Alternative Modes of Clinical Intervention

Alternative Modes of Clinical Intervention Dr. Kline FSU-PC

Socially Oriented Intervention Therapies • The traditional view of psychotherapy is a one-to-one relationship between a therapist & client. This model is still very popular & effective for individual counseling. • However, it many circumstances, counseling requires treating more than one person simultaneously for a given problem (or multiple problems). • Therefore, the need for therapies designed to treat multiple individuals (group therapy, family counseling) has increased substantially in the past 30 years.

Socially Oriented Clinical Interventions Intervention typeEmphasis Group Therapy Understand/alleviate problems in interpersonal relationships in a group setting. Couples Therapy Facilitate problem solving of intimate problems in couples. Family Therapy Change maladaptive & dysfunctional patterns in family systems to improve functioning. Psychosocial Improve clients’ abilities to cope with mental Rehabilitation disorders, live in the community, gain independence

Group Therapy • Focuses on treating multiple individuals in a group setting with a special emphasis on interpersonal relationships of the clients involved. E.g., Weight-control groups, assertiveness groups, alcoholics anonymous • Originally practiced at the turn of the 20th century (early 1900s), group therapy became a more common form of therapy due to a shortage of clinical personnel during WWII. • Its popularity skyrocketed in the 60s & 70s & is now considered a valid & well respected form of therapy.

Therapeutic Factors in Group Therapy • 1. Sharing New Information: more information about a given problem is available (and shared) in a group therapy setting than a one-on-one setting. This information comes from two sources: ***The leader of the group (i.e., the counselor) ***The other members of the group Because multiple viewpoints are available & shared in this setting, a more comprehensive picture of the problem emerges. Moreover, a given member of the group will have more difficulty dismissing the opinions of the group members compared with the sole opinion of the group leader. (Power in numbers!!!!)

2. Instilling Hope: • In group therapy, individual members may be “optimistic” they will progress in their treatment, because they are encouraged by the progress other group members have made. • Additionally, a given member of the group may discover he or she has made improvements in their treatment because such progress has been pointed out to them from other group members. • Evidence of the progress either one has made or the progress that has been made by other members both work to increase motivation & commitment to the group therapy sessions.

3. Universality: • Because individual members in group therapy have the opportunity to see other members experiencing the same or similar problems, a sense of cohesion develops among the members. • That is, an individual member doesn’t have to feel isolated, alone, and “uniquely” the only person to have dealt with this problem before. • Seeing other individuals struggling with the same issues offers comfort to clients who thought this was something only they had the burden of experiencing (e.g., bereavement, parents of children with problems, etc.).

4. Altruism: • Individual group members may play the role of therapist to other group members. • This offers each individual member an opportunity to facilitate another members progress. • Being able to promote the well-being of other group members, improves the self-esteem of the individual members who contribute to such positive events.

5. Interpersonal learning: • An interesting by-product of the group therapy setting is the opportunity for individual members to practice their social skills. • Given that social skills may be part of a given client’s problems, this “safe” setting offers members the chance to “practice” their responses to others with constructive feedback.

6. Recapitulation of the Primary Family: • The therapist leading the group may view the group therapy dynamic as a model for the clients’ families. • This dynamic provides the therapist & members with an opportunity to “reenact” the problems/dysfunctions found in the clients’ family backgrounds. • This concept is the group therapy version of transference which is found in the one-one-one counseling settings (Neitzel et al., 2003).

7. Group Cohesiveness: • As groups develop and grow, the members become more cohesive. • Cohesiveness (the strength of the bond among the group members) promotes more disclosure, acceptance of other members, & counteracts the feelings of inadequacy & anxiety many individual members experience. • Cohesiveness appears to be the most important factor in the positive effects of the group.

Practicing Group Therapy: How it works!! • 1. Number of members: Generally groups will consist of 6 -12 members. • 2. Variability of group members: may be small or large depending on the group format: **Homogenous groups have members who are similar in age, sex, type of problem, etc. (e.g., WWII Veteran’s group). This is in contrast to heterogeneous groups who differ in these & other characteristics (e.g., AA members). 3. Length of Meetings: meetings for group therapy tend to be longer than individual counseling (e.g., 2 hours or more) because more time is needed for individual members to talk during the meetings. Also more time is needed for significant progress to occur.

Marital and Family Therapy • Both marital & family counseling settings focus on dysfunctional relationships in couples, marriages, & families. • Couples therapy focuses on dyads and the interactions that occur within the relationship of two people. • Family therapy treats some or all the members of a given family unit (often goes hand-in-hand with couples therapy).

Couples Therapy Reasons why couples seek counseling Sexual Dissatisfaction Intimacy problems Personal autonomy/identity issues Financial problems Child care responsibility issues Communication issues Dominance-Submission issues Argument style Fidelity

Couples Therapy-Why & How it works Although couples therapy may be the main form of therapy for helping couples with relationship difficulties, it can also be combined with other treatment techniques to address other issues. For instance, a couple may go to counseling, when one of the partner’s is having “other” problems in their life (e.g., alcohol/drug use, depression, anxiety, or some other problem that effects the relationship). When both partners go through counseling at the same time, this is called conjoint therapy. However, a couple may go through couples counseling with the same therapist, but at different times. ***Goals of therapy depend on the problem the couple is dealing with and the orientation of the therapist.***

Couples Therapy & therapist’s orientation: • 1. Behaviorist approach: here therapists focus on changing couples’ communication style so that the couple can address their problems with reduced hostility. To do this, the therapist may require that couples learn how to replace hostile comments with benign ones that convey information (e.g., no name calling). Therapists may even give out a list of words/phrases that are acceptable to use in discussions. Couples may also be required to create and sign a contract (called a Behavioral Exchange) that spells out what each partner wants and what each partner should do once an action of his/her “wish list” has been produced by the other partner.

2. Cognitive-Behavioral approach: • Therapists urge couples to change the way they think about their relationships. That is, change the maladaptive beliefs (attributions) they have about their partner. • For instance, if one or both members of a couple are invested in “blaming” the other partner for the problems in the relationship, its very unlikely they could work on resolving real conflicts fairly (a zero-sum game, everybody loses). • Therapists with this orientation, aim to teach each partner how to focus on improving communication with their partners to reduce distortion of the other partners’ motives, changing problem behaviors in the relationship, and improving how they view the other partner.

3. Humanistic Approach: • Therapists with this orientation try to promote the overall feelings of well-being in the couple’s relationship. • Here, therapists will try to get couples to focus on the positive emotional bonds that once brought them together as well as what’s good in their relationship. • Strengthening positive feelings for each other may “buffer” the couple from the painful aspects of therapy where they have to resolve the problem that brought them to therapy. • If a partner is disarmed and their hostility level reduced, they may be more open to the honest comments made by the other partner.

4. Eclectic Approach: • Therapists today often use a variety of methods from different orientations to treat couples and families. • Regardless of the therapist’s orientation, the goal of most couples counseling is on problem solving. • This usually entails training couples on how to effectively communicate their feelings, thoughts, and wishes to their partner. • Factors that are also examined are: **Couples accepting mutual responsibility for issues in relationship. **Releasing grudges/focusing on the present **Express preferences, not demands or ultimatums **Agreeing to a compromise on issues where both parties disagree.

Family Therapy-Goals • The goal of family therapy is to modify maladaptive family interactions to correct family dysfunctions. • This form of therapy became popular when it was observed that clients treated in individual therapy sessions in hospital settings relapsed when they returned to their families. • Therapists made the connection between individual psychopathology & its relationship to dysfunctional family systems (e.g., link between dysfunctional families & substance use disorders).

Differences between family & individual therapy • Family therapy is based on “systems theory” which emphasizes three major points: • Circular causality: events are interrelated & mutually dependent (not a simple cause-effect relationship). Each family member’s behavior has an impact on another member in the family. • Ecology: Systems are integrated patterns. Thus, a change in one family member’s behavior has an effect on all the other members. • Subjectivity: Family members each have their own perception of family events (i.e., subjective).

Family Therapy (Systems approach model)

How Family Therapy Works • Family therapy is usually initiated because one family member has a problem that effects the family as a whole. • Frequently, the family member with the problem is an adolescent male child with behavior problems that the parents identify as a “problem,” or a teenage girl with an eating disorder (Nietzel, et al., 2003). • Family therapists need to identify what family communication issues may be causing/exacerbating the problem (e.g., the “identified” child is often the scapegoat for the families difficulties). • Therapists adopt a variety of methods to treat family problems, starting with improving and clarifying communication among the family members as well as reducing blaming behavior that is so pervasive in these types of situations (strategic family therapy).

Family Therapy Techniques • 1. Behavioral: Teach family members appropriate ways to communicate. Parents are instructed to be consistent in their discipline methods as well as interactions with their children. • 2. Strategic: Train family members to focus on family problem instead of the individual family member with a problem. The goal here is to reduce scapegoating, and promote problem solving. • 3. Intergenerational Family therapy: here the therapist intentionally limits direct family interaction during sessions. This is done to reduce overall anxiety while forcing the focus on the problems and not on any one person in the family. • 4. Narrative or Constructionist: Therapist has each family member describe what their individual role is within the family system. Theoretically, making family members explicitly describe their roles forces them to take responsibility for their actions within the family system.

Diagnosing Marital & Family problems • Unlike individual counseling, where clinicians assess and diagnose their client’s problems using the DSM, there is no gold standard for diagnosing relationship problems. • There is one source for making diagnoses on interpersonal problems, but its fairly recent and not widely accepted yet. • This source is: Handbook of Relational Diagnosis and Dysfunctional Family Patterns by Koslow, (1996), where 30 diagnostic categories for relationship problems are presented.

Psychosocial Rehabilitation • The high efficacy of medications used to treat severe psychopathology (schizophrenia, bipolar disorder, etc.) has resulted in reduced abnormal symptomatology & greater level of functioning. • In fact, antipsychotics & other meds have resulted in the release of thousands of patients from mental institutions across the country. • Problematically, once these “treated” patients are released they are unprepared for the demands of functioning in normal life & many stop using their medications resulting in a relapse of their symptoms.

Psychosocial Rehabilitation (contd.) • The intervention field of psychosocial rehabilitation was developed to teach patients with psychopathology (e.g., schizophrenia) how to cope in society. • To do this, patients are taught a variety of skills needed for daily life as well as the need to stay on their medication.

Four components of Psychosocial Rehabilitation • 1. Teach individuals about the nature of their psychopathology and how to deal with it. **teach patients how to recognize onset of maladaptive symptoms **educate patient’s how to self-monitor their moods. **avoid situations that might put patient at risk (drug use) **educate patients about taking their medications regularly. • Educate patients how to live in the community. **obtaining medical care **using public transportation **obtaining a job **Assist patients in acquiring housing **teach patients how to buy groceries & cook for themselves **educate patients on social skills needed for interacting with others

3. Case management: a staff member helps patients obtain services related to employment, housing, medical care, finances, etc. • 4. Treatment is promoted by these types of clinicians by maintaining an alliance with mental health professionals, family, and patients (Nietzel et al., 2003). • **Self-help groups may be formed to promote and offer treatment.

Levels of Preventive Interventions • 1. Tiertiary Prevention: clinicians aim to lessen frequency & severity of disorder in patients. This is mainly dealt with via psychosocial rehabilitation. • 2. Secondary Prevention: interventions for individuals at risk for developing a disorder. Assessment & detection of early onset of symptoms is crucial here. • 3. Primary Prevention: eliminating/reducing disorders’ occurrence by changing environmental contingencies or strengthening patients to reduce vulnerabilities to disorder. These programs aim to counteract factors promoting risk for individuals with a diathesis for a given disorder.

Primary Prevention programs • 1. Encouraging Secure Attachments & reducing family violence. • 2. Teaching cognitive & social skills • 3. Modifying environments • 4. Enhancing stress & coping skills • 5. Promoting empowerment

Alternative Modes of Clinical Intervention