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Psychology 339 Joy Bolger

Lecture 1: Psychotherapy Who Are the Experts?  Psychiatrists  Psychologists  Licensed Clinical Mental Health Counselors  Licensed Clinical Social Workers  Psychiatric Nurse Practitioners  Licensed Marriage and Family Therapists What Do Psychotherapists Do?  Conduct patient assessments  Treat patients with psychotherapeutic approaches  Monitor patient outcomes  Conduct research Psychotherapists Conduct Assessments  The interview  Observation  Psychological tests  Neuropsychological assessment Assessment  The clinical interview o Assists in identifying problems and determine the nature and extent of maladaptive behavior  Structured interview o Typically used in institutional and research settings o Uses a standard series of questions to determine whether specific symptoms are present o Interviewer is provided with specific symptom definitions, specific questions pertinent to specific symptoms, instructions for quantifying responses in order to determine the presence and severity of symptoms  Unstructured interview o Utilized when the interview may have to move back and forth among a number of topics o Although unstructured, the interviewer should attempt to answer the following questions:  Who is the client? (Age, ethnic/cultural background, marital status)  How does the client feel about his/her life at this time?  What is the history of the problem and the clients developmental background?  What is the client’s present psychological state? (Speech, thought, judgement, cooperativeness, social skills)  What are the client’s assets and liabilities? MSE  Components of the mental status exam o Appearance

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Behavior Speech Mood Affect Thought process Thought content Cognition Insight/judgement

DSM-5  The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders. DSM contains descriptions, symptoms and other criteria for diagnosing mental disorders. Classification  Placing a clinical condition into a category based on shared characteristics  Benefits of classification o Provides information about the cause(s) of a condition o Provides common language o Realistic prognoses o Founded in research o Indicates treatment options o Provides outlines for possible prevention programs  Drawbacks to classification o Labeling  Contributes to stigma  Stigma contributes to discrimination in housing, employment, relationships, treatment, etc o Imperfect diagnostic categories  The same label may be applied to similar behaviors that have varying causes DSM-5 Structure  Neurodevelopmental Disorders  Schizophrenia Spectrum and Other Psychotic Disorders  Bipolar and Related Mood Disorders  Depressive Disorders  Anxiety Disorders  Obsessive-Compulsive and Related Disorders  Trauma-and Stressor-Related Disorders  Dissociative Disorders  Somatic Symptom and Related Disorders  Feeding and Eating Disorders  Elimination Disorders  Sleep-Wake Disorders  Sexual Dysfunctions  Gender Dysphoria  Disruptive, Impulse Control, and Conduct Disorders  Substance-Related and Addictive Disorders  Neurocognitive Disorders  Personality Disorders  Paraphilic Disorders  Other Mental Disorders

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 Medication-Induced Movement Disorders and Other Adverse Effects of Medication  Other Conditions That May Be a Focus of Clinical Attention Outcomes Monitoring  Routine Outcome Monitoring (ROM): Monitoring patient progress through questionnaire feedback in order to identify clients at-risk for potential treatment failures  Detect respective causes for deterioration in order to improve treatment Do We Track Outcomes in Private Practice and Clinical Settings?  The OQ-45.2 measures: o Symptom Distress (Anxiety, Depression) o Interpersonal Relations (Difficulty with marriage, family, friends, colleagues) o Social Roles o Behaviors that are expected to be manifested by adults in our society o Work, school, home responsibilities. Anything above a 12 is considered a functioning problem Psychotherapists Prepare Reports  Reports for CPS, child custody cases, school districts, treatment, team members  Progress reports  Disability benefits  Other court cases where the person’s mental status is in question Psychotherapy – What Is It?  “Healing practice based on verbal persuasion and human interaction that occurs in a social context”  “Psychotherapy is 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, cognition, emotions and/or other personal characteristics in directions that the participants deem desirable”  Regardless of the approach, the patient should be active in making meaningful change with the therapist Broad Overview of Major Therapy Orientations  Psychodynamic: Our thoughts, feelings, and behaviors are out of our conscious control. They are in our unconscious mind o The therapist helps the patient delve into their unconscious to resolve conflicts  Free association, dream interpretation  Humanistic: Person-centered therapy such as empathy, unconditional positive regard, being authentic and honest with clients  Cognitive: Focuses on emotional responses that occur from our thoughts  Behavioral: Looks at the power of behavior on our moods and wellbeing  From those two “cognitive behavioral therapy” or “CBT”, evolved o This works on the premise that thoughts, feelings, and behaviors are a connected loop. By working on your negative thoughts and behaviors, you’d like to change using various techniques, you can change how you feel and interact with the world  Integrative Psychotherapy: Many modern practitioners subscribe to this school of thought o The idea is to train in different schools of psychotherapeutic thought, then integrate them in a way that best helps each patient depending upon their issue as well as their personal characteristics o Recognizes transtheoretical similarities in the different schools/orientations (integrates them)  Within the major approaches, common factors exist

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Issues Within the Field  There are over one thousand types of psychotherapy  Many of which have not been subjected to scientific scrutiny  There is no guarantee a patient is receiving treatment that is grounded in research and being provided by a skilled therapist  Many individuals with psychological disorders receive questionable or pseudoscientific treatments o Energy therapy, aromatherapy, laughter therapy, etc. Laughter Therapy can’t hurt Anyone, why is this a problem?  The patients receiving this treatment are forgoing other treatments  Theft of services, costing time and money  Compromises the integrity of the field – people less likely to seek treatment  Some people deteriorate during therapy Is Psychotherapy Effective?  Yes  It’s demonstrated effective in randomized trials  Practicing therapists using structured and cogent approaches get outcomes similar to randomized clinical trials for medical interventions  Research suggests it’s as effective as medication-and it’s longer lasting  It’s highly cost-effective  Individuals who receive treatment for a presenting problem do significantly better than those who do not  The APA considers psychotherapy “an established evidence-based practice”  The findings of individual studies have been quantified in meta-analytic research using effect size as the metric. (The difference between the mean of the treatment and control groups)  Different meta-analyses report different effect sizes  Average for psychotherapy is .6  This is more effective than some evidence-based medical interventions  Research suggests therapy can increase the efficacy of a pharmaceutical intervention Addressing Methodological Issues with Meta-Analyses  Threats to validity: o The tendency of studies with no effect or a small effect to not be published o Mixing poorly designed studies with quality ones o Combining studies with different phenomena o Even when controlling such issues; reanalysis still produces an effect size of between .2 and .4 The NNT  Number needed to treat (NNT) statistic developed to facilitate the practice of evidencebased medicine  This can help: o Compare the consequences of doing nothing with the benefits of doing something o Summarizes the potential harm of a treatment o Identify who are likely to be responsive to therapy o Permit comparison between different treatment approaches  Mathematically defined: It’s the reciprocal of the Absolute Risk Reduction (ARR)  For a therapeutic treatment, the ARR is calculated by subtracting a post-treatment measurement of disease severity in the treatment group from measured disease severity in the comparison group  ARR = Disease severity in the control group – Disease severity in the treatment group

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NNT = 1/ARR Example: In a pharmaceutical clinical trial with a response rate in the treatment group of 50% and the response rate in the placebo group of 35% o NNT = 1 / (0.5-0.35) = 6.67 or 8  Some difficulties with this: o In many psychological disorders, clear categorical outcomes such as response vs. non-response don’t exist o The definition of response is debated in conditions such as schizophrenia, and other major mental illnesses o However, the NNT for psychotherapy is 3, which is considered good. For every 3 patients seen in psychotherapy, 1 has a better outcome than if they didn’t come to therapy Evidence-Based Treatment  This varies between organizations  This varies between researchers and clinicians  However, the gap is closing a bit  “Evidence-based practice in psychology is ‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences’”  Within evidence-based treatment we need to know that: o The bulk of this research focuses on the disorder, but some therapies work better for certain patient-characteristics o It’s not just about pairing the tx to the dx o This doesn’t mean we can’t combine factors from different modalities for an efficacious approach Some Research Suggests  Only one-fifth of individuals receive evidence-based treatment for their depression  Less than 15% received adequate treatment Competing Models  Medical models o Presenting Problems  Psychological Explanation  Mechanism of Change is Based on Explanation  Specific EB Treatment  Problem Resolved  Pathway o Relationship: Forming a trusting and genuine relationship o Expectations: What we tell our parents and how we are able to articulate ourselves. They trust us o Alliance: Agreement about the goals, how you will go about them o With a structured EBT or combined approaches Clinically Meaningful Outcomes  Treatment approach + Therapist-Patient relationship Effective Therapists  Able to form a strong alliance with a range of patients  Verbally fluent: Succinctly and articulately what they are explaining  Read the affective state of the patient  Modulate their own reactions  Empathic  Unconditional positive regard  Praise the patient when progress is made  Skilled at their treatment approach  Understand many areas of psychology  

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