulatin psyche, or soul; the unconscious, which was considered compensatory and elaborate; the relationship with the patient, which facilitates awareness and health; and several stages to self-improvement

Society shares a collective unconscious that influences various aspects of life and certain archetypes that govern personality are adopted from it

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Adlerian Psychotherapy, cont.

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symptoms are considered a product of the whole personality rather than one symptom alone. TX emphasizes the creation of healthy balance between internal opposites and different aspects of people's lives, focusing on present and future goals.

techniques:

confession- recalling personal experiences

elucidation- insight into internal processes

education- improvement of personal/health behavior

transformation- process of self-actualization

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Client-Centered Therapy

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conditions for healing to occur include the creation of a nurturing and nonthreatening environment, genuineness, unconditional positive regard, and empathy. (increased self-esteem, internal locus of control, and enhanced openess and coping) Conditions for change including maintaining a nondirective attitude, respect, and partnership with the client.

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Existential Psychotherapy

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focuses on observing human existence, perspectives on life, an the world attained from this observation. The foundation of existential psychotherapy relies on the notion that individuals' perceptions of the world differ, and therapeutic issues need to be viewed within and individuals worldview. The therapist's serves as a guide, demonstrating possibilities the patient can achieve.

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Gestalt Therapy

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Believe that individuals are defined by their environment, social networks, family, and memories. Dysfunction results from a failure to learn from experience and engaging in repetitive patterns of behaviors. The goal of therapy is to achieve homeostasis, as internal balance between physical and internal mechanisms used to achieve homeostasis; including: imagining reactions to real-life events, writing and expressing emotions to a significant person without actually sending it, and then writing a response based on what you believe that person may say, and increase a patient's awareness of his or her reactions, both psychologically and physiological, to a specific situation

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Behavioral Therapy

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believe that poor mental health is a product of learned dysfunctional behavior. techniques can be placed in three categories: applied behavior analysis, neobehavioristic meditation stimulus response, and social cognitive theory. Does not see abnormal behavior as pathological. Treatment strategies associated with behavioral therapy include antecedents, behavior, consequences, and behavioral reconstruction, tailored the individual's unique presentation. There is empirical evidence for the efficacy of behavioral therapy in treating depression, autism, childhood developmental disorders, etc.

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Cognitive Therapy

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Stress response entails an interaction btw cognitive, affective, motivational, and behavioral responses that are on experience and learning. Maladaptive responses to the world result from inaccurate perception of internal or external cues and rigid responses that do not change regardless of environmental cues, external or internal

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Family Therapy

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Defines a family as a system of individuals and sheds lights on how the members influence each other and how they, themselves, are influenced-- a concept known as reciprocal causality. Looks at the network between all members of the family. Looks at maladaptive patterns within the family. Manuchin's Structural Family Therapy is an approach that focuses on the family as as system, rather than focusing on the individual family member as being problematic

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Contemplative Therapies

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Specifically, Yoga and meditation, and more recently, breathing techniques, are becoming increasingly popular in the US. These therapies focus on the creation of psychological, physiological, spiritual balance, and harmony to enhance well-being. These therapists believe that dysfunction and psychological suffering arise because the mind is uncontrolled; suffering may also be a product of shared dysfunction, cultural beliefs, and defenses

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Integrative Therapies

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This approach focuses on the uniqueness of the individual patient and tailors tx to the patient's needs. The basic concepts are: technical eclecticism, which enables mental health professionals to choose the best treatment approach for a particular person and problem, and theoretical integration, in which at least two modes of therapy are combined

Also can utilize assimilative integration, which entails firmly rooting oneself in one mode of therapy with an openness to incorporate methods outside of one's orientation.

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Depression

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lifetime prevalence rates for this disorder are estimated to be as high as 16.5% in the US. Women tend to demonstrate rates that are double those of men. Cognitive therapy combined with psychopharmacological treatment has also been consistently found to reduce rates of relapse significantly more than psychopharmalogical tx alone. IPT and behavioral activation are also empirically supported txs for this disorder

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Criteria for a depressive episode

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Characterized by by atleast 2 weeks of depressed mood and or anhedonia, plus 4 more of the following symptoms: weight loss or gain, sleep disturbance, psychomotor agitation or retardation, fatigue or reduced energy, feelings of worthless and guilt, difficulty in concentration, and thoughts of suicide and death. There must also be a significant distress or impairment in fx in important life areas.

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TX for BPD

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Medications have traditionally been viewed as the treatment of choice for bipolar disorder, and there is little deniability that pharacotherapy be be effective for symptom reduction. However, CBT has also been found to be effective. From the STEP-BD study, it was found that individuals benefitted most from the combination of therapy and medication, although there was not a specific advantage for any specific therapy.

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TX for eating disorders

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Cognitive Behavioral Therapy is the current standard of psychosocial for eating disorders. Several adaptations of CBT have been developed specifically for the TX of eating disorders. (CBT for bulimia nervosa, enhanced CBT)

Family therapy has also been widely researched and a significant amount of empirical evidence exists that use of family therapy, part. the Maudsley Model of family therapy, for tx of anorexia nervosa

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info on disorders via DSM-5

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review DSM-5 resource book for changing criteria and categories

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Anxiety Disorders and Panic Dx

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CBT has the best outcome as compared to supportive and medication tx; for panic, especially psycheducation and skills training

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Phobias

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Have been effectively treated by in vivo exposure, virtual reality, and cognitive therapy, however, for specific phobias, relapse tends to occur after 1 year. CBT is an effective treatment for social anxiety disorder

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OCD

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Exposure and ritual prevention is an evidence-based psychotherapy for TX of OCD. Serotonergic antidepressant medications have also been shown to effectively reduce OCD symptoms. Medication does not necessarily contribute additional benefit above and beyond those of psychotherapy

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PTSD

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Lifetime prevalence of PTSD are estimated at 6.8% and rates of PTSD are almost three times higher in women then men. Evidenced-based tx for PTSD include prolonged exposure, cognitive processing therapy, EMDR, and pharmacological treatments

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Psychotic Disorders

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Primarily treated with antipsychotic medication; however, there is evidence that individuals with this disorder may also benefit from psychotherapy, particularly, when combined with pharmacological treatments. Patients with schizophrenia experiencing positive symptoms have benefited from CBT and those suffering from acute episodes of psychosis have also benefitted from CBT supplemented by pharmacotherapy.

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Addictions

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Wide range of available treatments. Support groups, cognitive behavioral treatments aimed at identifying triggers and coping with urges. Generally, treatments are adapted and applied for specific substances (CBT for cocaine use) Other empirically supported treatments for substance use disorders include contingency management, motivational interviewing, and behavioral couple therapy.

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Personality Disorders: Classifications

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Cluster A: Odd or eccentric

paranoid, schizoid, and schizotypal

Cluster B: emotional disorders

antisocial, borderline, and histronic

Cluster C: Disorders of ANX

avoidant, dependent, and obsessive compulsive

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Personality Disorders TX

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Traditionally, these disorders have been treated with psychodynamic therapies, however, more recent therapies based on cognitive behavioral theory and aimed at specific personality disorders have been developed. DBT is the leading empirically supported treatment for BPD.

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Treatment for Pevasive Developmental Disorders

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Typically involve behavioral interventions that may rely on strategies based on learning theory, such as use of positive reinforcement to shape behavior. Goals of therapy usually improve desirable behaviors (functional communication training)

TEACH, Treatment and Education of Autistic related Communication-handidcapped Children. It is a classroom-based program that provides highly individualized tx to children with PDDs.

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ADHD TX

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Tx of choice for this disorder is a combination of stimulant medication and behavioral interventions. Parent training is also supported as treatment for ADHD, and the primary goal of this TX is to teach parents skills to support their children and manage the disorder

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Disruptive Behavior Disorder TX

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Parent training, in addition, cognitive problem solving skills training is another supported therapy aimed at teaching prosocial behavior to children with these disorders

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prevention

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an action or method aimed at the general population, or at segments of the population with varying levels of risk for any health-related problem. The goal is to enhance protective factors and reduce risk.

Encompasses three tiers of action: primary, secondary, and tertiary.

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Primary

tiers of prevention

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relies on education, motivational encouragement, social support, law and policy, and environment to inform the public of risk factors that lead to disease; it is universal and may involve campaigns that target the general population or groups that are not necessarily at immediate risk and equip these groups with knowledge they apply to future risks

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selective prevention

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targets high risk groups within a population to prevent the development of disease and disability.

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indicated prevention

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refers to strategies toward target groups that exhibit symptoms indicative of illness but that do not meet full criteria

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Secondary prevention

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refers to the efforts aimed to reduce prevalence and impact of disease by promoting the adoption of behaviors that protect and improve health.

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Tertiary prevention

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Reduce the negative impact of disease by restoring function and reducing disease-related complication. Goals include the reduction of disability, improvement, of function, enhancing rehabilitation efforts and impact, and relapse prevention.

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Victims of Trauma

prevention in special populations

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Rape crisis centers re an example of indicated prevention method and a primary preventative measure for women who have been victimized

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Immigrants

prevention in special populations

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Primary methods include the provision of resources to ameliorate the challenges encountered by immigrants, including language training, promotion of general health, and education.

A secondary prevention program targeting substance abuse may include education about pressures and dangers resulting in alcohol and drug use.

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PTSD

prevention in special populations

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PTSD in returning military was 9%-15% for Vietnam is expected to be higher in more current times/wars (10-18%) (IRAG/AFG)

Current preventative approaches for PTSD in military personnel include exposure strategies coupled with education and stress management skills training

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Athletic Performance

^ growth and performance

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The psychological skills training theory uses cognitive techniques such as imagery and self-talk to improve self-confidence and lower anx. Recently there has been a trend toward mindfulness and acceptance and commitment techniques. Approaches must be specific to sport. More empirical research is needed in many areas related to athletic performance

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Coaching

^ growth and performance

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In professional organizations, coaching has become common; however, activities that comprise coaching may not differ significantly from activities and goals of human resource development.

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Effects of Burnout

^ growth and performance

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Multiple factors that increase the likelihood of burnout; these include: work overload, insufficient reward, breakdown of community, absence of fairness, lack of control, and conflicting values.

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Organizational Development

^ growth and performance

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Refers to the act of enhancing performance of organizations by promoting change of individuals and systems. The common aspects of OD include using an individual to facilitate change, focusing on relationships within the orgranization,; support from management of the organization, and perceiving change as an ongoing process.

Strives to improve the organization's capacity to benefit all parties involved, including financially, quality of life, and work performance.

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Three phases of conducting Organizational Development

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1) Identifying the problem through consultation with managing officials and the entity hat requested OD implementation

2) Diagnostics through information gathering and interviews in order to interpret and address the issues

3) intervetion; in which the plan of action to diminish the problem is implemented, otherwise known as the joint action planning (JAP)

- Evaluation process; to assess the effectiveness of the intervention

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Human Resources Management

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Primary function is to maintain and improve performance in the institution.

- customer satisfaction

- socialization tactis

- cross-training activities to improve facets of the institution

Research has demonstrated that the use of HR increases company profits and lowers employee turnover, however; there are many management and organizational theories and techniques with little consensus on impact of these theories and techniques on performance

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Career Performance

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Psychologists use both objective and subjective measures to assess current as well as to predict a potential employees future performance. Objective measures include validated tests used to evaluate a potential employees projected performance, such as cognitive and personality tests. Subjective measures include interview ratings (clinical psychs, I/O psychs, human resource workers)

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Consultation

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Defined as an interaction btw a professional psychologist or a consultant and consultee who may be a client, group of colleagues, or a system. It differs from supervision, in that there is no significant ongoing relationship and the dynamics are necessarily hierarchical

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current models of consultation

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- client-centered consultation; focused on problem resolution

- consultee-centered consultation (CCC); concerned with improving the clients' skills, confidence, and professional objectivity in addition to problem resolution.

- consultee-centered administrative consultatuon; entails assessing professional performance in unfamiliar situations

- program-centered administrative consultation; used to create a plan of action that suits and improves the mental health affinity of a community (specific tailored approaches)

- behavioral consultation; (School setting) involves identifying problematic behaviors and using problem-solving techniques

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Constructivism Theory

Career Counseling

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This approach allows people to shape their work lives though active participation and decision making, enabling them to discriminate btw alternatives and construct their own personal goals.

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Systems Theory

Career Counseling

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Career development is viewed as a result of the involvement btw the individual and contextual variables

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Action and Paradoxical Theory

Career Counseling

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Connects action and career with action being individual, social, and all other goal-oriented activities. The main idea in paradoxical theory is to explain and enhance concise career decisions with confidence and a realistic view. "planned happenstance" which describes career development arising from random events; however, the probability of these random events occurring is influenced by certain traits such as curiosity, optimism, and risk-taking

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Narrative Career Counseling

Career Counseling

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The most recent approach*** A constructivist approach to career counseling that has been increasingly used over the last decade. listening to the client's accounts; the counselor's role is to engage the client as a personal agent in his career development. (use real-life situations)

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Career Assessments

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In conjunction with the action theory, qualitative assessment may consist of interviewing the family in order to gauge the client's interests and aptitude in career development. Formal quantitative measures used in career development are the Strong Interest Inventory to measure interest and the Skills Confidence Inventory, which measures the relationship between self-assurance and career choice.

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Support Groups

Adjunctive Interventions

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These type of groups have been demonstrated to be effective in improving mental health outcomes in populations with anxiety, depression, chronic mental illness, and those suffering from bereavement. Currently, research is lacking in well-designed empirical studies on effectiveness of support groups and the results of existing studies have been mixed.

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Individual Self-Help

Adjunctive interventions

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Benefits of self-help materials; self-empowerment, anonymity, and reduction of costs. In addition, utilization of self-help materials sought out by individuals has been demonstrated to be effective for relief in some psychiatric symptoms, specifically for anxiety disorders and assertiveness. *Therapist assisted self-help was found to be more effective treatment then self-help alone.

There is also evidence for the need for effective social support as an adjunctive to traditional treatments and it is imperative for enhanced quality of life

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Spirituality

Adjunctive Interventions

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Although traditionally thought to be exclusively for religious individuals, using spirituality in a broader sense has been effective for many nonreligious individuals. In addition, evidence shows that spirituality is protective against disease

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Complementary and Alternative Medicine

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The use of techniques such as yoga, meditation, mindfulness, acupuncture, and many others has become a very effective treatment for those with pain, dealing with chronic disease, and those who may be averse to traditional intervention techniques such as talk therapy or pharmacotherapy.

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Psychological Assessment

Technology

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using the internet for psychological assessment has become a popular choice for professionals due to ease of use and convenience; however, caution must be exercised as a complete evaluation and integration of scores is difficult when completed over the internet. Additionally, most assessment is enhanced by behavioral observation, which is not possible over the internet.

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Intervention

Technology

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Evidence indicates that computer-based interventions may be effective for anxiety and depressive disorders; however, there are currently multiple limitations to this treatment: adherence and attrition are more difficult to monitor via computers, and evidence for efficacy is limited for use with severe presentations.

Internet interventions may provide individuals in remote locations to assess; however, this remote access may lead to fewer therapists being present in these areas and also presents ethical issues.

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Research

Technology

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Using computers and the internet to collect data has become an efficient and cost-effective mechanism for accessing large amount of data. There are limitations and disadvantages of collecting data online such as a biased samples, inability to monitor whether individuals are answering truthfully, and protection of data.

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Documentation

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The current APA guidelines for management of electronic records involve ensuring appropriate documentation storage and privacy.

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Structures

Health Care Systems

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Beveridge model: often referred to as the public model, which primarily funded through taxation, budgets compete with spending priorities within its system

Bismarck model: referred to as the mixed model and funded through a combination of premiums and social/mandatory insurance.

Private insurance: funding is based on premiums through private insurance companies, with the exception of public social care as Medicare and Medicaid, which are publicly funded.

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Health Economies

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Public funding by the govt and private funding by insurance companies provide the financial basis of US health care (provided by individual and business income tax) Businesses also provide most of the premiums for insurance they delegate through private insurers

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Cost/Benefit Consideration

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Roughly 80% of health care spending is at the recommendation of physicians and at time not all physicians are current in their knowledge of efficient and newer treatments. Insurance and payment organizations tend to favor the use of medication over traditional mental health treatments such as psychotherapy. Deciding what treatment a patient receives is usually based on clinical info, but cost to the patient should also be considered. The utilization and cost of medication have increased, and may with limited resources are forced to consider affordable treatment alternatives.

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Risk Reduction

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Reducing risk, whether in a universal or target population, involves identifying risks that could lead to health issues without the implementation of prevention or intervention programs. Early intervention has been found to be important in risk reduction especially for issues that include an early developmental trajectory. Risk reduction includes the identification and acknowledgement of risk factors and protective factors across diverse settings such as community, family, school, and social networks.

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Resilience and Wellness

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resilience develops through individuals' life experiences, with childhood events having a greater impact. The salient effects of early childhood experiences on the development of resilience point to the importance of preventive promotion in early years of life; important preventive strategies in early childhood include the development of self-esteem, self-efficacy, self-control, social competence, and problem-solving skills/

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Health Promotion

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Strategies such as community organizing, entertainment education, distribution of health-related devices, Internet-based education, mass media advertising, education provider, and policy change and enforcement all constitute methods of health promotion.

The goal behind this method is to provide a conceptual link between certain risk behaviors and images of consequences

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Supervision

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Many current researchers have that effective supervision consists of a positive working relationship, continual assessment of student's skills and needs, and constructive criticism as well as praise.

Researchers found that three tools were used consistently for supervision: giving feedback, using educational role play, and modeling

There has been little evidence to support the techniques used in the field and very little research on effectiveness. Supervision is sometimes viewed as a purely clinical event, but in fact, it needs to be incorporated into mentoring research, teaching and administration skills

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Supervision, contd.

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a supervisor can be essential in providing assistance in the areas of conducting and implementing research effectively, while adhering to the specific institution's ethical and administrative requirements. Unfortunately, the current state of clinical psychology has not provided a structure for supervisor training, and counseling centers are currently most proficient at providing training in clinical supervision, compare to all other types of training sites.

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Developmental model

supervision

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based on the understanding that learning clinical skills occurs in stages. Different levels of supervision at different stages.

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Cognitive Behavioral Therapy Model

Supervision

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may be an effective strategy as it as an evidenced-based practice. Consists of many tools thats are used in a CBT therapy session, such as setting the agenda, and assigning homework.

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Psychodynamic Model

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Varies, but can be focused on content or process oriented, and can involve the relationship btw supervisor and supervisee or can focus solely on the dynamic themes of the pt being discussed

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Supervision, general info

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It is imperative that supervision encompasses teaching appropriate skills such as documentation and knowledge of current ethical, legal, and multicultural issues. Specifically, supervisors must focus on dealing with multiple relationships, guidelines to prevent malpractice, and fostering multicultural compotence.