Chapter 11 INTRODUCTION TO CLINICAL PSYCHOLOGY, THIRD CANADIAN EDITION by John Hunsley and Catherine...
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Transcript of Chapter 11 INTRODUCTION TO CLINICAL PSYCHOLOGY, THIRD CANADIAN EDITION by John Hunsley and Catherine...
Chapter 11
INTRODUCTION TO CLINICAL
PSYCHOLOGY, THIRD CANADIAN EDITION
by John Hunsley and Catherine M. Lee
• Questions
• Evidence-based practice
• The ethics of intervention
• Psychotherapy & psychological treatment
• Theoretical approaches
• Seeking psychological treatment
• The duration and impact of psychotherapy
• Alternative modes of service delivery
Overview
Best research evidence
Patient preferences & values
Clinical expertise
Evidence-Based Practice: Institute of Medicine 2001
• Scurvy: Greater mortality in early European navies than due to shipwrecks and naval battles
• Vasco de Gama (1497): 100/160 sailors die of scurvy on voyage from Portugal, around Africa, to India
• Jacques Cartier (1535): Iroquois provide assistance to sailors over-wintering on St. Lawrence River
• James Lancaster (1601): 4 ships from England to India, 3 with regular diet, 4th with 3 teaspoons of lemon juice a day– At half-way point, 40% of sailors on ships 1-3 had died; none on ship 4 died
• James Cook (1776): “early adopter” of evidence-based practice, required all sailors to have fresh water, fresh food, and foods with antiscorbutic properties (e.g., citrus fruits, sauerkraut)
Early Example of Evidence-Based Practice
• 1795: British Navy (Royal Navy)– 194 years since Lancaster data available
• 1865: British Board of Trade (Merchant Navy)– 264 years since Lancaster data available
Routine adoption of diet including citrus fruit
1497-1500sAnecdotal reports
demonstration
1600-Mid 1700sEvidence of
intervention and prevention
1795-1865Implementation of
policy on consumption of vitamin C in navy
voyages
Timeline for adoption of anti-scurvy practices
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, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable.Norcross (1990)
Psychotherapy
• Be it resolved that as a healing practice and professional service, psychotherapy is effective and highly cost-effective….Consequently, psychotherapy should be included in the healthcare system as an evidence-based practice.
American Psychological Association, 2012
What are the benefits and shortcomings of this resolution?
APA Resolution on Effectiveness of Psychotherapy
• Within professional relationship
• Emphasis on psychological principles
• Broad: Affect, behaviour, cognition
• Acknowledges client/patient goals
But does not address whether services are evidence-based
Psychotherapy
Evidence based treatment of clinically significant emotional and behavioural problems.
Barlow (2004)
An Alternative Definition: Psychological Treatment
• Informed consent– Prior to starting treatment individuals have a right to know about evidence-
based treatments
• Medication options• Psychological treatments the psychologist can provide• Psychological treatments the psychologist is NOT trained to provide and for a which
a referral to another psychologist could be made
The Ethics of Intervention
• Not controlled in many jurisdictions
The practice of psychotherapy is the assessment and treatment of cognitive, emotional or behavioural disturbances by psychotherapeutic means, delivered through a therapeutic relationship based primarily on verbal or non-verbal communication
Ontario Psychotherapy Act (2007)
Psychotherapy as a controlled act
• Neurolinguistic programming
• Rebirthing
• DARE
• Scared Straight
Examples of Discredited Psychotherapies
Adopt the one that is closest
Adapt if necessary
Abandon if evidence it
does not fit and replace with another EBP
What if there is no evidence-based treatment that matches client needs exactly?
• Short-term psychodynamic therapies(STPT)
• Interpersonal psychotherapy (IPT)
• Process experiential therapy (P-ET)
• Cognitive-behaviour therapy (CBT)
Theoretical Approaches
• Weekly or biweekly sessions for 16-30 weeks
Short-term Psychodynamic Therapies
Develop positive transference and establish themes
Analyze transference
relationship through clarification and
confrontation
Dealing with loss; dealing with the
unexpected
Initial 1-3
• Assessment and case formulation
Intermediate
4-12
• Addressing interpersonal themes• Grief• Role disputes• Role transitions• Interpersonal deficits
Termination 13-16
• Acknowledge feelings about termination• Practice skills• Anticipate challenges
Interpersonal Psychotherapy
Exploring emotions & experience
s
Therapeutic relationship
Client self-determination
Therapist empathy
Process-Experiential Therapy
Assessment to develop case formulation and client goals
Cognitive and behavioural skills modeled and practised in session and generalized through homework tasks
Review goals & skills; anticipate challenges; booster sessions as required
Cognitive-Behaviour Therapy
• Use of psychotherapy vs. medication– Growth in use of psychotropic medication
• Characteristics of those who seek psychotherapy– Age
– Gender
– Education
– Use of other healthcare
– Urban vs. rural
Seeking Psychological Treatment
• Typical number of sessions is less than a dozen
• Most clients receive only one or two sessions
• For adults, effects of treatment as usual in clinics (TAU) vs. evidence-based treatments (EBT)– Hansen et al. (2002) improvement/recovery: 35% TAU vs. 67% EBT
– Wampold & Brown (2005) improvement/recovery: 29% TAU
• Differences in content and duration are likely between TAU and EBT
The Duration and Impact of Psychotherapy
• Blais et al. (2012)– 800 patients in university-based clinic
– 50% improved or recovered after psychotherapy
– 56% improved after psychotherapy + medication
Does this reflect the growing use of evidence-based treatments, or are these results simply specific to one clinic?
But, is psychotherapy in routine practice changing?
• Oldham et al. (2012) meta-analysis of strategies– Allowing client to choose therapist and appointment time
– Motivational interviewing to explore reasons for seeking treatment
– Preparing clients for what to expect
– Appointment reminders
– Case management for extremely distressed clients
Enhancing Attendance at Psychotherapy
• Group
• Couple
• Family
• Self-help
• Telepsychology
Alternative Modes of Service Delivery
• Assertiveness
• Communication
• Couple relationships
• Managing stress
• Anger
• Anxiety
• ADHD
• Dementia
• Eating disorders
• Mood disorders
• Schizophrenia
• Sexual abuse
• Sexual functioning
Evidence-Based Self-Help
• Videoconferencing
• Virtual reality
• On-line services
• Smart phone apps
Telepsychology
• Graduated dosage
• Provide minimum required to make a difference
Stepped Care
For next class…
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