- Psychological Intervention: A method of inducing change in a person's behavior, thoughts or feelings. Intervention in the context of a professional relationship (client-patient).
- In referring to treatment the terms intervention and psychotherapy have been used interchangeably.
- Woolberg (1967): symptoms and treatment, promoting positive growth (type of medical def.)
- Rotter (1971) and Frank (1982) pose different definitions using terms like—interaction between a healer and sufferer, reliving of distress & disability, personal growth.
Does Psychotherapy Help?
- Need to address both the efficacy of a treatment and the effectiveness of a treatment.
- Efficacy Studies: Average person receiving treatment is demonstrated to be less dysfunctional than the person not receiving treatment.
o Take place in a research lab/university clinic (focus on internal validity)
- Effectiveness Studies: Focus on external validity and the representativeness of the treatment in the “real-world”. May not include control groups or random assignment; focus is on whether a client receiving treatment as it is typically administered reports significant relief/benefits.
Evidence Based Treatment and Evidence Based Practice
- Focus on whether clinical evidence-based treatments (psychotherapy vs. no treatment) are more effective than other therapies.
- Evidence-Based Treatment (EBT): Refers to treatments/interventions that have produced significant changes in clients/patients in controlled trials.
o Treatment vs. control group (comes solely from controlled clinical trials)
- Evidence-Based Practice (EBP): Broader practice that includes treatment informed by various sources.
- Society of Clinical Psychology (sub-division of the APA) developed specific criteria to evaluation different approaches to therapy/intervention treatments.
- Referred to as “evidence-based treatments” these criteria addresses whether certain therapy mechanisms may be useful in reducing mental health symptoms.
Features Common to Many Therapies
- Supportive factors—positive relationship, trust lay the groundwork for change in person's beliefs & attitudes (learning factors) lead to behavioral change (action factors—mastery, risk taking.
Relationship/Therapeutic Alliance & The Expert Role
- Client-therapist relationship is important for successful psychotherapy (accepting, non- judgmental, insightful and professional)
- Therapists are also expected to be competent as a result of training, knowledge and experience.
- Help the client be a more competent human, greater satisfaction. Therapist may work with client to help them learn new things or alter their faulty ways of thinking.
- It can be a learning experience; develop feelings of self-efficacy in the individual.
- Mastery—confident, expect to do well and feel good about themselves; will function better.
- Faith, Hope or expectations for increased competence; individuals come to therapy believing that it will help promote mental health.
- The expectations of the client are vital to the therapy process.
Nature of Specific Therapeutic Variables
The Patient or Client
The Degree of the Patient's Distress
- Therapists generalization is that people that need therapy the least are ones that will benefit most from it.
- Research data on this has been inconsistent—greater individual distress^ greater improvement, vice-versa and curvilinear (of finding poorer outcomes).
- Communicating with a patient about past experiences, insight & introspection requires some level of intelligence.
- Behavioral therapy has been successfully used with individuals with different intelligence levels.
- Young adults are viewed as being better for therapy than older adults (more flexible)
- Considering the specific characteristics of the patient and not age alone is important.
- In Psychotherapy most of the work occurs outside therapy though homework and between therapy sessions. Need to engage in anxiety provoking “new behaviors” (i.e. Albert Ellis)
- Psychotherapy is a voluntary process & can't be forced on a patient
- Varied findings on how to best assess client motivation.
Openness and Gender
- Patients that willing to be open to psychotherapy and not wanting immediate medical treatment are easier to work with. More open patient better long-term outcomes.
- Biological sex is not directly linked to treatment outcomes; but therapist gender may be important to consider in psychotherapy (e.g. rape victims and male vs. female therapist).
Race, Ethnicity & Social Class
- Many therapeutic techniques have been designed for white middle and upper class patients, and not for minorities.
- Very little research indicating that social class, values, background, and ethnic minorities receive poorer outcomes.
- But when social class and values of the patient and the therapist differ extensively; there needs to be some level of cultural sensitivity.
Age, Sex & Ethnicity and Personality
- Therapist's age is not related to outcome; different genders do not produce better outcomes that patient-therapist similarity for ethnicity does not play that huge of a role.
- Therapist personality does effect treatment outcomes, but the research in the area is lacking.
o Mature, sensitive, tolerant, free of bias, intelligent, creative, personally secure...
Empathy, Warmth and Genuineness
- Commitment & interest in the patient. The focus on empathy, warmth and genuineness grew out of Carl Rogers Client-Centered Therapy.
o Necessary & sufficient variables for therapeutic change.
o Only modest relation between these 3 variables and outcomes.
- These three features can be viewed as indicators of the quality of therapeutic alliance.
- Therapists need to be aware of their emotional state; so self-awareness is an important aspect.
- Therapy is not a place for gratifying the therapist's emotional needs.
Experience and Professional Identification
- No consistent relationship between therapist experience and outcome; paraprofessional therapy outcome sometimes exceed even those conducted by trained psychotherapists.
- Psychiatrists often sought to prevent psychologists from conducting therapy without psychiatric supervision because they were concerned about the medical aspect of treating patients.
Course of Clinical Intervention: Typical Sequence
Often unknowing what to expect, may be anxious or suspicious.
To patients or parents that contact the clinic, they are first informed of what the clinic is about & what type of help will be provided.
- After the other steps in the sequence will be covered—professional staff, qualifications, fees...
- Variety of assessments are made but there is often an intake interview (to gain case history)
- Consultations with other specialties are also done—neurological workup, medical exam.
- Information is compiled to arrive at a label; will assist with identifying therapy approaches (assessment is an ongoing process).
The Goals of Treatment
- Negotiation of goals of treatment or therapist & client discuss how patient's problem will be
- In treating a child, they may not know what therapy is or why they are being asked to go to therapy. Parents legally have a right to know all information therapist communicates to the child (this makes confidentiality hard).
- Following goal establishment specific therapy forms/treatment is identified (ex: client-centered, cognitive, behavioral)
- Treatment needs to be described to client in detail (in terms of length and what is expected of them).
Termination, Evaluation and Follow-Up
- Once therapist begins to gauge that client is able to handle their problems themselves, termination discussion begins.
- Client's feelings and attitudes towards termination should be assessed.
- Sometimes termination is abrupt or forced (in which case referral is done).
Stages of Change
- Refers to a series of stages that represents a client's readiness of change in psychotherapy.
- Pre-Contemplation: Client has no intention of changing his/her behavior in the near future. Come in as a result of outside pressures.
- Contemplation: Client is aware that a problem exists but has not begun steps to make changes.
- Preparation: Client intends to make a change in the near future.
- Action: Clients are changing maladaptive behavior, emotions or environment
- Maintenance: Client is focused on preventing relapses and continuing the action stage.
- Termination: Client has made necessary changes (sort of like a habit), no concern for relapse.
- Therapists need to recognize that not all individuals are ready to make change; the action stage is where administered treatment is most likely to have an effect.
- As certain processes match certain stages, therapists should only use interventions specific to that stage.
Issues in Psychotherapy Research
- Hans Eysenck attacked the efficacy of psychotherapy, but many have criticized his work for its validity as he did not match participants in the treatment vs. control groups.
- Studies that seek to understand the efficacy of psychotherapy use an experimental design with a control group and a treatment/experimental group.
- Waiting List Control Group: Treatment is delayed until after study is completed
- Attention Only Control Group: Patient meets regularly with a therapist, but there is no treatment
o Matched on age, race, gender, severity of symptoms (factors that could influence outcome)
- Patient Functioning: Symptoms of psychopathology
- What is the sample? —ex: voluntary or coerced patients, were the therapist's behaviors or psychoanalysts
- What relevant variables were controlled? Ex: --control vs. treatment group variables.
- What were the outcome measures? —were outcomes measured identically for all patients or were they tailored? Was a single measure used or were there multiple measures?
- What was the overall nature of the study? (experiments, case studies, correlational studies.)
Studies comparing efficacy techniques and not only looking at outcomes.
The Temple University Study
- The study comparing 90 outpatients with neurotic symptoms concluded that patients that received Behavior Therapy (BT) did the best in the long-term
- Those who obtained Psychoanalytic therapy (PT) improved equally as well as the BT Group; but those in the BT Group showed slightly more improvement; flexibility & versatility of Behavioral therapy.
- A method of research that complies all studies relevant to a topic or question and combines the results statistically.
- Effect size: The size of the treatment effect
Mean of experimental group - Mean of control group
Effect size = -------------------------
- Refers to research that investigates the specific events that occur in the course of the interaction between therapist & patient. (Rogerians)
- Some therapy processes have been shown to relate to treatment outcome.
- Therapy investigators either looked at process research or outcome research.
- Process therapy researchers felt that the process that was used during therapy related to the outcome that occurred (film/tape therapy sessions).
- Factors that influence relationship between therapeutic process and outcome
o Client-therapist communication
o Therapist competence and adhere to treatment protocol
o Therapist use of guidance and advice not related to outcome
Focus of Psychotherapy Research
- Specific factors (motivation, SES) that are related to higher efficacy and effectiveness
- What aspects of specific therapy mechanisms (e.g. CBT therapy) are most important for the therapy outcome.
- Focus on types of therapies that work for each specific diagnosis.
- Clinical psychologists are being held accountable for the services they provide by insurance companies.
- Several professional organizations have developed practice guidelines that recommend specific forms of treatment/intervention for specific psychological problems.
- Treatment manuals were originally developed to ensure standardized treatment across patients.
- Manualized treatment has been criticized for undermining clinical judgement, treatment not being tailored to patients with comorbid conditions.
- Manualized treatment is more focused and, easier to teach and supervise and more focused from the patient's perspective and are far more appealing to managed care companies.