Chapter 14 INTRODUCTION TO CLINICAL PSYCHOLOGY, THIRD CANADIAN EDITION by John Hunsley and Catherine M. Lee

Questions Psychotherapy process and process-outcome research Common factors in psychotherapy Evidence-based psychotherapy relationships Empirically-based principles of therapeutic change For next class Overview

Psychotherapy Process and Process-Outcome Research

Client variables Therapist variables – account for 3% of variability of outcome in efficacy trials and 7% in effectiveness trials (Baldwin & Imel, 2013) How do process variables differ across theoretical orientations? Psychotherapy Research

VariableEngagementCompletion & Improvement Higher SES++ Similar ethnicity to therapist ++ GenderFemale +No difference Age+No difference Symptom severity ?Poorer outcome Positive expectations ++ Client Variables

Psychological Reactance Tendency to act against attempts to influence Low reactant: do best in directive treatments High reactant: do best in less directive treatments

VariableEffect on Outcome GenderNo effect AgeNo effect Professional backgroundMental health training is associated with more positive outcome than health training; inconclusive effects among different mental health professions ExperienceSmall positive effect Well-beingPositive effect Judicious self-disclosureSmall positive effect Therapist Variables

Therapist effects most marked in treatment of severe symptoms (Saxon & Barkham, 2012) Kraus et al. (2011): 6,690 patients in United States – Improvement varied across areas mania : 13% depression: 55% – Some therapists had patients whose symptoms worsened depression: 3% substance abuse & violence: 16% Helpful and Unhelpful Therapists

VariableTheoretical Orientation Outcome InterpretationPsychodynamic; process- experiential No consistent pattern across studies; positive effects with clients with good interpersonal skills DirectivenessCBTModerated by client reactance Between session assignments variousPositive effect InsightvariousMost important for internalizing clients Symptom reduction variousMost important for externalizing Treatment Variables

SupportLearningAction Common Factors in Psychotherapy

Affective bondsConsensus about goalsSense of partnership Therapeutic Alliance

Alliance measured in early sessions is consistent predictor of outcome of treatment for: – Adults – Children and youth – Couples and families Therapeutic Alliance Research

Cannot know, in absolute terms, as not all have been tested Variability across disorders, with multiple evidence-based options for some disorders and only one evidence-based option for other disorders When there are several options: – Start with the one that has greatest evidence (this suggests the likelihood of robust effects across various clients and various therapists) – Switch to another evidence-based option if necessary (including referral to another professional) Psychotherapy Equivalence?

APA Task Force on Empirically Supported Therapy Relationships, 1999 APA Task Force on Evidence-Based Therapy Relationships, 2009 Evidence-Based Psychotherapy Relationships

Probably Effective Goal consensus Collaboration Positive regard Adapting to: – Stage of change – Coping style Demonstrably Effective Alliance Cohesion Empathy Collecting client feedback Adapting – Reactance – Preferences – Culture Norcoss (2011)

ConfrontationAssumptionsRigidity Flexibility without fidelity Norcross (2011): What doesn’t work:

Client – Greater impairment – Personality disorder – Financial difficulties – Significant interpersonal problems in childhood – Unfavourable attitude to treatment Variables assumed to reduce chance of change Relationship – Alliance and cohesion Therapist behaviours – Collaboration – Sensitivity to ruptures – Empathy – Provision of structure with flexibility Variables predicted to promote change Empirically-Based Principles of Therapeutic Change: Castonguay & Beutler

Applying the Principles: An Example of Engaging Clients in CBT Empathy Warmth. Genuiness. Respect (positive regard) Psychoeducation about condition/problem and treatment options Collaboratively defining goals Anticipating barriers to treatment tasks and finding solutions Role plays to explore alternative options Homework/practice to enhance awareness and to consolidate skills Reinforcement of effort

For next class…

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