Clinical Psychology Quiz #3

DSM I and II

• More descriptive about psychopathology and less specific

• Focused on a very psychoanalytic/psychodynamic perspective

DSM III

The DSM III wanted to legitimize the field by moving away from the methods of the DSM I and II and instead medicalize the disorders it included

• This included adapting a categorization of disorders

• This took a more biomedical approach, even though less than 10% of disorders have a biological influence on heritability

Concerns about the DSM’s shift from a Psychoanalytical Model to a Medical Model:

• Raised questions about the validity of the disorders included: are all of them really disorders?, how do you account for comorbidity?, are they being diagnosed at the correct rates?

• Shifting to a medical model may de-contextualize the disorders from their environment, cultural context, and social context; all important aspects that feed into a disorder

Defining Psychological Disorders - Quadruple D Method

• Distress: Causes distress to either the client or others around them

• Deviance: Is deviant from normal behavior and/or functioning to a clinical degree

• Dysfunction: Causes dysfunction that harms the client’s ability to function in their daily life

• Dangerousness: May cause the client to become dangerous to themselves or those around them

Defining Psychological Disorders - Social Influences

• Social norms and values often influence what we describe as a “disorder” as it strongly influences whether we label something as “deviant” or “dysfunctional”

• Social pressures influence the cut-offs for diagnoses

The DSM V Task Force Structure

• 28 Directors (MDs)

• 13 Workgroups composed of 160 world-renowned researchers and clinicians - 30% international

• Advisory comities, professional input given online, and field trials at major medical centers feed into the information available to the workgroups

DSM V Task Force Criticisms

• 70% of DSM V Task Force members had conflicts of interest in some way that may influence their choices on what to include in the DSM, the criteria for diagnosis, and the cut-offs for diagnosis

• The DSM holds power over and is influenced by insurance companies, health care providers, pharmaceutical companies, and general people

• Much of the research used to empirically support the DSM was funded by pharmaceutical companies, calling to question the legitimacy of the data

Psychotherapy Definition

• Psyche = A person’s soul or being

• Therapeutics = Caring for another

  • Together = Caring for another person’s soul or being

Goals of Psychotherapy

Informed & intentional application of clinical methods, interpersonal stances, and psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and other personal characteristics in desirable directions

Therapy VS. Counseling

• Therapy: Treatment by someone to cure or care for problems; long-term

• Counseling: Providing support, encouraging change, suggested advice; shorter-term

Evidence-Based Practices (EBP)

• The use of evidence-based treatments, clinical expertise, and the integration of patient characteristics, values, cultures, and preferences

• Client variables have a more active position and are critical to include

General Process of Psychotherapy

1. Connect to the client to understand the problem and its contexts - “emotional experiencing”

2. Facilitate change in beliefs, attitudes, and behavior - gain cognitive mastery or control over the problem

3. Encourage use of new and more adaptive behavior - develop new strategies for controlling impulses and actions, instill hope for change

Factors of Psychotherapy

• Support Factors (Goal = Therapeutic Relationship): Reassurance, release of tension, structure, trust, warmth, respect, empathy, acceptance

• Learning Factors (Goal = Insight and Education): Changing expectations, cognitive learning and reframing, feedback and insight, specific skill development, corrective emotional experiences

• Action Factors (Goal = Tasks, Homework, and Hope): Behavioral regulation, encouragement to face fears, modeling and practice, taking risks, skill use and application feedback

Therapy Effectiveness Factors

• Client Characteristics: Expectations, levels of distress, motivation, perspective on therapy

• Therapist Characteristics: Experience and training, expertise/professionalism, use of techniques, flexible interpersonal style

• Problem Characteristics: Severity/impairment, chronicity, therapy matched to the problem

Who do we ask regarding treatment effectiveness?

The answer varies widely based on situations, but includes":

• The therapist

• The client

• Those close to the client

• Researchers

What kind of sample is the best to use in research regarding the effectiveness of treatment?

A sample that is large, diverse, representative, and includes varying degrees of the targeted problem

Eysenck’s “Bomb”

In 1952, Eysenck claimed that psychotherapy did not work and was a complete waste of time. He claimed that the improvements shown via psychotherapy were falsely percieved

• This created a huge push to empirically prove and legitimize psychotherapy and specific techniques

• Created a large influx of efficacy studies and effectiveness studies

Efficacy Studies

Studies that are highly controlled in a laboratory setting and aim to analyze the efficacy of a given psychotherapy technique. They have high internal validity which ensures that any observed changes are not due to extraneous variables. Use random assignment. May lack external validity as a result of the lab setting.

• Usually aims to use subjects that ONLY have the targeted disorder to control for extraneous variables

• Therapy is given manually with adherence checks to make sure it is being applied correctly

• Best used for establishing initial evidence that supports a new treatment

Effectiveness Studies

Studies that are less controlled and aims to achieve a higher external validity than an efficacy study. Ensures measured changes will translate better to the real world, uses random or quasi-random assignment

• Uses mixed disorders to assess how treatment handles comorbidity

• Therapy is given manually with guidance checks to make sure it is being applied correctly

• Best used to see if initial evidence in support of a treatment translated to more realistic cases

What do you need to be considered an evidence-based therapy?

Multiple supportive efficacy and effectiveness studies

Tripartite Model of Treatment Outcomes

• Client: Ask about distress, symptoms, quality of life, and interpersonal function

• Therapist: Ask about symptoms, diagnosis, interpersonal function, and client independence

• “3rd Parties”: Ask if client is self-supporting, if they have improved work performance, decreased medical costs, ease of relating and building friendships, and is avoiding legal and/or prison issues

Standards of Effecitveness

• P-Value: Statistical significance is indicated by a p<0.05

• Effect Size: The strength, degree, and impact of the result

• Clinical Significance: Is there real-world, meaningful change and difference in symptoms

What makes change hard from a client perspective?

Lacking skills/motivations to change, fear of change, unintended benefits of the unhealthy behavior, differing interpersonal styles

What makes change hard from a therapist perspective?

Lacking skills, alternate goals, trouble building a therapeutic relationship, unstructured or unrealistic goals/expectations

What makes change hard from an environmental perspective?

Significant others may not be supportive, lack of resources, family pathology/unsupportiveness

What makes change hard regarding problem factors?

Rigidity, impulsivity, dependence, physiological problems, cognitive abilities, severity of symptoms

Ultimate Goal of the Stages of Change Model

Meet your client where they are at so you can better facilitate their change and meet their goal of better functioning

Stages of Change Model Steps

1. Precontemplation: Passive consideration and low awareness of the issue

2. Contemplation: Active consideration and awareness of the issue, uncertain of how to change, no commitment

3. Preparation: Intent to change is high, ideas of change are being generated, but little to no action is happening

4. Action: Active attempts at change and learning skills to facilitate the change

5. Maintenance: Stabilizing the change and forming new patterns, preventing relapses

Stages of Change Model Backwards Movement

Relapse: Moving from the maintenance stage to any stage further back in the model

Lapse: Moving from the action stage back to the preparation stage or before

Prelapse: A failure to fully move from the preparation stage to the action stage resulting in ending back in the preparation stage

Methods to Enhance Readiness to Change

• Motivational Interviewing

• “DARN-C”

• “OARS”

• Additional techniques such as collaboration with the client, asking the client to rank their readiness, and pros/cons lists

Motivational Interviewing

1. Change Talk: Expectancy, attitudes, social norms, and self-efficacy

2. Intention: Intending to attend

3. Habits, knowledge/skills, salience, and constraints factor in

4. Action: Enacting change

“DARN-C”

A guide on what to listen for and reinforce:

• Desire for change

• Ability and confidence

• Reasons for change

• Needs and why they matter

• Commitment language

“OARS”

Key skills to use during therapy:

• Open questions

• Affirmations

• Reflections

• Summaries

Therapy Techniques and Processes

An mix of theoretical orientation, integration, and varied techniques with a therapeutic relationship being a foundational factor for success:

• Theoretical Orientation: Framework, preferred approach, can be narrow

• Integration: Purposeful use of techniques guided by case conceptualization and client goals

• Varied Techniques: Diverse options, eclectism, can lack focus and purpose, over-use is often not effective

Common Systems of Therapy Delivery

• Individual: Most common, single focus on individual only. Includes the growth of online therapy and digital therapy.

• Group: Excellent for interpersonal difficulties, universality, hope, altruism, and cohesiveness

• Couples: Improves problem-solving and communication, therapist provides neutrality between the couples

• Family: Changes interaction patterns within the family to facilitate better functioning, views the family as a system

“Targets” of Therapy

Interpersonal and sociocultural contexts that all interact with one another and influence learning, social modeling, and ways of communicating:

• Thoughts

• Emotions (Physiology)

• Behaviors

• Social (Interpersonal)

Behavioral Technique: Pleasant Activity Scheduling

1. Generate a list of enjoyed activities/experiences with a range of small, moderate, and large time involvements

2. Open the calendar for a typical week

3. Identify realistic places to do a pleasant activity

4. Obstacles and reinforcers: problem solve around obstacles, and monitor the impact of the activities

How is Psychotherapy a Culturally-Constructed Phenomenon?

Psychotherapy uses primarily a very American/Western European perspective to deliver a medical model-driven treatment

• This results in POC not seeking therapy nearly as much as white individuals

Cultural Variations and Values Regarding Therapy

• Expectations differ about therapy and problems may differ also

• Direct vs. non-direct approaches can be more or less successful on different cultural groups

• Problems may be manifested in the form of somatic symptoms more commonly in certain cultures

• Individualistic and collectivist cultures are likely to differ in who they want to be involved in their therapy with them

Social Validity of Therapy

• Acceptability: How much therapy is accepted by the individual/cultural group - stigmas

• Relevance: How relevant the culture is to the specific practices, values, and problems of the given cultural group

• Feasibility: Is the therapy accessible to the individual and their cultural group?

• Effectiveness: Cultural adaptations and flexibility produce positive changes regarding efficacy and likelihood of the client to remain in therapy

Cultural Adaptations of Therapy

• Modify the therapy process:

  • Modify the approach and structure of the service delivery

  • Modify the frequency, location, style or goals of therapy

  • Modify to adjust for cultural customs and the desired persons involved

• Modify the therapy content:

  • Retain the core contents + principles but packaged in a culturally responsive way

  • Conduct therapy in primary language (if possible)

  • Adjust to include cultural values and metaphors in the techniques used

  • Assess cultural stressors

• Modify the nature of the therapeutic relationship:

  • How the therapist engages with the client in and out of therapy

  • Maintain professionalism