COURSE OF CLINICAL COURSE OF CLINICAL INTERVENTIONINTERVENTION

Lecture 27Lecture 27

It may be useful to examine the overall It may be useful to examine the overall sequence of therapeutic progress as described sequence of therapeutic progress as described by Hokanson (1983).by Hokanson (1983).

INITIAL CONTACT:-INITIAL CONTACT:- When clients first contact the clinic or enter When clients first contact the clinic or enter

the clinician's office, they often do not know the clinician's office, they often do not know exactly what to expect.exactly what to expect.

The first order of business, then, is for The first order of business, then, is for someone to explain generally what the clinic is someone to explain generally what the clinic is all about and the kind of help that can be given.all about and the kind of help that can be given.

Whether this initial contact is made by a Whether this initial contact is made by a therapist, a social worker, a psychological therapist, a social worker, a psychological technician, or someone else, it is important that technician, or someone else, it is important that the contact be handled with skill and sensitivity.the contact be handled with skill and sensitivity.

Once the client's reasons for coming have been Once the client's reasons for coming have been discussed, the next step in the general se discussed, the next step in the general se quence can be explained. It may be useful at quence can be explained. It may be useful at this point to discuss several specific issues.this point to discuss several specific issues.

ASSESSMENT:-ASSESSMENT:- Once it has been mutually agreed that the Once it has been mutually agreed that the

client can likely profit from continued contact client can likely profit from continued contact with the clinic, one or more appointments can with the clinic, one or more appointments can be ar ranged for an assessment of the client’s be ar ranged for an assessment of the client’s problems.problems.

As we know that variety of assessment As we know that variety of assessment procedures may be followed, depending on procedures may be followed, depending on the exact nature of the client's problem, the the exact nature of the client's problem, the orientation of the professional staff, and other orientation of the professional staff, and other factors.factors.

Intake interview, psychological tests are Intake interview, psychological tests are often involved in assessment process.often involved in assessment process.

For some clients, consultations with other For some clients, consultations with other professionals may be desirable. like professionals may be desirable. like Neurologists, medical physicians.Neurologists, medical physicians.

For some clients whose problems are related to For some clients whose problems are related to economic problems or unemployment, economic problems or unemployment, additional consultation with social workers or additional consultation with social workers or job counselors may be appropriate.job counselors may be appropriate.

After all the information has been compiled and After all the information has been compiled and analyzed, a preliminary integration is attemptedanalyzed, a preliminary integration is attempted

What is desirable here is not a simple What is desirable here is not a simple diagnostic label but a comprehensive diagnostic label but a comprehensive construction of the client's problems in light of construction of the client's problems in light of all the psychological, environmental, and all the psychological, environmental, and medical data available.medical data available.

THE GOALS OF TREATMENT:-THE GOALS OF TREATMENT:- As soon as the assessment data are integrated As soon as the assessment data are integrated

(the therapist and client can begin to discuss (the therapist and client can begin to discuss more systematically the nature of the problem more systematically the nature of the problem and what can be done about them.and what can be done about them.

Some therapists describe this phase as a Some therapists describe this phase as a period of negotiation over the goals of period of negotiation over the goals of treatment. Others suggests that client and treatment. Others suggests that client and therapist enter into a ‘contract’therapist enter into a ‘contract’

No one can absolutely promise a perfect cure No one can absolutely promise a perfect cure or resolution of or resolution of all all problems.problems.

It is important to understand that various It is important to understand that various features of the contract may be modified as features of the contract may be modified as time goes on.time goes on.

As therapy proceeds, that client may become As therapy proceeds, that client may become more open and comfortable and thus better more open and comfortable and thus better able to accept an expanded set of goals.able to accept an expanded set of goals.

Some clients will want to expand their goals for Some clients will want to expand their goals for treatment as they gain more confidence and treatment as they gain more confidence and trust in the therapist.trust in the therapist.

Therapists must try to take clients only where Therapists must try to take clients only where they are psychologically prepared to go. Moving they are psychologically prepared to go. Moving too fast or setting up grandiose treatment too fast or setting up grandiose treatment objectives can frighten or alienate certain objectives can frighten or alienate certain clients.clients.

Hokanson (1983) uses a classification of Hokanson (1983) uses a classification of therapy goalstherapy goals

Therapeutic Goal is Crisis managementTherapeutic Goal is Crisis management Therapeutic goal is Behavior changeTherapeutic goal is Behavior change. . Therapeutic goal is Corrective Therapeutic goal is Corrective

emotional experienceemotional experience.. Therapeutic goal is Insight and change.Therapeutic goal is Insight and change.

The goal of psychotherapy is to improve The goal of psychotherapy is to improve the patient's level of psychosocial the patient's level of psychosocial adjustment and to increase the patient's adjustment and to increase the patient's capacity for achieving satisfactions from capacity for achieving satisfactions from life.life.

IMPLEMENTING TREATMENTIMPLEMENTING TREATMENT After the initial goals are established, the After the initial goals are established, the

therapist decides on the specific form of therapist decides on the specific form of treatment.treatment.

It may be client-centered, cognitive, behavioral, It may be client-centered, cognitive, behavioral, or psychoanalytic.or psychoanalytic.

Exactly what is expected of the client will be Exactly what is expected of the client will be detailed as well free association, "homework" detailed as well free association, "homework" assignments, self monitoring, or whatever.assignments, self monitoring, or whatever.

Inherent in all of this is the issue of informed Inherent in all of this is the issue of informed consent.consent.

TERMINATION, EVALUATION AND TERMINATION, EVALUATION AND FOLLOWUPFOLLOWUP

As the therapist begins to believe the client is As the therapist begins to believe the client is able to handle his or her problems able to handle his or her problems independently, dis cussions of termination are independently, dis cussions of termination are initiated.initiated.

Sometimes termination is a gradual process in Sometimes termination is a gradual process in which meet ings are reduced,which meet ings are reduced,

Clients do sometimes terminate suddenly, in Clients do sometimes terminate suddenly, in some cases before the therapist feels it is some cases before the therapist feels it is appropriateappropriate

Many therapists find that "booster sessions" Many therapists find that "booster sessions" scheduled months after termination-perhaps 6 scheduled months after termination-perhaps 6 months and then one year later can be quite months and then one year later can be quite helpful.helpful.

It is important to evaluate with clients the It is important to evaluate with clients the progress they have made.progress they have made.

Therapists should also compile data and make Therapists should also compile data and make notes on progress.notes on progress.

The most reliable data, of course, will come The most reliable data, of course, will come from formally designed re search projectsfrom formally designed re search projects

Common Elements of Common Elements of PsychotherapyPsychotherapy

1. Realistic relationship between patient and 1. Realistic relationship between patient and therapisttherapist

2. Restoration of morale2. Restoration of morale

3. Release of emotion3. Release of emotion

4. Rationale4. Rationale

5. A combination of active listening and 5. A combination of active listening and talkingtalking

6. Suggestion6. Suggestion

Types of PsychotherapyTypes of Psychotherapy

Psychotherapy encompasses a large number of Psychotherapy encompasses a large number of treatment methods, each developed from treatment methods, each developed from different theories about the causes of different theories about the causes of psychological problems and mental illnesses. psychological problems and mental illnesses.

There are more than There are more than 250250 kinds of kinds of psychotherapy, but only a fraction of these psychotherapy, but only a fraction of these have found mainstream acceptance.have found mainstream acceptance.

The methods of therapists vary depending on The methods of therapists vary depending on their theory of personality, or way of their theory of personality, or way of understanding another individual. understanding another individual.

Most therapies can be classified as Most therapies can be classified as (1) Psychodynamic, (1) Psychodynamic, (2) Humanistic, (2) Humanistic, (3) Behavioral, (3) Behavioral, (4) Cognitive, (4) Cognitive, Or (5) Eclectic. Or (5) Eclectic.

In the United States, about 40 percent of In the United States, about 40 percent of therapists consider their approach eclectic.therapists consider their approach eclectic.

Popular Therapies Include : Popular Therapies Include :

Forms of therapy that treat more than one Forms of therapy that treat more than one person at a time include person at a time include

Group therapy, Group therapy, Family therapy, Family therapy, and Couples therapy. and Couples therapy.

These therapies may use techniques from These therapies may use techniques from any theoretical approach. Other forms of any theoretical approach. Other forms of therapy specialize in treating children or therapy specialize in treating children or adolescents with psychological problems.adolescents with psychological problems.

Another Class of TherapiesAnother Class of Therapies

Psychotherapeutic Research Psychotherapeutic Research

Now we will briefly review the methods of Now we will briefly review the methods of psychotherapy research, the results of several psychotherapy research, the results of several major outcome studies, and the recent trends in major outcome studies, and the recent trends in psychotherapy research.psychotherapy research.

Cartwright (1956), Bergin (1971), and Hadley Cartwright (1956), Bergin (1971), and Hadley and Strupp (1977) called attention to the and Strupp (1977) called attention to the likelihood of deterioration effects in some likelihood of deterioration effects in some psychotherapy patients and the need, psychotherapy patients and the need, therefore, to study out comes in therapy.therefore, to study out comes in therapy.

The work that really stood the psychotherapy The work that really stood the psychotherapy establishment on its ear was Eysenck's (1952) establishment on its ear was Eysenck's (1952) report.report.

The significance of Eysenck's work lies less in The significance of Eysenck's work lies less in the validity of his conclusions (which many the validity of his conclusions (which many deemed flawed) than in the attack he made on deemed flawed) than in the attack he made on the field's complacency.the field's complacency.

To better understand the nature of therapeutic To better understand the nature of therapeutic change, we will consider issues of research change, we will consider issues of research design and method, the results of out come design and method, the results of out come studies, and the process of change itself.studies, and the process of change itself.

SOME GENERAL CONCLUSIONSSOME GENERAL CONCLUSIONS

J. D. Frank's (1979) conclusions about psychotherapy:J. D. Frank's (1979) conclusions about psychotherapy: Nearly all forms of psychotherapy are some what Nearly all forms of psychotherapy are some what

more effective than unplanned or in formal help.more effective than unplanned or in formal help.

One form of therapy has typically not been shown to One form of therapy has typically not been shown to be more effective than another for all conditions.be more effective than another for all conditions.

Clients who show initial improvement tend to maintain Clients who show initial improvement tend to maintain it.it.

Characteristics of the client, the therapist, and their Characteristics of the client, the therapist, and their interaction may be more important than therapeutic interaction may be more important than therapeutic technique.technique.

Telch (1981), for one, argues that the more potent Telch (1981), for one, argues that the more potent the therapeutic technique being used, the less the therapeutic technique being used, the less important are therapist or client characteristics.important are therapist or client characteristics.

Lazarus (1980) also argues that specific therapies Lazarus (1980) also argues that specific therapies are indicated for specific problems.are indicated for specific problems.

At the same time, however, he seems to suggest At the same time, however, he seems to suggest that various nonspecific factors play an important that various nonspecific factors play an important role in improvement.role in improvement.

Careful research should be designed to help us Careful research should be designed to help us predict which therapy will best work for a given predict which therapy will best work for a given problem.problem.

Therapy is an intermittent process that occurs, for Therapy is an intermittent process that occurs, for example, once a week. Thus, it is only a small part of a example, once a week. Thus, it is only a small part of a client's ongoing life.client's ongoing life.

What happens in therapy may interact with other What happens in therapy may interact with other experiences in complex ways.experiences in complex ways.

Changes in the client may threaten family members, Changes in the client may threaten family members, who then quietly conspire to sabotage treatment. who then quietly conspire to sabotage treatment.

Example of a client who had done Masters and wanted Example of a client who had done Masters and wanted to be married, became numb and paralyzed.to be married, became numb and paralyzed.

The whole process is so complex and interactive that The whole process is so complex and interactive that it is difficult for research to show what factors in it is difficult for research to show what factors in therapy are related to client change or lack of it.therapy are related to client change or lack of it.

Perhaps the greatest reality limitation of all is Perhaps the greatest reality limitation of all is suggested by Barlow's (1981) charge that many suggested by Barlow's (1981) charge that many clinical psychologists simply do not pay clinical psychologists simply do not pay attention to outcome research.attention to outcome research.

Persons (1995) discuss how deficits in training Persons (1995) discuss how deficits in training and the perceived inaccessibility of resources and the perceived inaccessibility of resources have caused clinicians to delay adopting have caused clinicians to delay adopting empirically supported treatment techniques.empirically supported treatment techniques.

However, Chambless et al. (1996) has said it best:However, Chambless et al. (1996) has said it best:

Psychology is a science. Seeking to help those in Psychology is a science. Seeking to help those in need, clinical psychology draws its strength and need, clinical psychology draws its strength and uniqueness from the ethic of scientific validation. uniqueness from the ethic of scientific validation.

Whatever interventions that mysticism, authority, Whatever interventions that mysticism, authority, commercialism, politics, custom, convenience, or commercialism, politics, custom, convenience, or carelessness might dictate, clinical psychologists carelessness might dictate, clinical psychologists focus on what works. focus on what works.

They bear a fundamental ethical responsibility to They bear a fundamental ethical responsibility to use where possible interventions that work and to use where possible interventions that work and to subject any intervention they use to scientific subject any intervention they use to scientific scrutiny.scrutiny.