Final Exam Flashcards
(171 cards)
1
Q
Multicultural goal of therapy
A
Help well-being and “to help clients thrive and push past internalized oppression”
2
Q
Multicultural view of psychopathology
A
- Expression of symptoms influenced by culture and identity
- Understand how the client views the causes of their symptoms
- Oppression and inequality can influence psychopathology - so does being in a dominant group
3
Q
Multicultural guiding principles
A
- “Unity through diversity”
- Draws from many types of psychological theories as well as paradigms outside of psychology
- Often integrative
- Can focus on change processes
- Psychotherapy is culturally embedded
- Differences between therapist and client can affect assessment and diagnosis
- Cultural competency is important for understanding functional vs. Nonfunctional behaviors
4
Q
Multicultural 6 propositions
A
- A metatheory - each theory represents a worldview
- The interrelationship of experiences and contexts of the client and counselor matter - both client and counselor have multiple identities
- Level of cultural identity development influences goals and processes
- Use modalities and goals consistent with the experiences and cultural values of the client
- The importance of multiple helping roles
- Counselor competence involves awareness, understanding, and culturally appropriate intervention strategies
5
Q
Multicultural techniques
A
- Reflexivity
- Emphasize strengths and cultural resilience
- Power differential analysis
- Empowerment (acknowledging how oppression affects mental health)
- Pluralism (what treatment works for who and in what context)
- Focus on the therapeutic relationship
6
Q
Multicultural outcome data
A
- Traditional research more difficult (not many RCT’s)
Evidence for strength of culturally adapted treatments
Meta-analysis overall effect was d = -.51
- research on cultural competence
- research of effects of discrimination and racism on mental health
- research on microaggressions
- beyond research, many accomplishments
7
Q
Multicultural therapist characteristics
A
- Cultural competence (knowledge, attitudes, skill, and policies)
- Cultural humility
8
Q
Feminist view of psychopathology
A
-
Psychology must be interpreted within the framework of an “oppressive social context”
View of psychopathology arises from:
1. The conflicts and nature of traditional feminine roles
2. Tactics used to exercise personal power
3. Arbitrary labels that society has assigned to certain behaviors in order to impose sanctions or exert social control
9
Q
Feminist goal of therapy
A
- Empowering the client
- Identifying oppressive societal forces and altering them
10
Q
Feminist Key techniques
A
- Egalitarian relationship
- Avoiding labels
- Avoid victimization and blame
- Involvement in social/political activism
11
Q
Psychodynamic therapy view of psychopathology
A
- People are not aware of reasons for their behavior
- At least some of our motivation is biologically motivated
- emphasis on the role of the past
12
Q
Freudian theory of psychopathology
A
- Unconscious and unresolved conflicts from childhood
- May react to current events as a reaction to past events
- Things early on in life shapes your unconscious and you are reacting to it
13
Q
Psydomanic therapy goal of therapy
A
- Bringing the unconscious into conscious awareness and integrate repressed things into the personality
14
Q
Psychodynamic therapy mechanisms of change
A
- Therapeutic alliance
- Insight
- Defense mechanisms
- Transference/countertransference
- Object relations
- Mentalization/reflective functioning
15
Q
Therapeutic alliance (psychodynamic)
A
1. Goal consensus or agreement
2. Collaborative engagement in mutual tasks
3. Development of a relational bond
- medium effect size
- it helps to collect feedback on the alliance
16
Q
Effects of transference/countertransference (psychodynamic)
A
- Transference = large effect size in one meta-analysis
- Countertransference (overall and outcome) = small and negative
- Countertransference management = larger, r =-.56
?
17
Q
Freudian therapy techniques
A
4 key techniques:
- confrontation
- clarification
- Interpretation
- working through
also focus on the relationship:
- working alliance
- transference and countertransference
18
Q
Psychodynamic therapy outcome data
A
- Outperformed waitlist and treatment as usual
- No differences between this therapy and others
- For depression and anxiety, more effective than control (medium effect size)
- for personality, no difference in core symptom between this and other treatment
- great degree of heterogeneity
- most of the things we know about it come from brief psychodynamic
19
Q
Key features of psychodynamic therapy
A
- Therapeutic alliance is really important
- Lack of homework
- Less guidance and more open questions
20
Q
Brief psychodynamic therapy goal
A
- Focus on patient expression of emotion
- Explore avoidance and resistance
- Find patterns in patient’s lives and relationships
- Emphasize past experiences
- Explore wishes, dreams, and fantasies
- Emphasize the therapeutic relationship
21
Q
Brief psychodynamic therapy outcome data
A
Leichsenring - meta-analysis of pre to post treatment effect sizes
- Target problems (d = 1.39)
- General psychiatric symptoms (d. =. 90)
- Social functioning (d. =. 80)
- Short-term dynamic therapy significantly outperformed a waitlist and treatment as usual
- No difference between this therapy and others
22
Q
Brief psychodynamic therapy for depression
A
- More effective than control (medium effect size)
- Not different effects from alternative therapies
23
Q
Brief psychodynamic for anxiety
A
- Better than control (PTSD and social anxiety)
- Not different than other treatments in short or long term
24
Q
Brief psychodynamic for personality disorders
A
- No difference in core symptoms between this treatment and others
25
Brief psychodynamic number of sessions
14-20
26
Humanistic/experiential view of psychopathology
People have an actualizing tendency
27
Humanistic/experiential goal of therapy
Self-awareness, growth, and meaning
28
Humanistic/experiential techniques/principles
**Focus on therapeutic relationship** - seen as potentially curative, can provide client with a new, corrective, and validating experience
- Authentic, collaborative, and egalitarian therapy relationship
- In-therapy experiencing
**Person-centered** and genuine concern for whole person - not a diagnosis or symptom
- Focus on client's subjective experiences
- Self-determination and **self-actualization**
- Focus on *current/present* (not past)
- Reject assessment and diagnosis
29
Humanistic/experiential outcomes
- **Large effects compared to no therapy**
- CBT appears to have an advantage over these therapies (non-directive supportive therapy does worst vs. CBT)
- For depression (especially severe) person-centered may need to be supplemented
- For anxiety, CBT may be better
- Chronic medical conditions does as well as CBT
- May be effective for psychosis but contradicts some guidelines
30
Examples of humanistic/experiential
- Person-centered therapy
- Gestalt therapy
- Emotion-focused therapy
- Motivational interviewing
- Existential therapy
- Psychodrama
- Relationship control intervention
31
Person-centered therapy view of psychopathology
- An inconsistency between ones' view of self and ones' experiences
32
Person- centered therapy goal of therapy
- To creat **personality reorganization** (resolve incongruence between actual self and experience)
- To become **self-actualized**
33
Person-centered therapy guiding principles
**Three core conditions**
1. Congruence
2. Unconditional positive regard
3. Empathy
Carl Rogers argued that these are necessary and sufficient for change to occur
34
Congruence
- **Genuineness**
- *A person's thoughts, feelings, and behaviors match*
- The therapist's internal and external experiences match
- Being honest with the client
- Involves self-disclosure and immediacy
35
Unconditional positive regard
- **Accepting the client's experiences and caring for the client as a separate person**
- Caring for them for who they are and not placing conditions of worth on them
- Do not directly express it but do so indirectly - arriving on time, let clients talk, remember client stories, empathy, respect clients, affirmations
36
Empathy
- **Understanding the client from the client's point of view**
- At the same time knowing that you can never truly know the client's POV because you are not the same as them
- Reflection of feeling, interpretive reflection of feeling, feeling validation
- Do not say "I know how you feel", I've been through that before", "that is horrible"
37
Person-centered therapy outcomes
**Congruence**
- r=.24 (small to medium effect size)
- 6% of treatment variance
**Unconditional positive regard**
- medium effect size r =.27 (ethnic minority status of client might moderate the effect with bigger effect size in such groups)
**Empathy**
- medium effect size with much variability
- 9% of treatment variance las much or move than the alliance)
38
Transdiagnostic therapies definition
- No uniform definition
- Apply the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses
39
Transdiagnostic therapies target
- Shared processes and several diagnoses at once
40
Enhanced cognitive-behavior therapy
**Transdiagnostic therapy**
- Developed out of CBT for bulimia nervosa (CBT-BN is an effective treatment for bulimia nervosa)
- Eating disorders have many things in common with each other, core underlying pathology (people often switch diagnoses)
- One transdiagnostic protocol to apply to all eating disorders because there are similar transdiagnostic mechanisms (overevaluation of weight and shape)
41
Examples of transdiagnostic therapies
- Unified treatment protocol for emotional disorders
- Internet CBT (ex: The wellbeing course)
- Acceptance and commitment therapy and other third wave therapies
42
Solution-focused therapy view of maladaptive behavior
- Maladaptive behavior is irrelevant
43
Solution-focused therapy goal of therapy
- Find solutions to problems by assisting the client in recognizing strengths and resources
44
Solution-focused therapy key techniques
- Client is the expert, therapist collaborates
- Heavy use of questions (miracle question, exception questions, scaling questions)
45
Interpersonal therapy for depression view of psychopathology
- Disruptions are a consequence or contributor to maladaptive interpersonal communication patterns that can result in less support
- **Interpersonal triad**: acute interpersonal crisis (stressor), biopsychosocial vulnerability (diathesis), and social support (contex) all contribute to distress
46
Interpersonal therapy goal of therapy
- **Depressive symptom reduction and better interpersonal function**
- Helps you see connections between depression and relationships
- Present focused
47
Interpersonal therapy techniques
- **Education**
- **Instillation of hope**
- **Positive regard and collaboration**
- **Closeness circle** and **interpersonal inventory** resulting in case formulation of primary problem area
- **Communication analysis** → (how your communication impacts others), modeling, role-playing, affective expression, clarification of expectations for relationships, problem-solving
- kind of like psychodynamic but very behavioral
- very directive
- very manualized
- you don't talk about the past much (present-focused)
48
Interpersonal therapy background
- Informed by interpersonal approaches and attachment theory
- **Combines psychodynamic and cognitive-behavioral**
49
Interpersonal therapy structure
- Brief, manualized therapy
- First developed for depression
- Tested in randomized clinical trials
- 12-16 sessions with 3 phases (consciousness raising, primary problem area, termination)
Problem areas = unresolved grief, interpersonal role disputes, role transitions, interpersonal deficits, etc.
50
Interpersonal therapy for depression outcome data
- NIMH collaborative treatment study
- Interpersonal therapy, cognitive therapy, and imipramine and clinical management, and placebo plus clinical management for outpatient depression
- **Overall, neither treatment significantly different from placebo**
- **For move severely depressed, evidence that IPT outperformed placebo** (the same was not the for cognitive therapy)
51
Interpersonal therapy for adolescents parent involvement
- Parents involved in assessment/initial phase
- May attend middle phase if relevant, otherwise coached to be supportive and that adolescent will be trying new skills
- Termination - parents involved in progress and treatment planning review
52
Behavioral therapy theory of psychopathology
- Maladaptive behavior is acquired and maintained through the same learning principles as normal behavior
53
Behavior therapy guiding principles
- A reaction to unscientific methods of psychoanalytic perspective
- **We should only study what we can directly observe**
- Tries to understand how we learn new behaviors, change them, and make them extinct
- Focus on changeable behaviors
- Focus on changing the stimulus and response
- Focus on ongoing assessment of current behaviors (treatment is empirical in nature)
54
Foundations of behaviorism
- **Classical conditioning** (neutral stimulus paired with unconditioned stimulus)
- **Operant conditioning** (punishment decreases the late of responding, reinforcement increases)
55
Behavior therapy techniques
- Graduated homework assignments
- Exposure
- Stimulus control
- Behavioral/functional analysis
- Communication skills
- Problem solving
56
Cognitive (or cognitive-behavioral) therapy view of psychopathology
- Thoughts and how we process information can lead to problematic emotions and behaviors
- Underlying cognitions have content specificity to the psychopathology they produce
57
Cognitive therapy background
Response to the failure of behaviorism to capture higher-order mental processes (e.g. Thinking)
58
Cognitive therapy techniques for **guided discovery**
- Socratic dialogue and questioning
- Thought records
- Behavioral experiments
- Core beliefs and prediction log
- Imagery
- Role play
- Planning for relapse
- Homework
59
Cognitive therapy for depression view of psychopathology
- **Thoughts, feelings, behaviors, and your physiology/biochemistry are interconnected** → and they're all influenced by the environment and can influence the environment
- People prone to depression have negative cognitive biases
- **Cognitive triad of depression** = negative view of yourself, the world, and the future
- People with depression distort their interpretation of events so that they stay in line with their negative views → people distort information without awareness ("automatic thoughts")
60
The cognitive model
- Negative automatic thoughts arise from depressogenic **core beliefs** (I am a failure) and **underlying assumptions** (If, then. If I don't do this, then I am a failure.)
- These core beliefs and underlying assumptions are part of larger **schemas** (Your template for how things work. Your perceptions, goals, expectations, memories, and learning.)
- Schemas control how you are taking in and processing info from the world
- Schemas develop through past experiences
- People with depression have negative schemas
- Early maladaptive schemas (EMS) develop when a child's core needs are not met
- EMS are dormant until a life event activates them
61
Cognitive therapy goal of therapy
- Work on the level of people's thoughts to change how they feel
62
Cognitive therapy outcome studies
"Well established" or "efficacious and specific” and "strong research support"
- Outperforms a bonafide treatment or placebo in at least 2 well-designed studies
63
Cognitive therapy immediate outcome data
- Reduces depression for about half of clients
- **Seems similar to alternative treatments and antidepressant medication**
- Studies have shown slightly different results for mild-moderate depression vs. severe depression
64
Cognitive therapy relapse prevention data
- Several studies and a meta-analysis have shown that **cognitive therapy produces lower relapse rates than medication**
- Cognitive therapy also has *many other qualities over medication* including less side effects; can't be used in suicide attempts; cost-effective; time-limited
65
Cognitive therapy chronic depression outcomes
- **40-50% of patients for "acute depression” do not respond after cognitive therapy**
5 treatments have been developed for chronic depression:
1. DBT applications
2. Mindfulness-based cognitive therapy (MCBT)
3. Metacognitive therapy (MCT)
4. Cognitive - behavioral analysis system of psychotherapy (CBASP)
5. Schema therapy (ST)
66
Cognitive therapy ideal characteristics of therapists
- Good non-specific skills, including "accurate empathy"
- Logical and good planners
- Active (structured, confident, and professional)
67
Cognitive therapy ideal characteristics of clients
**Need more empirical data**
- Usually those without personality disorders or more severe disorders
- Introspective
- Well organized and good planners and thinkers
- Not too dogmatic or inflexible in thinking
- Can identify a precipitating event
- Have relationships with others and are employed at some point
- Not too angry
68
Cognitive therapy early sessions
- Work on symptom reduction
- Overcome hopelessness
- Develop rapport
- Identify problems and set goals
- Socialize to cognitive therapy/demonstrate the cognitive therapy model
- Immediate symptom relief (using behavior therapy)
- Discover the link between thoughts and emotions
- Label thinking errors
69
Cognitive therapy middle and later sessions
- Changing schemas and core beliefs and relapse prevention
- Examining core beliefs and underlying assumptions
- Restructuring and modifying core schemas
- Relapse prevention plan
- **As therapy progresses, client plays a more active role and therapist becomes more and more like an advisor/consultant**
70
Cognitive therapy structure of each session
1. Check in and set agenda
2. Talk about learning since the last session, including the homework
3. Talk about new skills and ideas
4. Decide on homework/learning activities for the week
5. Give the client a summary of the session and get feedback on the session
71
Cognitive therapy: fostering a spirit of collaboration
1. Interpersonal qualities of therapist
2. Joint determination of goals for therapy
3. Regular feedback (make sure they are not misinterpreting assignments, share rationale, summarize key points in writing)
4. Collaborative empiricism
72
Collaborative empiricism (cognitive therapy)
- Work with client using the scientific method
- Hypothesis → experiment (gather evidence) → accept or reject null hypothesis and modify belief
- Guided discovery - clients will discover their own inconsistencies if the therapist can guide them through the method (use questions - Socratic questioning)
73
Behavioral activation (cognitive therapy)
- **Early treatment**
- Activity planning, weekly activity list
- Graded tasks
- Cognitive rehearsal of the steps involved in the task
- Role playing
74
Socratic questioning (cognitive therapy)
- **Use questions to help clients uncover rather than telling them**
- Looking at the evidence and the assumptions the client makes (What is the evidence for that?)
- Consider the alternatives, different perspectives (what would you tell a friend?)
- Consider implications (how does it benefit you?)
75
Identifying core beliefs (cognitive therapy)
1. Identify recurring patterns on thought records
2. The downward arrow technique (downward spiral of thoughts) leading to core beliefs (query automatic thoughts that lead to core beliefs)
76
Modifying core beliefs (cognitive therapy)
- Think of evidence to suggest that it is not 100% true all of the time
- Create a modified core belief
- Think of evidence that supports the new modified core belief
- Rate the confidence in core beliefs over time
77
Cognitive therapy for depression key techniques
- Behavioral activation (activity scheduling)
- Guided discovery of automatic thoughts, underlying assumptions, and core beliefs (Socratic questioning and thought record)
- Homework assignments
- Planning for relapse
78
Behavioral models background
- Depression is associated with person-environment relationships
- Contingent relationships between behaviors and the environment occur (if-then relationships)
- Seek to change the environment or the contingencies
79
Cognitive therapy techniques
- Collaborative empiricism
- Socratic dialogue
- Psycoeducation about the cognitive model
- Identifying hot thoughts and cognitive distortions
- Thought records
- Experiments
- Downward arrow technique
80
Behavioral activation model
- People get depressed because changes in the context of their lives provide low levels of positive reinforcement and high levels of aversive control
- When feeling depressed (because of above), people pull away from activities and also have difficulty solving problems → secondary problem behaviors
81
Behavioral activation treatment for depression goals
- Modify behavior so more sources of positive reinforcements
- Target avoidance and routine disruptions
- Increase awareness of escape and avoidance patterns
- Develop active coping responses
- Change routines
82
Guided activation (behavioral activation)
- Functional analysis
- Contingency management
- Graded tasks
- Avoidance modification and problem solving
- Engagement strategies to avoid rumination
- Reviewing treatment gains and preparing for relapse
83
Activity monitoring and scheduling (behavioral activation)
- Monitor environments and behaviors and how they make you feel
- Purposefully schedule things that make you feel better
84
Contingency management (behavioral activation)
- Changing the contingencies of behaviors
- Can use public statements for commitment
- Can structure environments to help
- Can use arbitrary reinforcers (rewards for behaviors)
- At times, use aversive contingencies
85
Functional analysis (behavioral activation)
What are the antecedents and consequences of the behavior?
Antecedent → behavior → consequence
- do this by talking about the model and activity monitoring, especially outside of session)
86
10 core principles of behavioral activation
1. The key to changing how people feel is helping them change what they do
2. Changes in life can lead to depression, and short-term coping strategies can keep people stuck
3. The clues to find out what will be helpful for the client lie in the A's and C's
4. Structure activities that follow a plan, not a mood
5. Change will be easier when starting small
6. Emphasize activities that are naturally reinforcing
7. Act as a coach
8. Emphasize a problem-solving, empirical approach, and recognize that the results are useful
9. Don’t just talk, do!
10. Troubleshoot possible and actual barriers to activation
87
Behavioral activation therapist characteristics
ENLIVEN
Establishes and follows agenda
Nurtures activation
Learns together with client
Is nonjudgmental
Validates
Encourages
Naturally expressed warmth
88
Behavioral activation client characteristics
- Follow through with homework
- Engaged with treatment rationale
89
Behavioral activation outcomes
- BA plus interventions to modify automatic thoughts vs. full cognitive therapy → **BA comparable to full CT**
- **BA and antidepressant medication better than cognitive therapy** (BA vs. CT has an effect size up to .96)
- BA and antidepressant medication were similar in effect size but **more people stayed in BA condition** (for less severely depressed patients, all were similar)
- **CT and BA have enduring effects** (no significant differences between the two but evidence was not clear for CT)
- Meta-analysis: **BA better than control conditions but the same as other treatment conditions**
- BA has *“strong research support”*
- BA is promising because it is relatively straightforward to disseminate and train people in and new technology can support it
90
12-step facilitation view of psychopathology
- Sees alcoholism as a disease
- Based on AA principles
91
AA principles
- Alcoholism is a *"physical, emotional, and spiritual disease"*
- **It is a lifelong disease**
- **Abstinence is the goal**
- Work through the 12 steps
- Participants are paired with a sponsor and attend AA related activities
92
Goal of AA
- Acceptance and surrender
93
Goal of 12-step facilitation
- Abstain from alcohol and foster commitment to attending AA
94
12-step facilitation session structure
1. **Review** → review sober days, and urges and slips; review and reinforce AA participation of meetings and readings
2. Introduce and talk about the **theme of the week**
3. **Recovery task** → set goals for participation in this week's AA meeting and assign readings
- *Homework* = journals, reading, and AA
95
12-step facilitation outcome data
- **A social network more supportive of drinking** prior to treatment did better with 12-step than MET
- Participants higher in anger did better in MET and **lower in anger** did better in CBT and 12-step
96
Alcohol treatment therapist characteristics
- Empathy behavior
- Distinguish between person and drinking
- Active listening
- Instillation of hope/positive about change
- Integrity
- Flexible application of therapeutic techniques
- Work toward mutually agreeable goals
97
Alcohol treatment client characteristics
- Positive experiences
- Greater motivation to change
- Less severe problems
98
CBT for alcohol use goals
- **Identify situations that present a high risk of relapse/drinking** → anticipate where the problems are going to be and help develop the specific coping strategies
- **Overcome skills deficits and poor coping strategies** in the situations → develop positive skills and strategies, develop social rapport
- Prepare to **maintain change**
99
CBT strategies for sobriety
- **Stimulus-control strategies** → to eliminate/rearrange high risk situations (e.g. Do not go to restaurants with liquor licenses
- **Skills to cope with urges** → urges are learned responses to situations and they will dissipate with time (urge-surfing or help of a friend/family)
- **Addressing cognitive distortions** about alcohol
- **Identify alternative behaviors** instead of engaging in high-risk situations or develop a self-control plan in the situation
- **Develop alternative ways to obtain reinforcers** obtained from drinking
- **Drink refusal skills** (holding another drink in your hand, role-playing what to say)
- **Coping strategies for life** (negative affect, lifestyle balance, and pleasureable activities)
- discuss a long-term relapse plan
100
CBT for alcohol use outcome data
- Participants higher in anger did better in MET and **lower in anger** did better in CBT and 12-step
101
Motivational Interviewing/Motivational enhancement therapy background
- Derives from **transtheoretical model of change** → tries to help move people through change
- Also based on **brief therapy models** - feedback, responsibility, advice, menu of alternative choices, empathy, and self-efficacy
- Based on **Roger's client-centered therapy** and “accurate empathy" → based on the idea that people with substance use are often not treated very well or their therapist and others may be confrontational
102
MET structure in project match
- Thorough assessment (7 - 8 hr)
- Breathalyzer before each session
- 4 sessions:
1. Provide feedback about the assessment, symptoms, and future plans
2. Motivational enhancement and consolidate commitment to change
3. And 4. Week 6 and 12 - monitor and encourage process
103
Motivational Interviewing basic principles
- **Express empathy**
- **Develop discrepancy** (have them identify where they are and where they want to be)
- **Avoid argumentation**
- **Roll with resistance**
- **Support self-efficacy** (ability to change)
104
Motivational Interviewing techniques
- OARS
- Rolling with resistance
105
OARS
Open-ended questions
Affirmations
Reflective listening
Summary
106
Techniques for rolling with resistance
1. Simple reflection
2. Amplified reflection (exaggerate their statement)
3. Double-sided reflection (point out discrepancies)
4. Shifting focus
5. Agreement with a twist (agree with them but twist it to propel them forward)
6. Siding with the negative (be the voice of no change and they become the voice of change)
107
MET outcome data
- A social network more supportive of drinking did better with 12-step than MET
- Participants **higher in anger** did better in MET and lower in anger did better in CBT and 12-step
108
Culturally adapted MI background
- MI should work well for different populations
- May be a welcome contrast to how others have treated them
Added social contextual factors to the treatment:
- Historical and political experiences around immigration
- Context of immigration
- Receptivity of host community
- Language barrier
- Discrimination
Hypothesized that by adding and acknowledging discrimination and immigration, etc.it would help the client feel better understood
Qualitative research done first to understand social contexts and drinking
109
Adaptations made for culturally adapted MI
1. Focus on social context of immigration → typical day, context like discrimination, low status employment, missing family at home, and the influence this has on drinking
2. Changing family dynamics → pros and cons of drinking includes effects on family
3. Social support → how do close others influence drinking?
4. Alcohol health literacy → elicit-provide-elicit on negative health impacts of alcohol
- also emphasized the right for participants to speak even if they disagreed with clinician
- altered strategy for recruiting → "health education study"
110
Structure of culturally adapted MI
1 session - 1.5 hrs
111
Culturally adapted MI vs not adapted
Lee et al. (2013)
- Both treatments had decreases in drinking days and consequences
- **Adapted version had greater reductions at 2 and 6 months in consequences of drinking** and also trend (but medium effect size) for number of heavy drinking days per month
112
Project match outcomes
- Compared CBT, MET, and 12-step
- **Little difference between treatment groups**, especially after 3 years (difference in abstinence at 1 year with 12-step doing better)
- Tried to match participants with treatment depending on individual characteristics → **very few matches found**
- Higher anger = MET
- Lower anger = CBT and 12-step
- Social network supportive of drinking = 12-step over MET
113
Mindfulness and acceptance-based treatments view of psychopathology
Psychopathology maintained by **avoidance** or problem attempts to control distressing or undesirable internal experiences
114
Third wave CBT therapy similarities
- Additional focus on acceptance
- Mindfulness
- Defusion (undoing thought fusion)
- Patient values and relationships
- Rationale for treatment
- Client-therapist relationship
- Relationship to thought and emotion vs their content
- **Focused on more than symptom change**
115
Third wave CBT therapies
- ACT
- DBT
- cognitive behavioral analysis system of psychotherapy (CBASP)
- functional analytic psychotherapy (FAP)
- mindfulness-based cognitive therapy
- schema therapy
- integrative behavioral couple therapy (IBCT)
116
Mindfulness and acceptance-based treatments evidence
- *Generally no evidence that the perform better than standard behavioral approaches*
- Except **mindfulness based cognitive therapy for depression relapse** and **acceptance based behavioral therapy for obesity**
117
Dialectical behavior therapy background
- Developed by Marsha M. Linehan, trained in CBT and behavior modification
- 75% of clients with BPD have a history of suicide attempts and 10% die by suicide
- Inspired by symptoms of BPD
118
DBT origins
- Blend of different treatments
- **Add acceptance to CBT** which focuses on change (pushing for change can be seen as invalidating)
- Combine this with **dialectics** → every thesis has an antithesis, they are always coming together to make a new synthesis
- Combined with **zen practices** (where acceptance comes from)
119
Philosophy of dialectics
- Both a worldview and a therapeutic approach
Worldview = **principle of interrelatedness** (you view everything in relation to a system, you need to take context into account during treatment), **principle of polarity** (thesis and antithesis), **principle of continuous change** (everything is always changing, you continual synthesis)
- *one key*= there is always an opposite side/proposition → what is being left out?
Approach= client and therapist can arrive at a new synthesis by considering both the thesis and antithesis and nothing is ever final
120
Biosocial theory of BPD
- BPD is a disorder of emotion regulation
- **Emotional vulnerability + invalidating environment**
- Not all people with vulnerabilities for emotional dysregulation develop BPD
121
Emotional vulnerability (BPD)
**Emotional vulnerability** → high sensitivity to emotional stimuli, intense responses, slow return to baseline
Difficulties modulating emotional reactions caused by problems with:
- Stopping mood dependent behaviors
- Organizing behavior to achieve goals independent of current mood
- Changing arousal as needed by the situation
- Distracting attention from emotional stimuli
- Experiencing emotion without withdrawing or having another extreme emotion
122
Invalidating environment (BPD)
- **Rejects the person's communication of private experiences or their behaviors**
- Punish emotional displays and at times reinforce emotional escalation
- Oversimplification of solving the problem and attaining goals
123
Goal of DBT
To help clients build a life worth living
124
What DBT is designed to do
1. Enhance behavioral capabilities by teaching the client skills
2. Improve motivation to change by changing the contingencies of behavior
3. Have new behaviors generalize past therapy sessions
4. Improve the motivation and skills of the therapist
5. Structure the environment so that effective behaviors are reinforced (and ineffective ones are not
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Modes of DBT
- Individual therapy
- Skills training (group therapy)
- Phone consultation
- Consultation team
- Ancillary care
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Individual therapy DBT
- The primary therapist responsible
- Meet at least 1 time per week, 50-90 min
- Attends to the targets of the treatment, structures therapy
- 5 stages of treatment + pretreatment phase
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DBT pretreatment phase
- Come to an informed decision to work together first 1-4 sessions
- Common set of expectancies for therapy and explains what the therapy is about:
1. A life enhancement program and client and therapist work as a team
2. CBT
3. Skills oriented training
- Commit to not engaging in NSSI or suicidal behaviors for a certain time
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DBT individual therapy Stage 1
**"Attaining basic capacities"**
Behavioral targets:
- reduce life threatening behavior
- therapy-interfering behaviors
- quality of life interfering behaviors
- increase behavioral skills - therapist monitors this and helps apply but they are taught in group
- These are in a hierarchy but all are addressed in sessions
- Also encourage dialectical thinking
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DBT individual therapy Stage 2
**"Quiet desperation"**
- Teach client to experience emotions while still being in control of them and not shutting down
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DBT individual therapy Stage 3
- Achieve a normal level of happiness/unhappiness
- Work on problems of living
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DBT individual therapy Stage 4
- Work on becoming complete/ connect
- Attain freedom
- Expand awareness
- Spiritual fulfillment
- Experience flow
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DBT individual session structure
- Each session is based on targets for that session
- They are set by the hierarchy, stage, and what the client notes on their diary record cards
- Then problem solve these problems and also validate the client
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DBT strategies
**Dialectical strategies**
- playing devil's advocate
- extending
- making lemonade out of lemons
- what is being left out?
**Core strategies**
- validation
- problem solving
**Stylistic strategies**
- reciprocal communication
- irreverent communication (calling their bluff)
**Case management strategies**
**Integrated strategies**
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Skills group training (DBT)
- Leader teaches skills
- Co-leader manages group process
- Meet weekly for 2-2.5 hours
- Clients will be referred to individual therapists for problem behaviors and crises
**4 skills modules**
- Mindfulness
- Interpersonal effectiveness
- Emotion regulation
- Distress tolerance
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Phone consultation (DBT)
- Clients call primary therapist between sessions
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Consultation team (DBT)
-Therapists are in a team with other therapists
- Weekly meetings
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Ancillary care (DBT)
For case management and crisis situations
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DBT client characteristics
- Need to agree to voluntary treatment
- For group, need to control overly aggressive behaviors
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DBT therapist characteristics
- Acceptance vs change
- Unwavering centeredness with compassionate flexibility
- Balance nurturing with benevolent demanding
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DBT efficacy
- Very researched therapy
4 randomized trials of BPD among people high in suicidal behavior
→ **DBT superior in terms of reducing suicidal behavior** over treatment as usual, client-centered therapy, community treatment, and dynamic emotion-focused therapy plus medication
- Many studies have shown effectiveness in other types of samples and for reducing other difficulties
- **Parts of DBT may work instead of needing the whole treatment**
- The skills component is a mechanism of change
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Racial trauma or race-based stress
- Events or danger related to real or perceived experience of racial discrimination
- Including: threats of harm/injury, humiliating/shaming events, and witnessing harm to other POC due to real or perceived racism
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How racial trauma is similar to PTSD
- Hypervigilance to threat
- Flashbacks
- Nightmares
- Avoidance
- Suspiciousness
- Somatic expressions such as headaches and heart palpitations
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How racial trauma differs from PTSD
- **Ongoing injuries** due to exposure and re-exposure to race-based stress
- "hidden wounds”
- Can have **intergenerational and community impacts**
- Important to note **resilience**
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HEART framework goal
- Promote healing for individuals, families, and communities
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HEART framework
- **Healing ethno and racial trauma** (HEART) for Latinx immigrants
- Influenced by intersectionality theory, trauma-informed care, and liberation psychology
- Focuses on trauma symptoms and systems of oppression that generate distress
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HEART framework 4 phases
1. Develop a sanctuary space during treatment
2. Acknowledge, reprocess, and cope with symptoms of ethno-racial trauma
3. Strengthen and connect individuals, families, and communities to survival strategies and cultural traditions to heal (using 7 Latinx psychological strengths)
4. Promote a social justice orientation
- racial trauma recovery
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Trauma-focused CBT combined with concientizacion (HEART)
1. Acknowledge impact of ethnoracial trauma
2. In a sanctuary space
3. Culturally responsive coping
4. Challenge assumptions about sources of difficulties by contextualizing distress
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APA strongly recommended treatments for PTSD
- CBT
- Cognitive processing therapy
- Cognitive therapy
- Prolonged exposure
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APA suggested treatments for PTSD
- Brief eclectic therapy
- EMDR
- Narrative exposure therapy
*Could get moved to strongly recommend with more studies*
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APA treatments for PTSD with insufficient evidence
- Seeking safety
- relaxation
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APA guidelines for PTSD
- only looked at treatment for adults
- looked at symptom reduction and serious harm
- did not look at subthreshold symptoms
- used DSM-IV diagnoses
- **guidelines are not mandatory**
- use clinical judgment
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CBT for PTSD
- Reevaluate unhelpful ways of thinking
- Exposure to trauma narrative, emotions, and cues
- Psychoeducation
- Relaxation
*all types of CBT that didn't fit into other categories; didn't have to be trauma focused*
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Cognitive therapy for PTSD
- **Modify evaluations and memories of trauma to modify ineffective behavior and thoughts**
- specific type of CBT
- understand the meaning behind trauma memories and how appraised currently such that they lead to excessively pessimistic evaluations of the trauma or its sequale to create an exaggerated sense of threat
- new approach to trauma integrated with trauma memories/cues by thinking about it and writing about it
- establish a meaningful narrative account by **writing, imagine reliving, or visiting where trauma occurred** to elicit idiosyncratic memories that elicit strong emotions and can cognitively restructure in the moment
- then targets things like rumination, safety-seeking behaviors, thought suppression
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Cognitive processing therapy for PTSD
- **Learn to modify and challenge beliefs related to trauma**
- Specific type of CBT
- Results in new understanding and conceptualization of traumatic event such that its negative impacts are diminished
Steps
1. Psychoeducation about thoughts and emotion link; begins identifying automatic thoughts; writes impact statement about why trauma occurred and the impacts on beliefs about self, others, and world
2. Write detail of trauma and reads during session. Therapist uses Socratic questioning to talk about unhelpful thoughts.
3. Evaluate and modify beliefs about trauma.
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Prolonged exposure for PTSD
- **Gradually approach trauma-related memories, feelings, and situations**
- 8-15 sessions
- overview, psychoeducation, and breathing techniques
- exposure starts after assessment and an initial session
- therapy must be a safe place
- **imaginal and in vivo exposure**
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Imaginal exposure (PTSD)
- Client describes in detail in first person in present tense the event
- Record emotions experienced
- Story is recorded so can listen again between sessions
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In vivo exposure (PTSD)
- Confront feared stimuli outside of session as homework
- Plan decided on in-session
- Gradual
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Eye movement desensitization and reprocessing (EMDR)
- Briefly focus on the trauma memory while simultaneously experiencing bilateral stimulation (typically eye movements)
- Associated with a reduction in the vividness and emotion associated with the trauma memories
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Narrative exposure therapy (NET)
- Develop narrative to contextualize trauma
- Narrates whole life story
- **For complex and multiple trauma**
- Often in community settings and trauma from socio-political-cultural forces (refugees)
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APA PTSD guidelines evidence
- Comparatively **strong evidence for prolonged exposure with cognitive restructuring over cognitive restructuring alone**
- Could not include anything about the heterogeneity of the treatment effects in different subgroups
- Can't determine if findings applicable to all with PTSD orjust certain subgroups
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PTSD therapist characteristics
- Therapist knowledge about trauma
- Information about treatment
- Coping skills
- Personalized approach
- Awareness of cultural and socio-demographic differences
- Importance of the therapeutic relationship
- Preferences about intensity and pace of treatment
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PTSD future directions
- Need to know real-world application
- not many treatment comparisons
- studios do not evaluate moderators (small N)
- need to include comorbidities → substance use and suicidality
- need to report side effects/harm
- need to assess other outcomes
- need to assess patient preferences
- need long-term follow-ups
- need to address attrition, measure reasons why, and decrease missing data
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APA depression guidelines: children
Insufficient evidence
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APA depression guidelines: adolescents
- CBT
- Interpersonal psychotherapy for adolescents
- Fluoxetine
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APA depression guidelines: adults
Initial treatment
- Second generation antidepressants (SSRIs or SNRIs)
- Behavior therapy
- Cognitive, cognitive -behavioral, or mindfulness-based cognitive therapy
- Interpersonal psychotherapy
- Psychodynamic therapies
- Supportive therapy
- If medication + therapy then CBT or IPT
Conditional recs for:
- Problem-focused couples therapy (if relationship distress)
- If not therapy: exercise, St. John's wort, bright light, yoga, acupuncture + medication
*Clear evidence that CBT has an enduring effect and other types of psychotherapy as well that is not found for antidepressant medications*
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APA depression guidelines: older adults
- Group life review treatment or group CBT
- IPT plus medication over IPT alone
Also recommendations for:
- Subthreshold/minor depression
- MDD or minor depression + cognitiveimpairment/dementia
- Persistent depressive disorder
- MDD and medical comorbidities
- Prevention of MDD recurrence
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Key issue of scientist-practioner gap
Practitioners don't use research or research evidence to guide practice and researchers don't use input from practitioners to guide research
Underlying the issue:
- "deep seated attitudinal differences'
- "fundamental difference in how individuals conceptualize evidence's
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Boulder model
- **Scientist-practitioner**
- 1949 conference on graduate education in clinical psychology in Boulder
- train students to use scientifically-based assessments and interventions
- students should receive training in science and practice
- conduct both clinical work and a dissertation with supervision
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Vail model
- **practitioner-scholar**
- **PsyD degree**
- 1973 conference on graduate education in clinical psychology in vail, co
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Clinical-scientist model
- 1990’s
- founding of the academy of psychological clinical science
- “scientific psychology is the only legitimate and acceptable form of clinical psychology…”
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Special edition of behavioral therapy
- until now, communication has been a one-way street in which researchers tried to tell clinicians about research results
- now suggest that there should be a two-way street where clinicians also have input
Some recommendations:
1. Survey clinicians about experiences and conduct interviews with a subset of clinicians to get more in-depth information about barriers to effective implementation of the treatment
2. Clinical round tables of practitioners and researchers at major conferences
3. Encouraged papers in major journals from clinicians
