ch11.ppt

CHAPTER 11 – INTERVENTION: OVERVIEW COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. ETHICS OF INTERVENTION Focus on ‘evidence-based approaches’ to ther...

CHAPTER 11 – INTERVENTION: OVERVIEW COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. ETHICS OF INTERVENTION Focus on ‘evidence-based approaches’ to therapy: Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992. It started in medicine as evidence-based medicine (EBM) and spread to other fields such as audiology, speech- language pathology, dentistry, nursing, psychology, social work, education, library and information science.  COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. ETHICS OF INTERVENTION Evidence is research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses". Empirically supported treatments (ESTs) in some clinical settings are defined as "clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population"  COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. ETHICS OF INTERVENTION Evidence-based behavioral practice (EBBP) "entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected.  COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. ETHICS OF INTERVENTION Growing use of technology and treatment Informed consent: Client must agree to services that are being given  Client should know what works best for a given disorder as well  Adult gives consent for child, but child must assent (verbally agree) to be treated  ETHICS OF INTERVENTION Inform client of:  Confidentiality and limits of confidentiality  Financial arrangements  What to expect in therapy  Alternative treatments Therapist must monitor whether the treatment is working Treatment should be based on best-available evidence COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  PSYCHOTHERAPY Norcross (1990) defined psychotherapy as:  “…the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable.” COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. PSYCHOTHERAPY APA (2013) passed resolution recognizing psychotherapy as effective Intended to promote psychotherapy in health care systems as evidence-based care Psychotherapy practiced by professionals from many disciplines (psychology, psychiatry, social work, nursing) COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  SHORT-TERM PSYCHODYNAMIC THERAPY Based on psychoanalytic theories of Freud and recent theorists. Central concepts:  Unconscious: Most of what motivates an individual is outside of awareness  Conflicts between Id (impulsiveness) and Ego (planning, higher cognitive functioning)  Transference: Problematic interpersonal relationship re- enacted with therapist  Counter-transference: Therapist’s problematic interpersonal relations OR how the client makes the therapist feel COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. SHORT-TERM PSYCHODYNAMIC THERAPY Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo, MD. The therapy's primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful. The technique is intensive in that it aims to help the patient experience these warded-off feelings to the maximum degree possible; it is short-term in that it tries to achieve this experience as quickly as possible; it is dynamic because it involves working with unconscious forces and transference feelings. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. SHORT-TERM PSYCHODYNAMIC THERAPY Some versions of this approach:  Luborsky’s Supportive-Expressive Therapy  Strupp’s Time-limited Dynamic Therapy Most all focus on process of:  1) Bringing to awareness unconscious  2) Re-enacting problematic relationship with the therapist  3) Working through this pattern and development of new interpersonal patterns COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY Supportive-Expressive Psychotherapy is a time-limited, focused psychotherapy that has been adapted for heroin- and cocaine-addicted individuals. The therapy has two main components: Supportive techniques to help patients feel comfortable in discussing their personal experiences; Expressive techniques to help patients identify and work through interpersonal relationship issues. Special attention is paid to the role of drugs in relation to problem feelings and behaviors, and how problems may be solved without recourse to drugs. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY The term 'supportive-expressive' (SE) refers to the two main treatment techniques of this approach. Supportive techniques are ones developed by the therapist to create a positive, helpful and empathic relationship with the patient. Expressive techniques are those used by the therapist that are aimed at helping the patient to express and to understand and change problems. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY The focus is on identifying and interpreting each patient's recurring problematic interpersonal relationship themes as they occur (a) with the therapist (transference), (b) in relationships with other people, such as partners, family, friends and parents, and (c) around specific behaviors (e.g. drug taking) as attempts at finding solutions to the life problems. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. TIME-LIMITED PSYCHOTHERAPY In Time-Limited Psychotherapy an integration of classical and interpersonal psychoanalytic theory is attempted, with a major result of this being the emphasis on the analysis of transference even when the external conditions, such as lesser frequency and the training of the therapist, are not those of psychoanalysis proper. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. TIME-LIMITED PSYCHOTHERAPY Furthermore, in this manual’s theory, the psychological reality is not dichotomized into veridical and distorted, with transference defined as a distortion, but it is viewed as multiple and contributed to by both participants in the interaction. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  SHORT-TERM PSYCHODYNAMIC THERAPY Additional foci of this approach:  Identification of themes and central conflicts  Defensive patterns in the person’s life  Evoking emotions  Goal-setting  Termination of therapy Strong evidence of effectiveness in depression, panic disorder, substance abuse, borderline PD, etc. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL INTERPERSONAL THERAPY (IPT) Much more emphasis on problems with communication and on dysfunctional relationships than dynamic therapy (although some overlap) Clear understanding of current and past relationships is central to this approach Brief – usually 3-4 months Work on actively changing interpersonal patterns COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  INTERPERSONAL THERAPY (IPT) IPT is a time-limited psychotherapy that focuses on interpersonal issues, which are understood to be a factor in the genesis and maintenance of psychological distress. The targets of IPT are symptom resolution, improved interpersonal functioning, and increased social support. Typical courses of IPT range from 6-20 sessions with provision for maintenance treatment as necessary. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTERPERSONAL THERAPY (IPT) Focus is often on role transitions (becoming a parent, student to professional, etc.) Originally developed for depression, but has been applied to several populations including late life, different cultures, and several disorders (including eating disorders, anxiety and substance abuse) COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTERPERSONAL THERAPY (IPT) The Defining Elements of IPT Theory: Attachment Theory, Communication Theory Targets: Psychiatric Symptoms, Interpersonal Relationships, Social Support Tactics: Interpersonal Triad Biopsychosocial/Cultural/Spiritual Model Interpersonal Inventory Interpersonal Problem Areas Interpersonal Formulation IPT Structure COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. INTERPERSONAL THERAPY (IPT) Tactics: Non-Transferential Focus of Interventions Present Focus Collaboration & Goal Consensus Positive Regard for the Patient Techniques: Interpersonal Incidents Communication Analysis Use of Content and Process Affect Role Playing "Common" Techniques https://iptinstitute.com/about-ipt/ COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. PROCESS-EXPERIENTIAL THERAPIES History in existential, humanistic and client-centered approaches (though little data on these approaches as helpful) Emotionally focused therapy (EFT), also known as emotion- focused therapy and process-experiential therapy, is a usually short-term (8–20 sessions) structured psychotherapy approach to working with individuals, couples, or families. It includes elements of Gestalt therapy, person-centered therapy, constructivist therapy, systemic therapy, and attachment theory. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  PROCESS-EXPERIENTIAL THERAPIES Emotionally focused therapy proposes that human emotions have an innately adaptive potential that, if activated, can help clients change problematic emotional states or unwanted self-experiences. Emotions themselves do not inhibit the therapeutic process, but people's inability to manage emotions and use them well is seen as the problem. Emotions are connected to our most essential needs COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. PROCESS-EXPERIENTIAL THERAPIES Focus is on  Increasing awareness, reflection and expression of emotion  Enhancing emotion regulation  Transforming maladaptive emotions into adaptive emotions COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  PROCESS-EXPERIENTIAL THERAPIES Focus is also on in-session experiencing of affect along with processing the emotion experience Strong evidence for effectiveness with depression, couple distress and adult survivors of child abuse COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COGNITIVE BEHAVIORAL THERAPIES (CBT) Behavior Therapy is the oldest form of CBT – with a focus on operant and classical conditioning as etiology of symptoms and problems  Symptom and present focused Bandura – learning can take place by observation and imitation Self-efficacy: person’s sense of competence to learn and perform new tasks (best predictor of tx success) COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS  COGNITIVE BEHAVIORAL THERAPIES (CBT) Ellis’s Rational-Emotive Therapy and Beck’s Cognitive Therapy are based on idea that thoughts about environment are the key to etiology and maintenance of a disorder CBT is a mixture of cognitive and behavioral approaches CBT validated in numerous DSM disorders COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. RATIONAL-EMOTIVE THERAPY Albert Ellis, an important contributor to the ideas behind cognitive-behavioral therapy and the founder of Rational Emotive Behavior Therapy (REBT), discovered that people’s beliefs strongly affected their emotional functioning. In particular certain irrational beliefs made people feel depressed, anxious or angry and led to self-defeating behaviors. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. RATIONAL-EMOTIVE THERAPY Rational Emotive Behavior Therapy teaches the client to identify, evaluate, dispute, and act against his or her irrational self- defeating beliefs, thus helping the client to not only feel better but to get better. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. RATIONAL-EMOTIVE THERAPY The Rational Emotive Behavior Therapy framework assumes that humans have both rational and irrational tendencies. Irrational thought/images prevent goal attainment, lead to inner conflict, lead to more conflict with others and poor mental health. Rational thought/images lead to goal attainment and more inner harmony. In other words rational beliefs reduce conflicts with others and improved health. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. RATIONAL-EMOTIVE THERAPY REBT claims that irrational and self-defeating thinking, emoting and behaving are correlated with emotional difficulties such as self-blame, jealousy, guilt, Low Frustration Tolerance, depression, and anxiety. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COGNITIVE THERAPY Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one of the therapeutic approaches within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COGNITIVE THERAPY Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COGNITIVE BEHAVIORAL THERAPIES (CBT) Focus of treatment is on  Identification of thoughts and behaviors that might be causing problems  Very active role of therapist with client  Use of current research in psychopathology  Didactic methods and Socratic questioning (i.e., encouraging the client to reflect)  Homework set  Tailoring approach to given individual COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. GENERAL POINTS ON SEEKING PSYCHOLOGICAL SERVICES Anyone can refer to themselves as a ‘psychotherapist’ A license ensures the practitioner has met educational and experience guidelines Duration varies, but median number of visits is 5-13 sessions Evidence based treatments usually are between 10-30, so some may not be receiving the full ‘dose’ COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. ADDITIONAL FORMS OF PSYCHOLOGICAL SERVICES Couple therapy common for all types of couples going through various problems Many forms of family therapy where individual problem is thought to come from family communication dysfunction Group therapy (variety of orientations)  Process groups – use group to explore interpersonal dynamics  Structured groups – focus on a specific problem COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COUPLE THERAPY Couple therapy is a type of psychotherapy in which a therapist with clinical experience working with couples, most often a licensed Marriage and Family Therapist, helps two people involved in a romantic relationship gain insight into their relationship, resolve conflict, and improve relationship satisfaction utilizing a variety of therapeutic interventions. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COUPLE THERAPY Although the practice of couples therapy may vary depending on the therapist’s theoretical orientation, all couples therapy tends to involve the following general elements: 1.A focus on a specific problem (i.e. sexual difficulties, internet addiction, jealousy) 2.Active participation on the part of the therapist in treating the relationship itself, rather than each individual separately. 3.Solution-focused, change-oriented interventions early on in treatment. 4.A clear establishment of treatment objectives. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COUPLE THERAPY 1. Changes the views of the relationship. 2. Modifies dysfunctional behavior. 3. Decreases emotional avoidance 4. Improves communication 5. Promotes strengths COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. FAMILY THERAPY Family therapy is a well-established and evidence-based approach alongside other psychotherapeutic modalities. Family therapy addresses the problems people present within the context of their relationships with significant persons in their lives and their social networks. It is a well-recognized psychotherapeutic approach, primarily concerned with the family system as a social unit, in contrast to other psychotherapy approaches such as psychodynamic or cognitive-behavioral therapy, which focus on the individual. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. FAMILY THERAPY Family therapy and systemic practice is a heterogeneous field; there are different schools and models that share several principles and guiding assumptions. Some of the commonly shared goals of family therapy might be for example: improvement of family functioning on different levels, enhancement of mutual understanding and emotional support among family members, development of coping skills and problem-solving strategies in various life dilemmas and situations. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. GROUP THERAPY Group therapy involves one or more psychologists who lead a group of roughly five to 15 patients. Typically, groups meet for an hour or two each week. Some people attend individual therapy in addition to groups, while others participate in groups only. Many groups are designed to target a specific problem, such as depression, obesity, panic disorder, social anxiety, chronic pain or substance abuse. Other groups focus more generally on improving social skills, helping people deal with a range of issues such as anger, shyness, loneliness and low self-esteem. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. GROUP THERAPY Groups often help those who have experienced loss, whether it be a spouse, a child or someone who died by suicide. The broader concept of group therapy can be taken to include any helping process that takes place in a group, including support groups, skills training groups (such as anger management, mindfulness, relaxation training or social skills training), and psycho-education groups. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. GROUP THERAPY Benefits of group therapy:  helps the client realize she/he is not alone  facilitates giving and receiving support  helps the cilent find her/his “voice.”  helps the client relate to others (and herself/himself) in healthier ways  provides a safety net COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.  ADDITIONAL FORMS OF PSYCHOLOGICAL SERVICES Self-administered: self-help books based on evidence based care  Continuum of client working on their own to some work with a therapist  Some evidence that this is effective Computer-based treatment: Continuum of computerized aspects of evidence-based care to virtual reality Telehealth: Range of treatments not in person (phone, email, videoconferencing) COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS SELF-ADMINISTERED PSYCHOTERAPY The use of self-administered treatments (SATs) as an adjunct to psychotherapy is common among practicing psychologists, with over 80% of psychotherapists recommending some form of selfhelp intervention to their patients. SATs have been defined as “media-based treatment approaches (book, manual, audiotape, videotape, or some combination) that are used largely by an individual independent of a helping professional.” COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. SELF-ADMINISTERED PSYCHOTERAPY SATs have also been integrated into the therapeutic process for the handling of secondary or less complex aspects of the client’s complaint or accelerating the process of his or her getting acquainted with the therapeutic approach and techniques, thus saving in- session time for issues that may be better addressed with a therapist. SATs also have the advantage of potentially enhancing the client’s feelings of responsibility and self-efficacy for therapeutic change. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COMPUTER-BASED TREATMENT Computer- and Internet-assisted assessment methods and therapy programs have the potential to increase the cost-effectiveness of standardized psychotherapeutic treatments by reducing contact time with the therapist, increasing clients' participation in therapeutic activities outside the standard clinical hour, and streamlining input and processing of clients' data related to their participation in therapeutic activities. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. COMPUTER-BASED TREATMENT There are four types of computer-based intervention, namely: web-based interventions, online counseling, internet-operated therapeutic software, and a fourth category termed “other online activities. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. TELEHEALTH Telehealth is the delivery of health-related services and information via telecommunications technologies. Telehealth could be as simple as two health professionals discussing a case over the telephone or as sophisticated as doing robotic surgery between facilities at different ends of the globe. http://www.apa.org/practice/guidelines/telepsychology.aspx COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED. TELEHEALTH Telepsychology is defined, for the purpose of these guidelines, as the provision of psychological services using telecommunication technologies as expounded in the “Definition of Telepsychology.” The expanding role of technology in the provision of psychological services and the continuous development of new technologies that may be useful in the practice of psychology present unique opportunities, considerations and challenges to practice. COPYRIGHT © 2014 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.