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…

Copyright © 2014 John Wiley & Sons Canada, Ltd. All rights reserved. Reproduction or translation of this work beyond that permitted by Access Copyright (The Canadian Copyright Licensing Agency) is unlawful. Requests for further information should be addressed to the Permissions Department, John Wiley & Sons Canada, Ltd. The purchaser may make back-up copies for his or her own use only and not for distribution or resale. The author and the publisher assume no responsibility for errors, omissions, or damages caused by the use of these programs or from the use of the information contained herein.

All clipart courtesy of Microsoft.com

Copyright Notice