Abnormal Psychology - Clinical Persps. on Psych. Disorders, 6th ed. - R. Halgin, et. al., (McGraw-Hill, 2010 WW-86-90

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establish rapport with him, and he, in turn, must feel com- mitted to working with her. Another short-term goal might be to stabilize Peter on medication, so that his symptoms will be alleviated.

Long-term goals are the ultimate aims of therapeutic change. Ideally, the long-term goals for any client are to overcome the problem and to develop a strategy to prevent recurrence. In reality, these goals are diffi cult to achieve. The restructuring of a personality can be a lifelong endeavor.

With the help of Dr. Tobin, Peter will need to plan his life, taking his disorder into account. For example, Dr. Tobin may advise Peter to take medication aimed at preventing a recurrence of his symptoms. He may also need to prepare himself for some of the ways this disorder may affect his life.

In addition, Peter will have to work with Dr. Tobin to deal with the emotional scars he has suffered as a result of his disorder and the troubled childhood caused by his mother’s disorder.

A treatment plan, then, includes a set of goals for short- and long-range interventions. Having established these goals, the clinician’s next task is to specify how to implement the plan. This requires decisions regarding the optimal treatment site, the treatment modality, and the theoretical perspective on which the treatment is based.

Treatment Site

The severity of the client’s problem is one of the fi rst issues a clinician considers in deciding what kind of treatment site to recommend. Treatment sites vary in the degree to which they provide a controlled environment and in the nature of the services they offer to clients. Treatment sites include psychiatric hospitals, outpatient treatment settings, halfway houses and day treatment centers, and other treatment sites, such as the school or workplace, that provide mental health services. The more serious the client’s disturbance, the more controlled the environment that is needed and the more in- tense the services.

The severity of the client’s symptoms is assessed on several dimensions. Is the client suicidal, at risk of harming others, delusional, or otherwise incapable of maintaining control?

Does the client have physical problems, such as those that might result from a brain dysfunction, an eating disorder, or illness? What is the client’s support system at home? Are people there who can help the client deal with the problems caused by the disorder and its symptoms? Further, the clinician must be sensitive to the fi nancial resources available to the client. In an age in which cost-effectiveness is of major concern to insurance companies, treatment decisions are commonly dictated by a need to pursue the least expensive care. The clinician’s recommendation of a treatment site is also based on the match between the client’s needs and the services provided in a particular treatment setting. Depending on how clinical and fi nancial issues are addressed, the clinician will recommend a psychiatric hospital, outpatient treatment, or a halfway house or group home that provides a combination of services.

Psychiatric Hospitals The decision to hospitalize a client depends largely on the risk the client presents. A clinician usually recommends that the client be admitted to a psychiatric hospital when the client is at risk of harming self or others or seems incapable of self-care. Although some clients choose inpatient psychiatric care quite willingly, there must be demonstrable clinical need and evidence that the client presents a risk in order for this very expensive form of treatment to be covered by insurance or public programs. Often, clients who are at high risk of harm to self or others are involuntarily hospitalized by a court order until their symptoms can be brought under control (this is discussed in more detail in Chapter 15).

Hospitalization is also recommended for clients who have disorders that require medical interventions and inten- sive forms of psychotherapeutic interventions. Some medical interventions, such as a trial on a new drug regimen, are best done in a hospital setting, where the risks of potential side effects and treatment effi cacy can be monitored continuously.

Some psychotherapeutic interventions are also best done in a setting where the contingencies of the client’s behavior can be monitored and reinforced by trained personnel. For example, a young man prone to violent outbursts may require an

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At this crisis center, telephone counselors are available 24 hours a day.

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60 Chapter 2 Classifi cation and Treatment Plans

environment in which he is rewarded when he is quiet and is responded to aversively when he loses control.

In some cases, the clinician might recommend a special- ized inpatient treatment center. Such a treatment site would be appropriate for adults with substance abuse problems or for children and adolescents who need professional treatment in a residential setting.

Returning to the case of Peter, a hospital would be the treatment site of choice, because he is a threat to others, he needs medication monitoring, and the hospital could offer him various forms of therapy. As he improves, Dr. Tobin will develop a discharge plan that will undoubtedly include outpatient care.

Outpatient Treatment Because hospitalization is such a radical and expensive intervention, most clients receive outpatient treatment, in which they are treated in a private professional offi ce or clinic. Professionals in private practice offer individual or group sessions, usually on a weekly basis.

Some prepaid health insurance plans cover the cost of such visits, either to a private practitioner or to a clinician working in a health maintenance organization (HMO). Outpa- tient treatment may also be offered in agencies supported partially or completely by public funds. Community mental health centers (CMHCs) are outpatient clinics that provide psychological services on a sliding fee scale for individuals who live within a certain geographic area.

Outpatient services are, by necessity, more limited than those in a hospital, in terms of both the time involved and the nature of the contact between client and clinician. How- ever, additional services may be made available to clients who need vocational counseling, help with domestic man- agement, group therapy, or the support of a self-help organization, such as Alcoholics Anonymous.

Halfway Houses and Day Treatment Programs Clients with serious psychological disorders who are able to live in the community need more services than can be provided through conventional outpatient treatment. For such individuals, halfway houses and day treatment programs are the most appropriate treatment sites. These facilities may be connected with a hospital, a public agency, or a private corporation. Halfway houses are designed for clients who have been discharged from psychiatric facilities but who are not yet ready for independent living. A halfway house provides a living context with other deinstitutionalized people, and it is staffed by professionals who work with clients in developing the skills they need to become employed and to set up independent living situations. Day treatment programs are designed for formerly hospitalized clients as well as for clients who do not need hospitalization but do need a structured program during the day, similar to that provided by a hospital. Many day treatment programs are based on a social club model. Some of the clients who participate in day treatment programs reside

in halfway houses and some live independently, with rela- tives or in apartments supervised by paraprofessional mental health workers.

Other Treatment Sites Psychological treatment is also provided in settings not traditionally associated with the pro- vision of mental health services, such as the schools and the workplace. Guidance counselors and school psychologists are often called on to intervene in cases in which a student is emotionally disturbed or is upset by a pathological living situation. These professionals handle much of the intervention in the school, but they often fi nd it necessary to refer the student or family for outside professional help. In the workplace, many employers have recognized the importance of intervening in the lives of employees whose emotional problems are interfering with their job performance and could possibly result in termination from employment. A common program is the Employee Assistance Program (EAP) provided by most large companies. The EAP provides the employee with a confi dential setting in which to seek help for emotional problems, substance abuse diffi culties, or relationship problems. Often the EAP professional can work with the employee toward a resolution of the problem; at times, the EAP professional can help the employee locate appropriate treatment resources for the problem at hand.

Guidance counselors are often the ﬁ rst professionals to whom troubled students turn for professional assistance.

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Modality of Treatment

The modality, or form in which psychotherapy is offered, is another crucial component of the treatment plan. In indi- vidual psychotherapy, the therapist works with the client on a one-to-one basis. Typically, the therapist and client meet on a regular schedule—most commonly, once a week for about an hour. In couple therapy, partners in a relationship both participate, and, in family therapy, several or all of the family members are involved in the treatment. In family therapy, one person may be identifi ed by family members as being the “patient.” The therapist, however, views the whole family system as the target of the treatment. Group therapy provides a modality in which troubled people can openly share their problems with others, receive feedback, develop trust, and improve interpersonal skills.

Milieu therapy, which has been found to be helpful for hospitalized clients, is based on the premise that the milieu, or environment, is a major component of the treatment; a new setting, in which a team of professionals works with the client to improve his or her mental health, is considered to be better than the client’s home and work environments, with their stresses and pressures. Ideally, the milieu is constructed in such a way that clients will perceive all interactions and contexts as therapeutic and constructive. In addition to traditional psychotherapy, other therapeutic endeavors are made through group or peer counseling, occupational therapy, and recreational therapy.

The clinician’s decision to recommend a particular modality of treatment is based, again, on a match between the client’s specifi c needs and the treatment’s potential to meet these needs. For example, a teenage girl with an eating disorder may be seen in both individual therapy and family therapy if the clinician believes that the eating disorder is rooted in disturbed parent-child interactions. As this example

illustrates, the clinician has the option of recommending multiple modalities, rather than being restricted to one form of therapy. We will discuss the modalities in more detail in Chap- ter 4, along with their conceptual underpinnings.

In Peter’s case, three treatment modalities would be recommended, at least in the initial phase of his treatment.

Along with his individual therapy needs, Peter would benefi t from both family therapy and group therapy. Family therapy would be useful in helping Peter develop his support system with his mother and brother, and group therapy would provide Peter with the opportunity to interact with and derive support from other clients who have similar disorders.

Determining the Best Approach to Treatment

Whatever modality of treatment a clinician recommends, it must be based on the choice of the most appropriate theoretical perspective or the most appropriate aspects of several different perspectives. Many clinicians are trained according to a particular set of assumptions about the origins of psychological disorders and the best methods of treating these disorders. Often, this theoretical orientation forms the basis for the clinician’s treatment decisions. However, just as fre- quently, clinicians adapt their theoretical orientation to fi t the client’s needs. Further, the growing movement toward integrating diverse theoretical models in treatment planning is addressing the concerns of clinicians who feel that a single theoretical model is too narrow. Increasingly, clinicians are combining the best elements of various theoretical orienta- tions in tailoring the treatment plan to have the greatest likelihood of success for a given client (Chambless & Ollen- dick, 2001).

Determining the approach for treating each disorder is a complex matter, about which there has been considerable debate in the past several decades. You might assume that

In family therapy, all members of the family participate in treatment.

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62 Chapter 2 Classifi cation and Treatment Plans

most psychotherapists treating a given disorder would use a standard intervention, but, in fact, this is not the case. Con- sider a client with major depressive disorder. Some clinicians would recommend a brief intervention that focuses on the client’s distorted thoughts. Other clinicians would suggest that the client engage in lengthy psychotherapy to explore early life experiences that caused or contributed to adult depression. Still others would dispense with talk therapy and recommend antidepressant medication. And others would integrate components of each of these approaches.

Which treatment method is the most effective, and how can effectiveness be measured? In an effort to answer these questions, psychotherapy researchers have devoted considerable effort in recent years to reviewing all published outcome studies on specifi c disorders. From these efforts to identify empirically supported treatments have emerged treatment recommendations called practice guidelines (Nathan, 1998).

Although the process of developing practice guidelines might seem straightforward and relatively uncontroversial, these efforts have unleashed a storm of controversy.

Even though efforts to designate the most effective treatments have been admirable, these efforts have not yielded the simple solutions that experts had hoped would be found. To shed some light on the complexity of the issues, Martin Seligman, a leading psychotherapy researcher, has attempted to highlight some of the differences between research that is conducted in laboratory settings—effi cacy research—and outcome studies involving people who have sought professional help in a traditional helping context—effectiveness research (Seligman, 1995). Effi cacy studies are commonly conducted in university-based clinics, where therapists are carefully selected, trained, and monitored; patients are also carefully screened in order to exclude those with multiple problems (DeRubeis & Crits-Cristoph, 1998).

Seligman contends that what is measured in effi cacy studies has only a slight resemblance to what takes place in a real-world therapy setting. In the real world, clients are not assigned to random groups for fi xed durations and treated according to a predetermined script. Furthermore, rarely does a client’s diagnosis fi t neatly into one clearly delineated category. For example, a client with major depressive disorder may also have a personality disorder, an eating disorder, and a sexual dysfunction. In such a case, which practice guidelines would be followed? Seligman points out that, in effectiveness research, investigators study therapy as it is practiced in the fi eld. Therapy is conducted without a manual; patients may have several presenting problems, and they are choosing therapists in whom they believe.

Wampold (2001) joined the debate about what makes psychotherapy work by comprehensively reviewing decades of psychotherapy research. Wampold concluded that common factors, rather than specifi c technical ingredients, are most important. In other words, the many specifi c types of psychotherapeutic treatment achieve comparable benefi ts because of a common core of curative processes. Following a harsh critique of empirically supported treatments, Wampold

recommends that therapists and supervisors should deempha- size manual-based treatments and instead choose the therapy that accords with a client’s worldview.

Evidence-based practice in psychology is the term that has emerged to characterize clinical decision-making that inte- grates the best available research evidence and clinical exper- tise in the context of the cultural background, preferences, and characteristics of clients (APA, 2005). In other words, clinicians should base their treatments on state-of-the-art research fi ndings that they adapt to the particular features of the client, taking into account the client’s background, needs, and prior experiences. These criteria are now being used as the basis for curricula in graduate programs and post-doctoral continuing education (Collins, Leffi ngwell, & Belar, 2007;

Spring, 2007).

As you read about various disorders in this book, and the treatments that have been demonstrated as most effective, it will be important to keep in mind the empirical basis for the treatment conclusions. Findings from effi cacy studies shed light on appropriate interventions, but they are insuf- fi cient for making conclusive determinations about what is most effective with real people with complex problems.

Experienced clinicians recognize the importance of imple- menting treatments that have, time and again, been shown to be effective. McCabe (2004) recommends a four-step approach by which intelligent decisions based on scientifi c knowledge should be used in the treatment process. The clinician should (1) formulate a clear clinical question by conceptualizing the client’s problem with suffi cient specifi city to match the treatment with the most relevant practice guidelines, (2) search the literature for relevant clinical research articles, (3) appraise the scientifi c rigor of the research, and (4) replicate the intervention with as much fi delity to the original approach as possible.

REVIEW QUESTIONS

1. What are community mental health centers (CMHCs)?

2. _____________ research on psychological disorders is

conducted in laboratory settings, as compared with ____

______ research involving people who have sought psychological interventions in a traditional helping context.

3. What are the three components of evidence-based

treatment?

Treatment Implementation

When the diagnostic process and treatment planning have taken place, the clinician then implements the treatment.

Despite all the thinking and preparation that have gone into this plan, though, the exact way in which treatment unfolds varies according to the characteristics of the clinician, the client, and the interaction between the two. There are many individual variations among both clients and clinicians.

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Consequently, the potential for variation is virtually unlim- ited in the interactions between any one client and any one clinician. Some common issues, though, characterize all therapeutic interactions.

Above and beyond whatever techniques a clinician uses to treat a client’s problems, the quality of the relationship between the client and clinician is a crucial determinant of whether therapy will succeed or not. A good clinician does more than coldly and objectively administer treatment to a client. A good clinician infuses a deep personal interest, concern, and respect for the client into the therapeutic relationship. In this regard, psychotherapy is as much an art as a skill.

The Course of Treatment

The way treatment proceeds is a function of the contributions made by the clinician and the client. Each has a part to play in determining the outcome of the case, as does the unique interaction of their personalities, abilities, and expectations.

The Clinician’s Role in Treatment One of the skills the clinician develops is an ability to scan the client-clinician interaction for meaningful cues that will provide insight into the nature of the client’s problems. An important piece of information the clinician gathers is the way the client seems to respond to the clinician. Let’s use Dr. Tobin as an example. Dr. Tobin is a woman in her early forties. Each of her clients forms a unique impression of the kind of person she is. One client thinks of Dr. Tobin as an authority fi gure, because Dr. Tobin’s mannerisms and appearance remind him of his seventh-grade teacher. Another client perceives Dr. Tobin as a peer, because they are about the same age and professional status. Another client is in his sixties, and Dr. Tobin reminds him of his daughter. Thus, the same clinician is perceived in three different ways by three different clients. With each client, Dr. Tobin has a markedly different basis for a therapeutic relationship.

Not only do clients have unique responses to Dr. Tobin, but she also has individualized responses to each client. As a professional, Dr. Tobin is trained to examine her reactions to each client and to try not to let her reactions interfere with her ability to help. Moreover, she has learned how to use her perception of each client and the way she thinks she is perceived as aids in diagnosing the client’s disorder and in embarking on a therapeutic procedure.

The Client’s Role in Treatment In optimal situations, psychotherapy is a joint enterprise in which the client plays an active role. It is largely up to the client to describe and identify the nature of his or her disorder, to describe personal reactions as treatment progresses, and to initiate and follow through on whatever changes are going to be made.

The client’s attitudes toward therapy and the therapist are an important part of the contribution the client makes to the therapeutic relationship. There is a special quality to

the help that the client is requesting; it involves potentially painful, embarrassing, and personally revealing material that the client is not accustomed to disclosing to someone else.

Most people are much more comfortable discussing their medical, legal, fi nancial, and other problems outside the realm of the emotions. Social attitudes toward psychological disorders also play a role. People may feel that they should be able to handle their emotional problems without seeking help. They may believe that, if they can’t solve their own emotional problems, it means they are immature or incom- petent. Moreover, having to see a clinician may make a person believe that he or she is crazy. You would not hesitate to tell your friends that you have an appointment with a physician because of a sore knee. Most people would, though, feel less inclined to mention to acquaintances that they are in psychotherapy for personal problems. The pres- sure to keep therapy secret usually adds to a client’s anxiety about seeking professional help. To someone who is already troubled by severe problems in living, this added anxiety can be further inhibiting. With so many potential forces driving the troubled individual away from seeking therapy, the initial step is sometimes the hardest to take. Thus, the therapeutic relationship requires the client to be willing to work with the clinician in a partnership and to be prepared to endure the pain and embarrassment involved in making personal revela- tions. Moreover, it also requires a willingness to break old patterns and to try new ways of viewing the self and relating to others.

The Outcome of Treatment

In the best of all possible worlds, the treatment works. The client stays through the treatment, shows improvement, and maintains this improved level of functioning. Many times, though, the road is not so smooth, and either the goals of the treatment plan are never attained or unanticipated problems arise. Some of the obstacles that clinicians face in their efforts to help clients include some curious and frustrating realities. The most frustrating involve the client who is unwill- ing to change. It may sound paradoxical, but, even though a client may seem terribly distressed by a problem, that client may fail to follow through on a very promising treatment.

Mental health professionals know that change is very diffi - cult, and many clients have become so accustomed to living with a problem that the effort needed to solve the problem seems overwhelming. At times, clinicians also face frustration over fi nancial constraints. They may recommend a treatment that they are quite confi dent can succeed but that is fi nan- cially infeasible. In other cases there may be an involved party, such as a lover or parent, who refuses to participate in the treatment, even though he or she plays a central role.

Other pragmatic issues can disrupt therapy: Clients may move, lose jobs, or lack consistent transportation to the clinic. Over time, those in the mental health fi eld learn that they are limited in how effective they can be in changing the lives of people who go to them for help.

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