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

s Anecdotal reports demonstration 1600-Mid 1700s Evidence of intervention and prevention Implementation 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 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 Acknowledge feelings about termination Practice skills Anticipate challenges Interpersonal Psychotherapy

Exploring emotions & experiences 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

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