Clinical – Prevention, Consultation, and Psychotherapy Research

Caplan’s Model of prevention (primary prevention targets…)

-primary: entire population/group

-Goal = reduce new cases, prevent future onset

• Prenatal care for low-income moms

• School program about suicide

• Program for 5th graders to help with transition to MS

Caplan’s Model of prevention (secondary prevention targets…)

(Secondary = starting to show signs)

Secondary = Specific individuals Showing Signs of risk

-Goal = early detection/intervention, to reduce prevalence

• giving counseling to people who screen high for depression risk

• giving tutoring to students who’ve started to struggle academically

Caplan’s Model of prevention (tertiary prevention targets…)

(Tertiary, too late for them, adiagnosed)

-tertiary: already-diagnosed people

-Goal = tx, reduce severity/duration

• RP, AA, rehab, social skills training for ppl with Scz

Gordon’s Model of prevention (three types of prevention?)

USI

Universal

Selective

Indicated

Gordon’s Model of prevention (universal prevention targets?)

entire population/group, not restricted to at-risk

• drug abuse prevention program for all students in district

Gordon’s Model of prevention (selective prevention targets?)

people who have increased risk d/t exposure to known risk factors (biopsychosocial characteristics)

• drug abuse prevention program for teens with a parent with SUD

Gordon’s Model of prevention (indicated prevention targets?)

people who’re high-risk d/t showing early signs of the disorder

• drug abuse prevention program for teens who’ve experimented with drugs

Institute of Medicine’s continuum of care model

-expanded on Gordon’s prevention model

-Prevention = for people w/o diagnosis -universal, selective, and indicated prevention

-Treatment = for people with diagnosis

-Maintenance = for people who’ve received tx for a disorder

Caplan distinguished four types of consultation

-Client-centered Case consultation – focused on 1 particular client

-Consultee-centered Case consultation – improving consultee’s skills and objectivity to work with pt group

-Program-centered Administrative consultation – program-specific help

-Consultee-centered Adminstrative consultation – helping program admin’s professional fx

Client-centered Case consultation (goal)

(standard case consultation)

-provide consultee with a plan that’ll benefit the client

Consultee-centered Case consultation (goal)

-improve consultee’s skills, confidence, and objectivity to work effectively with particular pt group (e.g., racial/ethnic minority pts, TBI pts)

-consultee’s lack of objectivity can interfere

theme interference in Consultee-centered case consultation

-when consultee bias and unfounded beliefs lead to lack of objectivity, gets in the way of working effectively with the pt group

Program-focused Administrative consultation (goal)

-provide solutions for program administrator having problems with their MH program (e.g., developing, administering, and evaluating their program)

Consultee-centered Administrative consultation

-improve the professional functioning of the consultee (program administrator)

-so they’re better able to develop, administer, and evaluate MH programs in the future

Difference between MH Consultation and Collaboration

Consultants have little/no contact with pts and no responsibility over pt outcomes (collaborators usually do for both)

Interprofessional collaboration (what does it improve)

-aka “integrated care”

-most often in primary care settings, and for elderly pts with multiple complex healthcare needs

-meant to improve pt care, outcomes, healthcare costs

IPC shows positive outcomes for

-pt outcomes, pt satisfaction with services

-access to care, care process

-for elderly pts: fewer ED, hospitalizations, LT care placements

IPC shows mixed outcomes for

-mixed results for pt QOL, physical/emotional/social fx, health bxs and practices

Efficacy vs. effectiveness Research (internal vs. external validity)

-efficacy research = clinical trials

• maximizes internal validity by maximizing experimental control (random assignmentm, manualized tx)

-effectiveness = REAL WORLD

• maximizes external validity by using naturalistic settings

Hans Eysenck’s research on psychotherapy outcomes

-intelligence variability is predominantly hereditary (80%)

-personality also heredity: extroversion, neuroticism, psychoticism

-controversial conclusion that psychotherapy is ineffective

Luborsky and Bergin’s critiques of Eysenck’s methodological flaws

Luborsky: pts weren’t randomly assigned to tx; pt pre-tx characteristics could explain differences

Bergin: used questionable recovery criteria

Smith, Glass, & Miller meta-analysis (why special, effect size, avg psychotherapy pt had better outcomes that ____% of no-tx group?)

First meta-analysis of studies that used control/comparison groups

Mean ES = 0.85 (avg therapy pt was better off than 80% of pts who didn’t get any therapy)

Howard et al. (studied what?, what two models for psychotherapy outcomes?)

rship btwn duration of psychotherapy <=> outcomes

1.) Dosage model

2.) Phase model

Howard et al.’s dosage model (what % of pts improve at 6-8––26––52 sessions?)

therapy outcomes <=> # of sessions

6-8 sessions: 50% can expect clinically significant sx improvement

26 sessions (0.5 yr): 75%

52 sessions 1 yr: → 85%

Howard et al.’s phase model (3 phases)

therapy outcomes <=> phase of therapy

1.) ReMORALization: first few sessions

• increased hopefulness

2.) ReMEDiation: next 16 sessions

• sx reduction

3.) ReHABilitation

• unlearning maladaptive habits, establishing new ways

Howard’s phase model implies what in our approach to psychotherapy research?

-Using different outcome measures at each phase of tx:

-remoralization phase (increased hope) → measure subjective well-being

-remediation (sx reduction) → sx severity/frequency

-rehabilitation (unlearning maladaptive habits, establish new ways) → life functioning

Does racial/ethnic therapist-client matching impact therapy outcome?

*variable, depends on R/E group and outcome measure

-pt perception of therapist (ES = .32) > therapy outcome (ES = .09)

-Improved outcomes: for ONLY Hispanic pts

-Reduced premature termination: in Asian, Hispanic, EuroAmerican groups–but NOT African American pts

*Matching via cultural competence, compassion, worldview mattered more than R/E match

Personality matching in therapist-client rship impacts…

-Pt perception of alliance, no direct effect on outcomes

-Big Five: pt perception of similarity on O/C <=> stronger rship + better outcomes

Greatest MH Utilization (gender & age)

-W > M to use any MH tx in past yr

-Age: younger adults (18-44) most likely to have MH tx in past yr (then 45-64, 65+)

-But age has little/no impact on tx outcomes (younger adults more likely to seek tx, but not more/less likely to improve than older adults, d/t age alone)

Has college student MH utilization increased/decreased in recent years?

Increased, BUT majority of college students with MH problems DON’T seek services still

Why do majority of college students with MH problems still not seek MH services?

Attitudinal/stigma barriers are cited more than structural

-preferring to handle the problem alone, talk to family/friends, being embarassed

MH stigma is linked to… (what wrt tx?)

reduced willingness to seek tx + premature drop out

Personal MH stigma vs. perceived public stigma in recent years

Personal MH stigma has reduced, BUT perceived public stigma has not

Education-based and contact-based anti-stigma interventions (what are they, effective for what?)

Education-based: addresses stereotypes about MI

Contact-based: contact with lived experience, to challenge stigma

-Lead to improve attitudes towards MH tx + increased willingness to seek tx

Psychological tx reduces overall medical utilization/expenses (for who, and what % of avg cost savings?)

-Medical cost offset is seen in pts with a MH/SUD disorder, pts undergoing surgery, hx of medical overutilization

-Avg cost savings = 20%

Cost-Benefit analysis, cost-Effectiveness analysis, & cost-Utility analysis

Cost-benefit: compares cost with expected monetary earnings

Cost-effectiveness: (outcomes) non-monetary benefits

Cost-utility: (utility for life) QALYs, quality-adjusted life years

QALYs (quality-adjusted life years)

combines measures of gain in life quality (health) + quantity (years)

Example comparing analysis of cost-benefit, cost-effectiveness, cost-utility

Cost-benefit: individual placement and support had greater net benefit than standard vocational rehabilitation d/t greater expected earnings

Cost-effectiveness: IPS was more cost-effective than standard vocational rehab d/t increased % working LT, decreased % readmitted to hospital

Cost-utility: CT + REBT had greater cost-utility compared to Prozac d/t increased QALYs

Do age, gender, and SES have any effect on psychotherapy outcomes?

-inconsistent results; conclusion = little/no impact

-any observed differences are d/t third variables

e.g., controlling initial sx severity → pt age stopped explaining any variance in therapy outcome

-some studies show low SES <=> premature termination link

Why do some studies show association btwn low SES <=> premature termination?

-Rship is d/t transportation difficulties and other factors (not SES directly)

Rships btwn low SES, stress, and mental health?

1.) lower SES (income, occupation, education) <=> increased stressor exposure

• one exception: high education level reported more frequent (but less severe) daily hassles

2.) Stressor exposure mediates rship btwn low SES <=> poorer MH

3.) (think ACES) Stressor exposure is associated with increased risk for dep/anx/MH problems

• stressful life events <=> depression link is well-established

What mechanisms explain link between stressful life events and depression?

-HPA axis overactivity

-decreased serotonergic transmission

-epigenetic mechanisms

-altered cognitive processes

Alpha bias in psychological research

Women are from Venus, Men are from Mars

-exaggerating differences btwn M/W

→ reinforces gender stereotypes

→ justifies discriminatory practices

Beta bias in psychological research

-not accounting for M/W gender differences at all (or minimizing them)

→ male-based research is generalized to women

Alpha and beta bias are both linked to androcentrism

Androcentrism (“male-centered”) = M bx/traits are assumed as the norm; W bx/traits assumed as deviations/abnormal

WEIRD Sampling Bias and Big Five traits research

-it’s debated whether Big Five traits are universal, d/t being derived from WEIRD samples

e.g., may not describe the traits of mostly illiterate indigenous population of forager-farmers in Bolivian Amazon

Routine outcome monitoring (aka feedback-informed tx, measurement-based care)

-a transtheoretical practice

-includes 4 components:

• regularly administered measures (of sx, outcome, process) ideally before each clinical encounter

• provider reviews the data, pt reviews data

• collaborative re-eval of tx plan

-usually involves pt SR measures, can involve clinician rating

Client and clinician barriers for why ROM is underutilized

Client: confidentiality concerns, time

Clinician:

• lack of training, time

• utility (belief that ROM isn’t more accurate than clinical judgment)

• effect on rship (concern about this)

• how will this be used (concern about employers/insurance using results)

Ecological momentary assessment (what is it, advantages, disadvantages)

ecological – sampling in natural environment

momentary – occurs frequently and assesses current moment (or short recall–e.g., past 30 min)

-initially just SR measures, more wearable devices now

Advantages: reduces recall bias, increases ecological validity (compared to retrospective SR)

Disads: possibility of changing MH sxs in a beneficial way (lack of robust evidence here; e.g., mood monitoring app could reduce depressive sxs by increasing emotional awareness)

Different transdiagnostic txs (their core premise)

CBT-E (shared core pathology = overvaluation of body weight/shape)

Unified Protocol (neuroticism is core characteristic of dep/anx, address ER deficits and avoidance of intense emotions)

Emotion-Focused Therapy-Transdiagnostic (targets chronic painful emotions underlying dep/anx: loneliness, fear, shame)

PCIT (child emotion dysregulation is core process leading to early-onset psychological problems, improve child ER)

ACT

Unified Protocol for Transdiagnostic Treatment of Emotional Disorders is based on view that

-Neuroticism is a core shared characteristic across dep/anx/related disorders

-focuses on ER deficits, avoidance of intense emotion (mechanisms related to neuroticism)

PCIT (initially developed for, expanded to, tx goal)

-initially developed for disruptive bx disorders

-expanded to anx/mood, trauma/maltreatment

-child emotion dysregulation is core process leading to child psychological problems

-primary PCIT goal = improve child ER

Telepsychology is any MH service provided via

-phone, email, text/chat, Internet (e.g., self-help website, blog, social media)

-Advantages over in-person: decreased cost, increases access, reduces stigma/embarassment going to a tx facility

Most common pt challenges with telepsychology, reported by psychologists (in order):

(Connection + space)

-internet access, or connectivity

-general tech difficulties

-getting a private place to connect from

Most common barriers for psychologists (in order):

-inadequate access to tech

-diminished therapeutic alliance

-tech issues

-diminished care quality, or effectiveness

-privacy concerns

Comparative effectiveness of teletherapy for Bulimia Nervosa and PTSD

-If not on here, assume it’s comparable

Bulimia nervosa: teletherapy can help, but not as effective as in-person

• in-person CBT showed greater reductions in ED cognition + depression

• and non-significantly greater abstinence from binge/purge

• in-person CBT group therapy showed faster recovery pace (could be d/t omission of weight measurement?)

PTSD: comparable effectiveness, but some inconsistent results around therapeutic alliance (some reported no trouble with rapport-building, some reported difficulty detecting nonverbal communications)

Comparative effectiveness of teletherapy CBT for depression (wrt attrition)

-One study showed reduced attrition for teletherapy CBT group

-teletherapy also helped to alleviate insomnia and chronic pain, that often accompanied depression

Digital MH interventions

-online/mobile tools

-ranges from self-guided tools to full-blown CBT for depression

-digital interventions with human support are likely better than none

-no consistent difference if support comes from therapist vs. peer/non-professional

Stepped care model (two fundamental features, primary goal)

-recommend the tx that is least restrictive (of the available txs), but still able to provide significant health gain

-model is self-correcting – systematically monitor tx results and decisions, may decide to step-up if current tx not achieving significant gain)

-primary goals of stepped care = increase efficiency of health care services and accessibility of effective tx through better allocation of scarce MH resources

Depression-specific stepped care models (four steps)

Step 1: Assessment and Monitoring

• “watchful waiting” esp. for minor depressive sxs

Step 2: Interventions Requiring Minimal Practitioner Involvement:

• psychoed about sxs, course of depression, tx options, signs of relapse

• bibliotherapy as preventive or adjuctive technique (book/workbook to support MH, offer perspective, validate, facilitate emotional processing)

• computer-based interventions that track sxs, use interactive multimedia designed to help pts cope with dep/anx

Step 3: Interventions Requiring More Intensive Care and Specialized Training

• group therapy, individual psychotherapy, and/or meds

• some models choose group therapy + brief individual therapy initially

• → if inadequate response to group/individual → longer-term psychotherapy with/without meds is considered

Step 4: Most Restrictive and Intensive Forms of Care:

• inpatient (for severe depressive sxs)

Treatment fidelity (affected by what two therapist factors, why important for research & practice)

-Fidelity is affected by therapist adherence to protocol + competence in delivering tx

-important for research: tx effectiveness can’t be fully evaluated w/o high fidelity

-important for practice: determining why a tx outcome may be poor

**poor fidelity may explain why efficacious txs fail to translate those outcomes IRL

Four models of disability

1.) Biomedical

2.) Social (difference is d/t societal barriers)

3.) Functional

• focus = functional impairment + supporting person (accommodations/mods/assistive tech) to improve fx

4.) Forensic

• focus = objective proof, distinguishing malingering

• determine honesty/motivation of person

• focuses on legal concepts