Clinical Psychology

gc87-2025-10-25_02_15_51-clinical-psychology.docx

Psychodynamic Psychotherapies: Included in this category are Freudian psychoanalysis and Jung's analytical psychology.

One. Freudian Psychoanalysis: Freudian psychoanalysis reflects a deterministic and pessimistic view of human nature that views current psychological problems as being due to unconscious unresolved conflicts that arose during childhood. It also assumes that these conflicts cause anxiety and are the result of the divergent demands of the three aspects of personality - the id, ego, and superego: (a) The id is present at birth, and its life (sexual) and death (aggression) instincts are the primary source of psychic energy. It operates according to the pleasure principle and seeks immediate gratification of its instinctual needs using unconscious irrational means. (b) The ego develops at about six months of age and operates according to the reality principle. Although it also seeks to at least partially gratify the id's instincts, it attempts to do so in realistic rational ways. (c) The superego is the last aspect of personality to develop. It represents the internalization of society's values and standards and acts as the conscience. It attempts to permanently block (rather than gratify) the id's instincts.

Freud's theory also proposes that, when the ego is unable to resolve a conflict between the id and superego using rational means, it resorts to one of its defense mechanisms. The defense mechanisms deny or distort reality and operate on an unconscious level, and they include repression, denial, reaction formation, projection, and sublimation: Repression is the basis of all other defense mechanisms, is involuntary, and involves keeping undesirable thoughts and urges out of conscious awareness. Denial is an immature defense mechanism that involves refusing to acknowledge distressing aspects of reality. Methods of denial include ignoring, distorting, and rejecting reality. Reaction formation involves defending against an unacceptable impulse by expressing its opposite, projection involves attributing an unacceptable impulse to another person, and sublimation involves channeling an unacceptable impulse into a socially desirable (and often admirable) endeavor. The occasional use of defense mechanisms is adaptive, but repeated reliance on them keeps a person from resolving the conflicts that are causing anxiety.

The main goals of Freudian psychoanalysis are "to make the unconscious conscious and to strengthen the ego so that behavior is based more on reality and less on instinctual cravings and irrational guilt." The primary technique of psychoanalysis is analysis of the client's free associations, dreams, resistance, and transference, and the process of analysis consists of four steps: (One) Confrontation involves helping clients recognize behaviors they've been unaware of and their possible cause. (Two) Clarification brings the cause of behaviors into sharper focus by separating important details from extraneous material.

(Three) Interpretation involves explicitly linking conscious behaviors to unconscious processes. (Four) Repeated interpretation leads to catharsis (the experience of repressed emotions) and insight into the connection between unconscious material and current behavior and then to working through, which is a gradual process during which the client accepts and integrates new insights into his or her life.

Two. Jung's Analytical Psychology: Jung accepted some aspects of Freudian theory but rejected others. For example, Jung believed that behavior is driven by both positive and negative forces, that personality continues to develop throughout the lifespan, and that behavior is affected by the past and the future. Jung also divided the unconscious aspect of the psyche into the personal and collective unconscious: The personal unconscious consists of a person's own forgotten or repressed memories, while the collective unconscious consists of memories that are shared by all people and are passed down from one generation to the next. The collective unconscious contains archetypes, which are universal thoughts and images that predispose people to act in similar ways in certain circumstances. They're expressed in myths, symbols, and dreams and include the persona, shadow, hero, and anima and animus.

The primary goal of analytical psychotherapy is to bring unconscious material into consciousness to facilitate the process of individuation, which occurs primarily during the second half of life and is "the process by which a person becomes a psychological 'in-dividual,' that is, a separate, indivisible unity or whole." Techniques used to achieve this goal include dream interpretation and the analysis of transference, which Jung viewed as being due to the projection of elements of the personal and collective unconscious.

Humanistic, Existential, and Other Psychotherapies: This category includes humanistic therapies (person-centered and Gestalt therapies), existential therapies, reality therapy, positive psychology, and personal construct therapy.

The humanistic and existential therapies are sometimes categorized jointly as humanistic-existential therapies. However, while the two approaches share a number of similarities, they also differ in important ways: In terms of similarities, humanistic and existential therapies both focus on the here-and-now and adopt a phenomenological orientation, which means they prioritize a client's subjective experience over objective reality. They also reject the medical model and use of clinical labels and, consequently, concentrate on a client's internal qualities and perspective rather than the client's symptoms. In terms of differences, humanistic therapies emphasize acceptance and growth and help clients become more fully-functioning and self-actualizing. In contrast, existential therapies emphasize freedom and responsibility and "help clients confront the anxieties that arise from the awareness of one's existential condition ... [and cultivate] authentic engagement with one's world."

One. Person-Centered Therapy: Rogers's person-centered therapy is also known as client-centered therapy and is based on the assumption that all people have an innate drive toward selfactualization, which motivates them to achieve their full potential. According to Rogers, the drive toward self-actualization can be thwarted when a person experiences incongruence between his or her self-concept and experience. Conditions of worth are one source of incongruence and occur, for example, when parents provide a child with love and acceptance only when the child behaves in certain ways. According to Rogers, people often react to incongruence defensively by distorting or denying their experiences which, in turn, leads to psychological maladjustment.

The primary goal of person-centered therapy is to help the client become a "fully functioning person" who is not defensive, is open to new experiences, and is engaged in the process of self-actualization. To achieve this goal, person-centered therapists provide clients with three facilitative (core) conditions: empathy, unconditional positive regard, and congruence. Empathy involves understanding the client's perspective and communicating that understanding to the client, unconditional positive regard involves valuing and accepting the client as a person, and congruence involves being genuine, authentic, and honest.

Two. Gestalt Therapy: Gestalt therapy is based on the assumptions that (a) people are motivated to maintain a state of homeostasis, which is repeatedly disrupted by unfulfilled physical and psychological needs, and (b) people seek to obtain something from the environment to satisfy their unfulfilled needs in order to restore homeostasis. Neurosis (maladjustment) occurs when there's a persistent disturbance in the boundary between the person and the environment that interferes with the person's ability to fulfill needs. Boundary disturbances include the following: Introjection occurs when people adopt the beliefs, standards, and values of others without evaluation or awareness, while projection occurs when people attribute undesirable aspects of themselves to other people. Retroflection occurs when people do to themselves what they'd like to do to others; deflection occurs when people avoid contact with the environment; and confluence occurs when people blur the distinction between themselves and others.

Gestalt therapists consider gaining awareness of one's current thoughts, feelings, and actions to be the curative factor in therapy. Strategies used to increase awareness include dream work and the empty chair technique. Dream work involves having the client role-play parts of his or her dream that represent disowned parts of the client's personality. The empty-chair technique requires the client to interact with opposing aspects of his or her personality (e.g., top dog and underdog) or to resolve "unfinished business" with a significant person in the client's past or present. In contrast to psychodynamic therapists, Gestalt therapists do not foster or interpret a client's transference but, instead, help the client distinguish between his or her "transference fantasy" and reality.

Three. Existential Therapies: Existential therapies were derived from existential philosophy and were developed by several psychiatrists and psychologists including Irvin Yalom, Rollo May, and Viktor

Frankl. These therapies emphasize personal responsibility and choice and are based on the assumption that "each person must ultimately define his or her personal existence." Existential therapists view psychological disturbances as the result of an inability to resolve conflicts that arise when facing four ultimate concerns of existence: death, freedom, isolation, and meaningless. They also distinguish between two types of anxiety. Normal (existential) anxiety is in proportion to an objective threat, does not involve repression, and can be used constructively to identify and confront the conditions that elicited it and motivate positive change. In contrast, neurotic anxiety is disproportionate to an objective threat, involves repression, and keeps people from reaching their full potential. The primary goal of therapy is "to help clients lead more authentic lives ... by assisting them in taking charge of their life, helping them choose for themselves the values and purposes that will define and guide their existence, and supporting them in actions that express these values and purposes." Existential therapists consider an authentic therapist-client relationship to be the most important therapeutic tool but may use other techniques such as questioning, interpretation, and reframing.

Four. Reality Therapy: Glasser's reality therapy is based on choice theory, which proposes that people have five basic innate needs (love and belonging, power, fun, freedom, and survival) and that the ways a person chooses to fulfill his or her needs determine whether he or she has a success or failure identity: When a person chooses to fulfill his or her needs responsibly (in positive, constructive ways that don't infringe on the rights of others), the person has adopted a success identity. In contrast, when a person chooses to fulfill his or her needs irresponsibly (in negative, destructive ways that infringe on the rights of others and do not always help the person get what he or she wants), the person has adopted a failure identity.

The primary goal of reality therapy is to replace the client's failure identity with a success identity by helping the client assume responsibility for his or her actions and adopt more appropriate ways to fulfill his or her needs. Strategies used by reality therapists are summarized by Wubbolding's WDEP system: Therapists ask clients about their wants and needs, determine what the client is currently doing to foster awareness of his or her behaviors, encourage the client evaluate his or her own behaviors, and help the client create a plan of action.

Five. Positive Psychology: As described by Seligman and Csikszentmihalyi, positive psychology "is about valued subjective experiences: well-being, contentment, and satisfaction (in the past); hope and optimism (for the future); and flow and happiness (in the present)." Flow is an important concept in positive psychology and refers to "a state in which people are so involved in an activity that nothing else seems to matter; the experience is so enjoyable that people will continue to do it even at great cost, for the sheer sake of doing it." People are most likely to experience flow when there is a challenge-skill balance, which occurs when people believe that they have the skills needed to meet an activity's challenge and the challenge and skill level are both relatively high. A distinctive characteristic of positive psychology is its emphasis on using the scientific method to evaluate its theories, concepts, and interventions. For example, empirical research has linked positive emotions and optimism to increased longevity and positive psychology interventions to improved physical health.

Six. Personal Construct Therapy: Kelly's personal construct therapy focuses on how people construe (perceive, interpret, and anticipate) events. It proposes that there are alternative ways of doing so and that people can change the way they construe events to alleviate undesirable behaviors and outcomes. According to Kelly, construing involves the use of personal constructs, which are bipolar dimensions of meaning (e.g., fair or unfair, friend or enemy, relevant or irrelevant) that arise from a person's experiences and may operate on an unconscious or conscious level.

Practitioners of personal construct therapy consider the therapist and client to be partners who work together to help the client identify and replace maladaptive personal constructs. For example, Kelly developed fixed-role therapy to help clients try out alternative personal constructs. It involves having the client role-play a fictional character that is described by the therapist and construes events in alternative ways.

Interpersonal psychotherapy, solution-focused therapy, therapy based on the transtheoretical model, and motivational interviewing are brief therapies that are often asked about on the EPPP.

One. Interpersonal Psychotherapy: Interpersonal psychotherapy (IPT) focuses on the interpersonal factors that contribute to a client's current symptoms. It's based on the medical model and views depression and other mental disorders as treatable medical illnesses, and its primary goals are symptom relief and improved interpersonal functioning. Although IPT was originally developed by Klerman and Weissman as a treatment for acute depression, it has been modified to treat bipolar disorder, eating disorders, and several other disorders. Therapy involves three stages: (a) During the initial stage, the therapist determines the client's diagnosis and the interpersonal context of the client's symptoms. This information is then used to identify the primary problem area that will be the focus of treatment. For depression, the problem areas are interpersonal role disputes, interpersonal role transitions, interpersonal deficits, and grief. During this stage, clients are assigned the "sick role" in order to allow them to be ill without blaming themselves for their symptoms and to view their illnesses as temporary and treatable. (b) During the middle phase, the therapist uses a variety of strategies to address the problem area identified in the initial stage. Commonly used strategies include encouragement of affect, role-playing, communication analysis, and decision analysis. (c) During the final stage, the therapist addresses issues related to termination and relapse prevention.

Two. Solution-Focused Therapy: Solution focused therapy focuses on solutions to problems instead of the etiology and nature of problems. Solution-focused therapists adopt a goal-directed collaborative approach and use several types of questions to help clients identify treatment goals and personal strengths and resources that will help them achieve those goals: (a) The miracle question is used to help establish the focus of treatment as the future (rather than the past or present) and identify treatment goals. Example: If a miracle happened during the night and your problem was solved, how would you know that a miracle occurred? (b) Exception questions are used to help clients identify times when their problems did not exist or were less intense. Example: Can you think of a time in the past two weeks when you and your partner did not argue? (c) Scaling questions help clients evaluate their current status or their progress toward achieving their goals. Example: On a scale from one to ten, with one being totally relaxed and ten being the most stressed you've ever been, how stressed are you now?

Each therapy session is structured and involves asking questions, providing feedback, and assigning a task to complete before the next session. For example, the formula first session task is assigned at the end of the first session and requires clients to identify something in their lives that they want to continue.

Three. Transtheoretical Model: The transtheoretical model integrates concepts and strategies from multiple therapeutic approaches and is based on the assumption that strategies are most effective when they match the person's stage of change. It distinguishes between six stages of change, and the primary goal of the first five stages is to help the client advance to the next stage:

(a) Precontemplation: Clients in the precontemplation stage have no intention of taking action to change their behaviors in the next six months. They may be in denial about their problems or may have made multiple unsuccessful attempts to change and believe that change is impossible. These individuals are likely to resist advice or change interventions but may benefit from consciousness raising, dramatic relief (experiencing and expressing emotions), and environmental reevaluation (examining how the environment affects their behavior).

(b) Contemplation: Clients in this stage plan to change in the next six months but they're ambivalent about changing, which may make it difficult for them to transition to the next stage. These individuals benefit from self-reevaluation (evaluating how they feel about the situation) in addition to the strategies that are useful for individuals in the precontemplation stage.

(c) Preparation: Clients in the preparation stage plan to take action within the next month. Useful strategies for these individuals support their decision to change and include self-reevaluation and self-liberation (believing that change is possible and making a commitment to change).

(d) Action: Clients in the action stage are taking action to change their behaviors. Effective strategies for these individuals include contingency management, stimulus control, and counterconditioning.

(e) Maintenance: Clients transition to the maintenance stage when they have maintained the desired behavior change for six months. The primary focus of treatment for individuals in this stage is relapse prevention which involves the same strategies useful for individuals in the action stage.

(f) Termination: Clients in this stage are confident that their risk for relapse is low.

According to this model, motivation to change is affected by three factors - decisional balance, self-efficacy, and temptation. Decisional balance is the strength of the person's beliefs about the pros and cons of changing and is most important as a determinant of motivation during the contemplation stage. Self-efficacy refers to the confidence the person has about his or her ability to change and avoid relapse. It's an important determinant of whether a person transitions from the contemplation to the preparation stage and then from the preparation to the action stage. Temptation is the intensity of the urge to engage in the undesirable behavior and is usually strongest during the first few stages of change.

Finally, note that the order of the stages is fairly easy to memorize because the name of each stage describes the stage and its order in the sequence (e.g., the precontemplation stage occurs before the contemplation stage which occurs before the preparation stage). Alternatively, the acronym PC-PAM-T may help you remember the names and order of the stages.

Four. Motivational Interviewing: Motivational interviewing is a "method for enhancing intrinsic motivation by exploring and resolving ambivalence". It was originally developed as an intervention for substance use disorders but has since been applied to a number of other mental and physical health problems. Motivational interviewing incorporates elements of Rogers's person-centered therapy and Prochaska and DiClemente's transtheoretical model as well as Bandura's concept of self-efficacy and Festinger's notion of cognitive dissonance. Like the transtheoretical model, it assumes that interventions are most effective when they match the client's stage of change. Motivational interviewing can be tailored for clients in any of the transtheoretical model's stages of change, but it is considered to be particularly useful for reducing the resistance and ambivalence of clients who are in the precontemplation or contemplation stage.

Strategies used to enhance a client's motivation include evoking hope and confidence by, for example, (a) developing discrepancy by helping clients see the difference between their current behaviors and their values and goals and (b) eliciting and strengthening change talk, reducing sustain talk, and resolving discord. Change talk consists of statements that favor change - e.g., I'd probably feel a lot better if I stopped smoking. Sustain talk consists of statements that favor maintaining the status quo - e.g., I'm just not ready to stop smoking. Discord consists of statements that signal dissonance in the therapist-client relationship - e.g., You just don't understand what I'm going through. Another strategy is decisional balance which involves having the client identify the pros and cons of change. It was originally described by Miller and Rollnick as a useful technique for resolving a client's ambivalence, but they subsequently concluded that it is appropriate only in certain situations. According to Miller and Rollnick, decisional balance is useful when a clinician's goal is to maintain a neutral position about the direction of change while assessing a client's readiness for change. However, it is contraindicated when the goal is to resolve the client's ambivalence in order to promote change because, by identifying the negative consequences of changing, the client may actually become less willing to take steps to do so.

Research has shown that motivational interviewing is effective when used as a stand-alone treatment and can improve the benefits of other treatments when it is combined with them. For instance, Marker and Norton's meta-analysis of the research found that patients with anxiety disorders who received motivational interviewing prior to cognitive behavior therapy exhibited greater symptom reduction than did patients who received cognitive behavior therapy only. In addition, Randall and McNeil's review of the research found that the combination of motivational interviewing and cognitive behavior therapy was more beneficial than cognitive behavior therapy alone for several disorders, including general anxiety disorder and obsessive-compulsive disorder. Finally, there is evidence that, for some disorders and populations, motivational interviewing has similar beneficial effects whether it is delivered in-person or via telehealth. As an example, King et al. compared the effectiveness of in-person therapy and videoconferencing for providing Brief Alcohol Screening and Intervention for College Students, which is a brief intervention for high-risk drinking that combines motivational interviewing with personalized feedback, harm reduction, and relapse prevention. The results of their study confirmed that both methods of delivering Brief Alcohol Screening and Intervention for College Students significantly reduced alcohol use and related problems.

Five. Brief Psychodynamic Psychotherapy: Brief psychodynamic psychotherapy encompasses several time-limited alternatives to longer-term psychodynamic psychotherapies. The different versions vary in terms of their explanations for the development of psychological problems, the issues they focus on in therapy, and the specific techniques they use. For example, some versions focus on unconscious conflicts, while others focus on dysfunctional interactional patterns. Despite their differences, the brief psychodynamic psychotherapies share several characteristics: First, they assume that change can occur during a brief therapeutic process or that therapy can begin a change process that will continue after therapy ends. Second, they agree that therapy should have limited goals that are identified and agreed upon by the client and therapist during the initial sessions of therapy. Third, practitioners of these therapies believe they are appropriate for only certain types of clients (e.g., clients who can benefit from insight-oriented therapy and are able to form a therapeutic alliance). Fourth, practitioners adopt an active role from the beginning of therapy to quickly establish a therapeutic alliance with clients and then to ensure that therapy stays focused on major issues so goals can be accomplished within the time limits of therapy. Fifth, practitioners emphasize the development of positive (versus negative) transference and may rely more on exploration or education than on interpretation. Sixth, due to the brevity of therapy, practitioners address loss, separation, and other concerns related to termination of therapy early in treatment.

Foundations of Family Therapy: Most approaches to family therapy have their roots in general systems theory and cybernetic theory. General systems theory was originally used by biologists to describe the functioning of living and non-living systems. It predicts that all systems consist of interacting components, are governed by the same general rules, and have homeostatic mechanisms that help them maintain a state of stability and equilibrium. Cybernetic theory is concerned with the mechanisms that regulate a system's functioning and distinguishes between negative and positive feedback loops: Negative feedback loops resist change and help a system maintain the status quo, while positive feedback loops amplify change and disrupt the status quo.

Communication theory was another important contributor to family therapy. Bateson and his colleagues at the Mental Research Institute were not only among the first to recognize the usefulness of general systems theory and cybernetics for understanding family functioning but also proposed that certain types of repetitive patterns of communication and interaction produce problematic behavior. For example, Bateson linked the development of schizophrenia to double-bind communication, which occurs when a person receives two contradictory messages from a family member and is not allowed to comment on the contradiction. Bateson also distinguished between symmetrical and complementary interactions: Symmetrical interactions reflect equality and occur when the behavior of one person elicits a similar type of behavior from the other person. Symmetrical interactions can escalate in intensity and become a "one-upmanship game." In contrast, complementary interactions reflect inequality and occur when the behavior of one person complements the behavior of the other person. A common complementary pattern is for one person to assume a dominant role, while the other assumes a subordinate role. Problems occur in families when interactions between family members are exclusively symmetrical or complementary.

Several recent approaches to family therapy are influenced by postmodernism which challenges the basic premises of general systems theory, including the premise that there are universal laws that govern systems and can be discovered by scientific research. These approaches adopt a constructivist or social constructionist perspective and assume that there are multiple viewpoints and realities. They view family therapy as a shared process in which the therapist forms a collaborative relationship with the family and helps family members identify alternative ways of interpreting and resolving problems.

Specific Family Therapies: For the exam, you want to be familiar with the following family therapies:

One. Extended Family Systems Therapy: Bowen's extended family systems therapy is also known as intergenerational and transgenerational family therapy. Bowen derived his approach from work with children with schizophrenia and their families, which led to his conclusion that the transmission of certain emotional processes from one generation to the next is responsible for the development of schizophrenia in a family member. Terms used by Bowen to describe family functioning include the following:

(a) Differentiation: Differentiation is both intra- and interpersonal. The intrapersonal aspect is a person's ability to distinguish between his or her own feelings and thoughts. This ability makes it possible for the person to separate his or her own emotional and intellectual functioning from the functioning of others, which is the interpersonal aspect of differentiation. A person with a low level of differentiation becomes "emotionally fused" with other family members.

(b) Emotional Triangles: According to Bowen, when a family dyad experiences tension, it may recruit a third family member to form an emotional triangle which helps alleviate tension and increase stability. For example, a husband and wife may reduce the conflict between them by becoming overinvolved with one of their children. The likelihood that an emotional triangle will develop increases as the levels of differentiation of family members decrease.

(c) Family Projection Process: The family projection process refers to the parents' projection of their emotional immaturity onto their children, which causes the children to have lower levels of differentiation.

(d) Multigenerational Transmission Process: The multigenerational transmission process is an extension of the family projection process and refers to the transmission of emotional immaturity from one generation to the next. It occurs when the child most involved in the family's emotional system becomes the least differentiated family member and, as an adult, chooses a spouse or partner who has a similar level of differentiation. This couple then transmits an even lower level of differentiation to one of its children. This process continues in subsequent generations and eventually results in the development of severe symptoms in a child.

Bowen believed that increasing differentiation in one family member facilitates greater differentiation in other family members. Consequently, Bowenian therapists often see only two family members in therapy - usually the parents - or the individual family member who is most capable of increasing his or her level of differentiation. The primary goal of therapy is to increase each family member's differentiation, and several strategies are used to achieve this goal: Therapy begins with an assessment that includes constructing a genogram that depicts family relationships and important life events for at least three generations and is used to help family members understand intergenerational patterns of functioning. During therapy, Bowenian therapists ask questions that are designed to defuse emotions and help family members identify how they contribute to family problems. They also teach family members how to interact with their families-of-origin in ways that alter triangulated relationships. Bowenian therapists assume the role of coach and stay connected with family members but remain neutral and avoid becoming involved in the family's emotional processes. To reduce emotional reactivity, they have family members talk directly to them rather than to each other.

Two. Structural Family Therapy: Minuchin's structural family therapy is based on the assumption that a family member's symptoms are related to problems in the family's structure, and identifies subsystems and boundaries as important aspects of a family's structure: Subsystems are smaller units of the entire family system that are responsible for carrying out specific tasks. For instance, the parental subsystem consists of family members who are responsible for caring for the children. Boundaries are implicit and explicit rules that determine the amount of contact that family members have with each other. Boundaries differ in terms of degree of permeability and exist on a continuum: At one end of the continuum are boundaries that are overly diffuse and lead to enmeshed relationships; at the other end are boundaries that are overly rigid and lead to disengaged relationships. Midway between the two are clear boundaries that let family members have close relationships while allowing each member to maintain a sense of personal identity.

Minuchin identified four rigid family triads, which are boundary problems that help parents obscure or deny their conflicts: (a) A stable coalition occurs when one parent and a child form an inflexible alliance against the other parent. (b) An unstable coalition is also known as triangulation and occurs when each parent demands that the child side with him or her. (c) A detouring-attack coalition occurs when parents avoid the conflict between them by blaming the child for their problems. (d) A detouring-support coalition occurs when parents avoid their own conflict by overprotecting the child.

For practitioners of structural family therapy, maladaptive behaviors are due to a dysfunctional family structure that causes the family to repeatedly respond inappropriately to developmental and situational stress. The primary goals of therapy are to alleviate current symptoms and change the family structure by altering coalitions and creating clear boundaries. Therapy focuses on promoting behavior change rather than insight and consists of three overlapping phases - joining, evaluating, and intervening: (a) Joining is used by a therapist to establish a therapeutic alliance with the family and relies on three techniques: Mimesis involves adopting the family's affective, behavioral, and communication style; tracking involves adopting the content of the family's communications; and maintenance entails providing family members with support. (b) A therapist's next task is to evaluate the family's structure to make a structural diagnosis and identify appropriate interventions. Evaluation includes constructing a family map that depicts the family's subsystems, boundaries, and other aspects of the family's structure. (c) The therapist then uses reframing, unbalancing, boundary making, enactment, and other interventions to achieve therapy goals: Reframing involves relabeling a problematic behavior so it can be viewed in a more constructive way. Unbalancing is used to alter hierarchical relationships and occurs when the therapist aligns with a family member whose level of power needs to be increased. Boundary making is used to alter the degree of proximity between family members. And enactment involves asking family members to role-play a problematic interaction so the therapist can obtain information about the interaction and then encourage family members to interact in an alternative way.

Three. Strategic Family Therapy: Haley's strategic family therapy is based on the assumptions that struggles for power and control in relationships are core features of family functioning and that "a symptom is a strategy that is adaptive to a current social situation for controlling a relationship when all other strategies have failed. It also assumes that power and control are determined primarily by hierarchies within a family and that maladaptive family functioning is often related to unclear or inappropriate hierarchies.

The primary goal of therapy is to alter family interactions that are maintaining its symptoms. To achieve this goal, strategic family therapists assume an active role and use a variety of strategies that are aimed at changing behavior rather than instilling insight. The initial session is highly structured and consists of four stages: During a brief social stage, the therapist welcomes the family and observes the family's interactions. Next is the problem stage, in which the therapist elicits each family member's view of the family problem and its causes. In the interactional stage, family members discuss their different views of the family's problem, and the therapist observes how family members interact when addressing the problem. In the final goal-setting stage, the therapist helps family members agree on a definition of the family's problem and concrete therapy goals that target the problem.

During subsequent sessions, the therapist uses a combination of straightforward and paradoxical directives. Straightforward directives are instructions to engage in specific behaviors that will change how family members interact. Paradoxical directives help family members realize that they have control over problematic behavior or use the resistance of family members to help them change in the desired way. They include prescribing the symptom, restraining, and ordeals: Prescribing the symptom involves instructing family members to engage in the problematic behavior, often in an exaggerated way. Restraining involves encouraging family members not to change or warning them not to change too quickly. And an ordeal is an unpleasant task that a family member is asked to perform whenever he or she engages in the undesirable behavior.

Four. Milan Systemic Family Therapy: Milan systemic family therapy is based on the assumption that "the family as a whole protects itself from change through homeostatic rules and patterns of communication." Patterns of communication are referred to as family games, and family games associated with problematic behaviors are rigid, involve power struggles between family members, and are known as "dirty games." Leading contributors to systemic family therapy include Salvini-Palazzoli, Boscolo, Ceechin, and Prata.

The primary goal of therapy is to alter the family rules and communication patterns that are maintaining problematic behavior. This involves providing the family with information that challenges family games and helps family members develop communication patterns that increase the family's ability to adapt to change. Milan systemic family therapy is distinguished from other family therapies by its use of a therapeutic team and five-part therapy sessions (pre-session, session, intersession, intervention, and post-session) and gaps between therapy sessions of four to six weeks. Strategies include hypothesizing, neutrality, circular questioning, positive connotation, and family rituals: Hypothesizing is "a continual interactive process of speculating and making assumptions about the family situation." The first hypotheses are based on information obtained in the initial telephone interview, and hypotheses are modified during therapy as new information about the family's functioning is acquired. Neutrality refers to the therapist's interest in the family's situation and acceptance of each family member's perception of the problem. Circular questioning involves asking each family member the same question to identify differences in perceptions about events and relationships and uncover family communication patterns. For example, a therapist might ask each member, "When mom is depressed, what does Dad do?" Positive connotation is a type of reframing that helps family members view a symptom as beneficial because it maintains the family's cohesion and well-being. Its purpose is to change the family's perception of a symptom from an individual family member's illness to, instead, a behavior that's voluntarily controlled and well-intentioned and involves the entire family system. Family rituals are activities that are carried out by family members between sessions and are designed to alter problematic family games. For example, when parents are competitive in their control of children's behaviors or family events, the therapist might instruct the mother to make all family decisions on odd-numbered days and the father to make all family decisions on even-numbered days.

Five. Conjoint Family Therapy: Satir's conjoint family therapy is also known as the human validation process model and was influenced by humanistic psychology and communication and experiential approaches to family therapy. According to Satir, family systems seek a state of balance, with family problems arising when balance is maintained by unrealistic expectations, inappropriate rules and roles, and dysfunctional communication. With regard to the latter, Satir distinguished between four dysfunctional communication styles: Placating involves agreeing with or capitulating to others due to fear, dependency, and a desire to be loved and accepted. Blaming involves accusing, judging, and bullying others to avoid taking responsibility and to hide feelings of vulnerability and worthlessness. Computing involves taking an overly intellectual and rational (super-reasonable)

approach to avoid becoming emotionally engaged with others. Distracting involves changing the subject and making inappropriate jokes to distract attention and avoid conflict. Satir also identified a congruent (or leveling) style, which is a functional style that's characterized by congruence between verbal and nonverbal messages, directness and authenticity, and emotional engagement with others.

The primary goal of conjoint family therapy is to enhance the growth potential of family members by increasing their self-esteem, strengthening their problem-solving skills, and helping them communicate congruently. Satir viewed the therapist's "use of the self" as the most important therapeutic tool and proposed that therapists have multiple roles when working with clients, including facilitator, mediator, advocate, educator, and role model. She also used several techniques to achieve therapy goals, including family sculpting (which involves having each family member take a turn positioning other family members in ways that depict his or her view of family relationships) and family reconstruction (which is a type of psychodrama that involves role-playing three generations of the family to explore unresolved family issues and events).

Six. Narrative Family Therapy: Practitioners of narrative family therapy consider a person's problems "as arising from, and being maintained by, oppressive stories which dominate the person's life," and they view these stories as being socially constructed. They also assume that the problem - not the person - is the problem. In other words, the problem is not internal to the person but is something that exists outside the person. For example, instead of saying that a family member is depressed, a narrative family therapist would say that depression sometimes causes problems for the person. The leading contributors to narrative family therapy include White and Epston.

The primary goal of narrative family therapy is to replace problem-saturated stories with alternative stories that support more satisfying and preferred outcomes. The process of therapy varies somewhat among practitioners but generally involves the following stages: (a) Meeting family members involves getting to know them separate from their problems by asking them about their interests and everyday activities. (b) Listening involves paying attention to what family members say to identify dominant discourses and unique outcomes, which are also known as "sparkling moments" and are experiences that are not consistent with problem-saturated stories. (c) Separating family members from their problems involves externalizing the problems. (d) Enacting preferred narratives involves identifying alternative stories that lead to more satisfying realities and identities. (e) Solidifying involves strengthening alternative stories by, for example, writing letters of support to family members and expanding the family's network of social relationships to include individuals who will support its new stories.

A narrative family therapist assumes the role of collaborator and uses questions and other techniques to help family members identify current stories and construct alternative, healthier ones: For instance, externalizing questions are used to help clients view their problems as being outside themselves, while opening space questions help family members identify unique outcomes. Asking a family member what his anger tells him to do is an example of an externalizing question, and asking family members if there have ever been times when conflicts didn't control their lives is an example of an opening space question. Other interventions include therapeutic letters, therapeutic certificates, and definitional ceremonies: The therapist writes therapeutic letters to family members to reinforce their emerging alternative stories. Therapeutic certificates are given to family members toward the end of therapy to acknowledge their accomplishments. And definitional ceremonies provide family members with opportunities to tell others how they overcame their problems and celebrate the changes they've made in their lives.

Seven. Emotionally Focused Therapy: Emotionally focused therapy, also known as EFT, is a brief evidence-based treatment that integrates principles of attachment theory, humanistic-experiential approaches, and systems theory. It was originally developed as a treatment for couples but has also been applied to families and individuals. As a couple's intervention, EFT was designed to help emotionally distressed partners who want to strengthen their relationship and stay together. EFT for couples is contraindicated when the partners have different agendas for their relationship or therapy, when the therapist believes that emotional vulnerability is not safe or advisable (e.g., when there is ongoing physical abuse in the relationship), or when a partner has an untreated substance use disorder. (Note that the terms "emotionally focused therapy" and "emotion-focused therapy" are sometimes used interchangeably but that the two differ, with the latter referring to various therapies that emphasize emotion as the target of change.)

EFT is based on the assumptions that (a) emotions are essential to the organization of attachment behaviors and influence how people experience themselves and their partners in intimate relationships, (b) the attachment needs of partners are essentially healthy and adaptive but problems arise when needs are enacted in the context of attachment-related insecurities, and (c) relationship distress is maintained by the ways in which interactions between partners are organized and by the dominant emotional experiences of each partner. Practitioners of EFT assume that helping partners express and deal with their emotions is the fastest and most effective way to solve problems, and the primary goal of therapy is to expand and restructure the emotional experiences partners have with each other so they can develop new interactional patterns and experience attachment security within their current relationship. Therapy involves three stages: assessment and cycle de-escalation,

changing interactional positions and creating new bonding events, and consolidation and integration.

The potential usefulness of eye movement desensitization and reprocessing in couples therapy was first addressed by Shapiro, and it has subsequently been integrated into several approaches to couple therapy including EFT. For example, Eberro and Sommers-Flanagan have described how EMDR and EFT can be combined as a treatment for couples who were affected by war trauma, and Knox conducted a study to investigate the effectiveness of the combined treatment for members of this population. His study involved comparing outcomes for couples who received EFT only, EMDR only, combined EFT and EMDR, or no treatment. Knox found that couples in the combined EFT and EMDR group experienced the greatest improvement in marital satisfaction and attachment security, while those in the EMDR only group had the greatest reduction in posttraumatic symptoms.

Eight. Functional Family Therapy: Functional family therapy is an evidence-based treatment for at-risk adolescents (e.g., those who have conduct disorder and/or a substance use disorder) and their families. It incorporates elements of structural, strategic, and behavioral family therapy, and it is based on the assumption that problematic behaviors within a family serve important relationship functions - i.e., they regulate interpersonal connections and relational hierarchies. Consequently, the primary goal of FFT is to replace problematic behaviors with nonproblematic behaviors that fulfill the same relationship functions. Therapy ordinarily involves eight to thirty sessions over a three- to six-month period, and it consists of three stages: During the engagement and motivation stage, emphasis is on forming a therapeutic alliance with family members and helping family members reduce feelings of hopelessness and negativity, increase positive expectations for change, and develop a family-focused understanding of its presenting problems. Techniques used during this stage include joining and reframing. Once family members are engaged and motivated, the behavior change stage begins. During this stage, immediate and long-term behavioral goals are identified and an individualized treatment plan for the family is implemented. Techniques used during this stage include training in parenting, communication, problem-solving, and coping skills. During the final generalization stage, the focus is on linking family members to community resources and helping them generalize their acquired skills to new problems and situations and identify ways to avoid relapse.

Nine. Multisystemic Therapy: Multisystemic therapy is an evidence-based treatment that was originally developed for adolescent offenders at risk for out-of-home placement and their families, but it has subsequently been adapted for adolescents with other serious clinical problems including psychiatric disturbances, substance abuse, and childhood maltreatment. MST is based on Bronfenbrenner's ecological model which views individuals as being embedded in and influenced directly and indirectly by multiple systems. Consequently, it focuses "on the specific individual, family, peer, school, and social network variables that contribute to a youth's presenting problems, and on interactions between these factors linked with the presenting problems." The MST model includes nine treatment principles that are applied using an analytic process (the "MST Do-Loop") that structures the development, implementation, and evaluation of the treatment plan. The core principles are finding the fit between identified problems and their broader systemic context; focusing on positives and strengths; increasing responsibility; being present-focused, action-oriented, and well-defined; targeting behavior sequences; using developmentally appropriate interventions; encouraging continuous effort; stressing evaluation and accountability; and promoting generalization.

MST is provided in the family's home and community settings where problems occur, and it incorporates interventions derived from strategic and structural family therapy, behavior therapy, and cognitive-behavior therapy. It targets factors that are driving problem behaviors. For example, when an assessment indicates that the drivers of an adolescent's daily marijuana use are low parental monitoring of the adolescent's behavior and ineffective discipline, the adolescent's poor social skills and friendships with peers who use drugs, and the availability of drugs in the adolescent's neighborhood, these factors will be addressed in therapy. MST is delivered by a multidisciplinary team that is tailored to the adolescent's and family's target behaviors. For an adolescent with academic and conduct problems, frequent use of marijuana and cocaine, and a recent arrest for cocaine possession, the team will likely include a caseworker, family therapist, substance abuse counselor, and other individuals who will work with the adolescent in the adolescent's school and neighborhood. Research has confirmed that the effectiveness of MST is reduced when treatment fidelity is low (i.e., when MST is not implemented as intended). Consequently, a quality assurance system is used to promote treatment fidelity. System components include initial and booster training of therapists; ongoing supervision and consultation; measures that evaluate the adherence of the therapist, supervisor, and consultant to the MST model; and a program implementation review that is completed every six months by the supervisor and expert consultant.

Group Therapy: For the exam, you want to be familiar with the formative stages of group therapy and the therapeutic factors provided by group therapy.

One. Formative Phases of Group Therapy: According to Yalom and Leszcz, therapy groups usually experience three overlapping formative stages: During the initial orientation, hesitant participation, search for meaning, and dependency stage, group members are concerned with clarifying the nature and purpose of the group and depend on the leader for structure, acceptance, and answers to their questions. Interactions between members often focus on describing symptoms and previous treatments and involve giving and seeking advice. Next is the conflict, dominance, and rebellion stage. In this stage, members compete for power and control and attempt to establish a pecking order. Members tend to be critical of each other, and some may become hostile and resentful toward the therapist as they become aware that they're not going to become the therapist's "favorite child." The final formative stage is the development of cohesiveness stage. In this stage, conflict between group members decreases, and cohesiveness increases as members begin to trust each other and the therapist. Members may reveal the real reason why they have come to therapy and show concern when a member is absent or drops out of therapy. The development of cohesiveness marks the beginning of a mature group that can deal effectively with the concerns and problems of group members.

Two. Therapeutic Factors: Yalom and Leszcz describe eleven therapeutic factors that are responsible for the effects of group therapy: group cohesiveness, instillation of hope, universality, altruism, imparting information, development of socializing techniques, corrective recapitulation of the primary family group, interpersonal learning, imitative behavior, catharsis, and existential factors. Of these factors, group cohesiveness is considered to be the analogue of the therapeutic alliance in individual therapy, is viewed as a precondition for the other therapeutic factors, and has been most consistently found to be a strong predictor of positive group therapy outcomes.

Beck's Cognitive-Behavior Therapy: Beck's cognitive behavior therapy was originally developed as an intervention for depression and is now considered to be an evidence-based treatment not only for depression but also for bipolar disorder, generalized anxiety disorder, anorexia nervosa, bulimia nervosa, schizophrenia, obsessive-compulsive disorder, PTSD, and a number of other psychiatric disorders. It has also been found useful as an adjunct treatment for chronic pain. For example, there is evidence that, for patients with rheumatoid arthritis, CBT is useful not only for reducing comorbid depression and anxiety but also for improving coping skills and self-efficacy and reducing pain intensity and fatigue, especially when CBT is provided early in the course of the disease.

CBT is based on the assumption that psychological disturbance is due largely to maladaptive cognitive schemas, automatic thoughts, and cognitive distortions:

(a) Cognitive schemas are core beliefs that develop during childhood as the result of experience and certain biological factors such as biological reactivity to stress. Schemas are enduring, can be maladaptive or adaptive, and are revealed in automatic thoughts. Beck proposed that different disorders are associated with different maladaptive schemas, which are also known as cognitive profiles. According to Beck, the cognitive profile for depression consists of negative beliefs about oneself, the world, and the future.

(b) Automatic thoughts are verbal self-statements or mental images that "come to mind spontaneously when triggered by circumstances ... [and] intercede between an event or stimulus and the individual's emotional and behavioral reactions." Automatic thoughts can be positive or negative. Negative automatic thoughts are characterized by a distortion of reality, emotional distress, and/or interference with the pursuit of life goals and can contribute to psychological distress. Practitioners of CBT often have clients record negative automatic thoughts outside therapy in a Dysfunctional Thought Record (DTR) whenever they feel their mood is worsening. When using a DTR, the client records the event or situation that led to an unpleasant emotion, the automatic thoughts that preceded the emotion, the type of emotion and its intensity on a scale from zero to one hundred, an alternative rational response to the automatic thought, and the outcome (the emotion and any change in behavior elicited by the rational response).

(c) Cognitive distortions are systematic errors in reasoning that often affect thinking when a stressful situation triggers a dysfunctional schema that, in turn, affects the content of automatic thoughts. Common distortions include arbitrary inference, selective abstraction, dichotomous thinking, personalization, and emotional reasoning: Arbitrary inference involves drawing negative conclusions without any supporting evidence. Selective abstraction involves paying attention to and exaggerating a minor negative detail of a situation while ignoring other aspects of the situation. Dichotomous thinking is the tendency to classify events as representing one of two extremes - for example, as a success or a failure. Personalization involves concluding that one's actions caused an external event without evidence for that conclusion. And emotional reasoning is reliance on one's emotional state to draw conclusions about oneself, others, and situations.

The primary goals of CBT are "to correct faulty information processing and to help patients modify assumptions that maintain maladaptive behaviors and emotions." Practitioners of CBT adopt an active, structured approach and use a variety of cognitive and behavioral techniques to achieve these goals. Cognitive techniques include redefining the problem, reattribution, and decatastrophizing; behavioral techniques include activity scheduling, behavioral rehearsal, exposure therapy, and guided imagery (which is used to facilitate relaxation and decrease anxiety and pain). An essential feature of CBT is its reliance on collaborative empiricism, which is "a collaborative therapeutic alliance between the therapist and client in which they become coinvestigators as they examine the evidence to accept, support, reevaluate, or reject the client's thoughts, assumptions, intentions, and beliefs." Another feature is the use of Socratic dialogue, which involves asking the client questions that are designed to clarify and define the client's problems, identify the thoughts and assumptions that underlie those problems, and evaluate the consequences of maintaining maladaptive thoughts and assumptions.

Other Cognitive-Behavioral Interventions: For the exam, you also want to be familiar with the following cognitive-behavioral interventions.

One. Rational Emotive Behavior Therapy: Ellis's rational emotive behavior therapy (REBT) attributes psychological disturbances to irrational beliefs, which tend to be "absolute (or dogmatic) and are expressed in the form of 'must's, 'should's, 'ought's, 'have to's, etc... and lead to negative emotions that largely interfere with goal pursuit and attainment." "I must do well on all of the important projects I take on; if not, I'm an inadequate person" and "You must take care of me when I need you to do so; if not, you're not a good person" are examples of irrational beliefs.

Ellis uses an A-B-C-D-E model to explain psychological disturbance and the process of change in therapy: A is an activating event, B is the client's irrational belief about that event, C is the emotional or behavioral consequence of that belief, D is the therapist's use of techniques that dispute the client's irrational belief, and E is the effect of these techniques, which is the replacement of the irrational belief with a more rational one. Practitioners of REBT use a variety of cognitive, behavioral, and emotive techniques, including active disputation of irrational beliefs, rational-emotive imagery, systematic desensitization, and skills training. Research has found that REBT is an effective treatment for depression, anxiety, conduct problems, anger, and several other disorders and conditions.

Two. Self-Instructional Training: Self-instructional training (Meichenbaum, nineteen seventy-seven) was initially developed to teach problem-solving skills to children with high levels of impulsivity but has since been applied to other populations and problems. It consists of five stages: During the initial cognitive modeling stage, children observe a model perform a task while the model verbalizes instructions aloud. In the second overt external guidance stage, children perform the same task while the model verbalizes the instructions. Next is the overt self-guidance stage in which children perform the task while verbalizing the instructions aloud themselves. This is followed by the faded overt guidance stage in which children perform the task while whispering the instructions. And finally, during the covert self-instruction stage, children perform the task while repeating the instructions subvocally. The instructions used by the model and children while performing the task address four skills: identifying the nature of the task, focusing attention on the task and the behaviors needed to complete it, providing self-reinforcement that sustains appropriate behavior, and evaluating performance and correcting errors.

Three. Stress Inoculation Training: Stress inoculation training (Meichenbaum, nineteen ninety-six) focuses on improving the ability of clients to deal better with ongoing and future stressful situations by teaching them effective coping skills. It consists of three phases. During the initial conceptualization/education phase, clients are provided with information about stress and its effects and are encouraged to view stressful situations as "problems-to-be-solved." In the skills acquisition and consolidation phase, clients learn a variety of cognitive and behavioral coping skills which may include relaxation, self-instruction, and problem-solving. Finally, during the application and follow-through phase, clients use newly acquired coping skills, first in imagined and role-playing situations and then in real life situations.

Four. Acceptance and Commitment Therapy: Acceptance and commitment therapy (ACT) is based on the assumptions that "psychological pain is both universal and normal and is part of what makes us human" and that psychological inflexibility causes psychological problems and is characterized by a "rigid dominance of psychological reactions over chosen values and contingencies in guiding action." With regard to pain, ACT distinguishes between clean and dirty pain: Clean pain is also known as clean discomfort and refers to natural levels of physical and psychological discomfort that are inevitable and cannot be controlled. Dirty pain is also known as dirty discomfort and refers to the emotional suffering that's caused by attempts to control or resist clean pain.

The main goal of acceptance and commitment therapy is to increase psychological flexibility, which involves addressing six core processes that foster acceptance, mindfulness, commitment, and behavior change and counter the processes that contribute to psychological inflexibility: Experiential acceptance counters experiential avoidance and is "the active and aware embrace of private experiences without unnecessary attempts to change their frequency or form".

Cognitive defusion counters cognitive fusion and is the ability to distance oneself from one's thoughts and feelings and view them as experiences rather than reality. Being present counters attentional rigidity to the past and future and involves being in contact with whatever is happening in the present moment. Awareness of self-as-context counters attachment to the conceptualized self. It's the ability to view oneself as the context in which one's thoughts and feelings occur rather than as the thoughts and feelings themselves. Values-based actions counter unclear, compliant, or avoidant motives and depend on the ability to use one's freely chosen values to guide one's behaviors. And committed action counters inaction, impulsivity, and avoidant persistence and refers to a commitment to continue to act in ways consistent with one's values in the future, even when faced with obstacles. Interventions target these six processes and include metaphors, mindfulness strategies, and experiential exercises. Acceptance and commitment therapy is considered to be an evidence-based treatment for a number of conditions including chronic pain, psychosis, depression, anxiety disorders, and obsessive-compulsive disorder.

Five. Mindfulness-Based Interventions: Mindfulness refers to "moment-to-moment awareness of one's experience without judgment". It has been incorporated into several therapeutic approaches including acceptance and commitment therapy and dialectical behavior therapy and is the core strategy of mindfulness-based stress reduction and mindfulness-based cognitive therapy. Mindfulness-based stress reduction was originally developed "to make mindfulness meditation available and accessible in a Western medical setting while remaining true to the essence of Buddhist teachings". It's used to help people cope with stress, pain, and illness and consists of an eight-session group program that focuses on teaching participants several mindfulness meditation practices including awareness of breathing, yoga, and sitting and walking meditation.

Mindfulness-based cognitive therapy combines elements of mindfulness-based stress reduction and cognitive-behavioral therapy. It was originally developed as a method for treating recurrent depression, and research has confirmed that it's an effective treatment not only for depression but also for a number of other conditions including anxiety, chronic pain, and insomnia. The primary goal of mindfulness-based cognitive therapy is to "enable clients to become self-aware, so they can learn to de-centre from distressing thoughts, feelings, bodily sensations and behaviours". It incorporates psychoeducation, mindfulness meditation practices, and cognitive-behavioral techniques and, like mindfulness-based stress reduction, usually consists of an eight-session group program.

Based on their meta-analysis of research on the effectiveness of mindfulness-based interventions, Khoury and his colleagues concluded that they are effective for treating both psychological disorders and physical/medical conditions but are more effective for psychological disorders, especially depression, anxiety, and stress. Research has also been conducted to identify the change mechanisms that account for the beneficial effects of these interventions. A frequently cited systematic review and meta-analysis of this research conducted by Gu et al. found that there is consistent and strong research support for decreased emotional and cognitive reactivity as the change mechanism, moderate support for increased mindfulness and decreased rumination and worry, and insufficient support for increased self-compassion and psychological flexibility.

Six. Cognitive-Behavioral Therapy for Suicide Prevention: There are several versions of cognitive-behavioral therapy for suicide prevention: Wenzel, Brown, and Beck's cognitive therapy for suicide prevention is a brief intervention that was designed to prevent repeat suicide attempts by adults who recently attempted suicide. It consists of three phases: conceptualization of the suicidal mode and developing a safety plan; acquisition of cognitive, behavioral, and affective coping skills; and consolidation of coping skills and relapse prevention. Bryan's cognitive-behavioral therapy for suicide prevention is a brief treatment for suicidal patients, while Bryan and Rudd's brief cognitive-behavioral therapy for suicide prevention is a version of cognitive-behavioral therapy for suicide prevention for active-duty members of the military. Cognitive-behavioral therapy for suicide prevention and brief cognitive-behavioral therapy both focus on emotion regulation, cognitive flexibility, and relapse prevention. Finally, Stanley et al.'s cognitive-behavioral therapy for suicide prevention was developed for adolescents who recently attempted suicide and combines elements of cognitive-behavioral therapy and dialectical behavior therapy. It consists of acute and continuation phases that include individual and family sessions: The acute phase consists of chain analysis (identification of events that led to the suicide attempt), safety planning, psychoeducation, addressing reasons for living, and case conceptualization. The continuation phase focuses on generalizing and consolidating behavioral and cognitive skills and relapse prevention.

Safety planning is an essential component of cognitive-behavioral therapy for suicide prevention. For example, Stanley and Brown developed a safety planning intervention that can be used as a component of cognitive-behavioral therapy or as a stand-alone intervention in emergency departments or other emergency situations or any other time when longer-term care is not feasible or available. The safety planning intervention consists of six steps that start with the use of internal strategies and switch to external strategies when internal strategies do not work: One. recognizing the warning signs of an imminent suicidal crisis, Two. using internal coping strategies (e.g., going for a walk, reading a book), Three. utilizing social contacts as a means of distraction or support, Four. contacting family or friends who may help resolve the crisis, Five. contacting mental health professionals or agencies, and Six. reducing access to lethal means. Note that a safety plan is not the same as a no-suicide contract, which is a verbal or written agreement that requires clients to promise they will abstain from attempting suicide. While research has found the safety planning intervention and other safety plans to be useful for reducing suicidality, there is no empirical evidence supporting the use of no-suicide contracts.

Finally, with regard to effectiveness, there is evidence that cognitive-behavioral therapies for suicide prevention reduce suicidal ideation and suicide attempts, feelings of hopelessness, and depression. The research has also found that these benefits occur regardless of a person's gender, severity of suicidal ideation, and number of suicide attempts.

Prevention: The most frequently cited models of prevention were developed by Gerald Caplan and Robert Gordon.

One. Caplan's Model: Caplan distinguished between three types of prevention: primary, secondary, and tertiary.

(a) The goal of primary prevention is to reduce the occurrence of new cases of a mental or physical disorder. Primary preventions are aimed at an entire population or group of individuals rather than specific individuals, and the population or group may or may not be restricted to people who are known to be at elevated risk for the disorder. Examples are a public education program about depression and suicide, a school-based program for fifth graders to prepare them for the transition to middle school, and prenatal care for low-income mothers.

(b) The goal of secondary prevention is to reduce the prevalence of a mental or physical disorder in the population through early detection and intervention. Secondary preventions are aimed at specific individuals who have been identified as being at elevated risk for the disorder. Providing tutoring to elementary school students who are beginning to have academic difficulties and using a screening test to identify individuals at risk for depression and then providing identified individuals with counseling are secondary preventions.

(c) The goal of tertiary prevention is to reduce the severity and duration of a mental or physical disorder. Tertiary preventions target people who have already received a diagnosis of a mental or physical disorder and include relapse prevention and rehabilitation programs. Social skills training for patients with schizophrenia, halfway houses, and Alcoholics Anonymous are tertiary preventions.

Two. Gordon's Model: Gordon's model distinguishes between universal, selective, and indicated prevention: Universal preventions are aimed at entire populations or groups that are not restricted to individuals who are at risk for a disorder. A drug abuse prevention program for all high school students in a school district is a universal prevention. Selective preventions are aimed at individuals who have been identified as being at increased risk for a disorder due to their biological, psychological, or social characteristics. A drug abuse prevention program for adolescents whose parents have a substance use disorder is a selective prevention. Indicated preventions are for individuals who are known to be at high-risk because they have early or minimal signs of a disorder. A drug abuse prevention program for adolescents who have experimented with drugs is an indicated prevention.

The Institute of Medicine expanded Gordon's model to create a continuum of care model that includes prevention, treatment, and maintenance. In this model, universal, selective, and indicated preventions are restricted to people who have not received a diagnosis of a mental or physical disorder. Treatment strategies are aimed at people who have received a diagnosis, and maintenance strategies are for people who have received treatment for a disorder and focus on preventing chronicity or relapse and/or providing rehabilitation.

Mental Health Consultation: Caplan distinguished between four types of mental health consultation. Each type consists of a triad that includes a consultant, a consultee (therapist or program administrator), and a client or program.

One. Client-Centered Case Consultation: This type of consultation focuses on a particular client of the consultee who is having difficulty providing the client with effective services (e.g., is having trouble identifying an appropriate treatment). The consultant's goal is to provide the consultee with a plan that will benefit the client.

Two. Consultee-Centered Case Consultation: Consultee-centered case consultation focuses on the consultee with the goal of improving his or her ability to work effectively with current and future clients who are similar in some way - e.g., clients with traumatic brain injury, clients from a specific racial or ethnic minority group. The goal of this type of consultation is to improve the consultee's knowledge, skills, confidence, and or objectivity. Caplan identified several factors that contribute to a consultee's lack of objectivity. One of these is theme interference, which occurs when a consultee's biases and unfounded beliefs interfere with his or her ability to be objective when working with certain types of clients.

Three. Program-Centered Administrative Consultation: This type of consultation involves working with program administrators to help them clarify and resolve problems they are having with an existing mental health program. The consultant's goal is to provide administrators with recommendations for dealing with the problems they have encountered in developing, administering, and or evaluating the program.

Four. Consultee-Centered Administrative Consultation: Consultee-centered administrative consultation focuses on improving the professional functioning of program administrators so they are better able to develop, administer, and evaluate mental health programs in the future.

Mental health consultation differs from collaboration in several ways. For example, a consultant has little or no direct contact with a consultee's client and is not responsible for the client's outcomes. In contrast, a collaborator usually has direct contact with the client and shares responsibility for the client's outcomes.

Interprofessional collaboration: Interprofessional collaboration is a partnership between a team of health providers and a client in a participatory collaborative and coordinated approach to shared decision making around health and social issues. Dragan and Marino note that interprofessional collaboration most often occurs in primary care settings where it serves three primary functions: improvement of patient care, improvement of health outcomes for patients, and decreased healthcare costs.

However, reviews of the research suggest that the effects of interprofessional collaboration in primary care settings are inconsistent. For example, in their overview of previous systematic reviews of interprofessional collaboration in primary care, Carron et al. report that, while most studies confirm that interprofessional collaboration has positive effects on clinical outcomes, the process of care, and patient satisfaction, the research has provided mixed results with regard to its effects on quality of life; physical, emotional, and social functioning; and health behaviors and practices.

Interprofessional collaboration is considered to be particularly useful for addressing the multiple and complex healthcare needs of older patients, and it is often referred to as integrated care in research involving members of this population. Results of this research provide some evidence that integrated care for older patients is associated with improved access to care; increased patient satisfaction with services provided; and fewer emergency department visits, hospitalizations, and long-term care placements.

Efficacy and Effectiveness Research: Much of the empirical research evaluating psychotherapy outcomes can be categorized as efficacy research or effectiveness research. Efficacy research studies are also known as clinical trials and maximize internal validity (the ability to draw conclusions about the cause-effect relationship between therapy and outcomes) by maximizing experimental control. For example, participants are randomly assigned to groups in these studies and therapists use treatment manuals to ensure that treatment is provided in the same way to all participants. In contrast, effectiveness research studies maximize external validity (the ability to generalize the conclusions drawn from the study to other people and conditions) by providing therapy in naturalistic clinical settings. Both approaches have strengths and weaknesses, and a useful strategy for evaluating treatment outcomes is to first conduct an efficacy study to determine a treatment's effectiveness in well-controlled conditions, and then conduct an effectiveness study in real world settings to determine its generalizability, feasibility, and cost-effectiveness.

Psychotherapy Outcome Research: Frequently cited research on psychotherapy outcomes include studies conducted by Eysenck; Smith, Glass, and Miller; and Howard and his colleagues.

One. Eysenck: Hans Eysenck is probably best known for his conclusions about intelligence and personality: He proposed that intelligence is due primarily to heredity, with about eighty percent of variability in IQ scores being due to genetic factors. His personality theory also stresses the role of heredity and distinguishes between three major personality traits: extroversion, neuroticism, and psychoticism. Eysenck is also known for his controversial conclusions about the effectiveness of psychotherapy, which were based on his review of twenty-four empirical studies that reported treatment outcomes for "neurotic" patients who participated in psychoanalytic or eclectic psychotherapy. Because the studies did not include no-treatment control groups, Eysenck used other studies to estimate the spontaneous remission rates of neurotic patients who received custodial care in an inpatient facility or medical care from a physician. Based on this data, Eysenck concluded that forty-four percent of patients who participated in psychoanalytic psychotherapy, sixty-four percent of patients who participated in eclectic psychotherapy, and seventy-two percent of patients who did not participate in psychotherapy experienced an improvement in symptoms. He proposed that these results not only showed that psychotherapy is ineffective but that it may actually have detrimental effects since the average recovery rates for psychotherapy patients were lower than the average spontaneous remission rate for patients who did not receive psychotherapy.

Eysenck's conclusions were challenged by advocates of psychotherapy who pointed out that his study had several methodological flaws. For example, Luborsky noted that the comparisons Eysenck made were questionable because patients were not randomly assigned to groups and, consequently, initial differences in patient characteristics could account for at least some of the differences in recovery rates. In addition, Bergin noted that the criteria Eysenck used to determine recovery were questionable and found that use of different criteria produced a recovery rate of eighty-three percent for patients who participated in psychoanalytic psychotherapy and thirty percent for patients who did not receive psychotherapy.

Two. Smith, Glass, and Miller: Eysenck's article generated a great deal of research on psychotherapy outcomes, and Smith, Glass, and Miller were the first to use meta-analysis to combine the results of studies that compared the outcomes of patients who received psychotherapy to the outcomes of patients in either a no-treatment control group or an alternative (non-therapy) treatment group. Their analysis included four hundred seventy-five studies and produced a mean effect size of point eight five, which means that the average patient who received psychotherapy was "better off" than eighty percent of patients who did not receive psychotherapy. An effect size indicates the mean difference between groups in terms of a standard deviation, and an effect size of point eight five indicates that the mean outcome score for patients who participated in psychotherapy was point eight five standard deviation above the mean outcome score for patients who did not receive psychotherapy. In a normal distribution, eighty-four percent of scores are below a standard deviation of one point zero, and eighty percent (slightly less than eighty-four percent) are below a standard deviation of point eight five. Note that, for the exam, you just need to remember that an effect size of point eight five means that the average patient who received psychotherapy was better off than eighty percent of patients who didn't receive therapy. You do not need to understand why this is so, but we've included the explanation for those of you who are curious about the interpretation of an effect size of point eight five.

Three. Howard and Colleagues: Howard and his colleagues investigated the relationship between the duration of psychotherapy and its outcomes. Based on the results of their research, they developed two models to describe this relationship:

(a) The dosage model is also known as the dose-effect model and states that there's a predictable relationship between number of therapy sessions and the probability of measurable improvement in symptoms. Specifically, it predicts that fifty percent of therapy clients can be expected to exhibit a clinically significant improvement in symptoms by six to eight sessions, seventy-five percent by twenty-six sessions, and eighty-five percent by fifty-two sessions.

(b) The phase model proposes that psychotherapy outcomes can be described in terms of three phases: The initial remoralization phase occurs during the first few sessions and is characterized by an increase in hopefulness. This is followed by the remediation phase, which occurs during the next sixteen sessions and involves a reduction in symptoms. The final rehabilitation phase involves "unlearning troublesome, maladaptive, habitual behaviors and establishing new ways of dealing with various aspects of life (e.g., problematic relationship patterns, faulty work habits, and trouble-causing personal attitudes)" . An implication of this model is that different outcome measures should be used during different phases of therapy - i.e., measures of subjective well-being during the remoralization phase, the severity and frequency of symptoms during the remediation phase, and life functioning during the rehabilitation phase.