Psychotherapy Brown Bag

February 2010 Psychotherapy Brown Bag Featured Article: Is There a Research-Practice Gap? Not if You Listen to APA…

by Scott O. Lilienfeld, Ph.D.

Is there a gap between the research evidence concerning the most effective psychological techniques and the implementation of these techniques in routine clinical practice?  As is so often the case, the answer depends on whether we view the glass as half full or half empty.  Nevertheless, any reasonable evaluation of the survey evidence raises serious cause for concern.  This issue is of far more than academic importance.  If large proportions of practitioners are relying on treatment and assessment methods that have found to be wanting or have been insufficiently researched, they are placing thousands, perhaps tens of thousands, of mental health consumers at risk. 

The magnitude of research-practice gap, presuming it exists, has assumed new urgency with the recent publication of an influential, widely publicized, and controversial monograph by Timothy Baker, Richard McFall, and Varda Shoham (2009) (click here for PBB's coverage of this article) and published in Psychological Science in the Public Interest.  The core message of the Baker et al. report is that the state of psychology education, training, and practice is akin to the pre-scientific state of medical education prior to the 1910 Flexner report, which radically revamped the state of training in medical schools. 

What do survey data on the use of scientifically supported interventions among psychologists and other mental health professionals indicate?  Such surveys, we must acknowledge, have their methodological shortcomings.  They are based on potentially unrepresentative samples (clinicians who are willing to complete them) and self-reported information.   If anything, both limitations seem likely to underestimate the prevalence of scientifically unsupported techniques: Therapists who practice unscientifically may be reluctant to return surveys inquiring about their use of clinical techniques and to underreport their use of unscientific methods.  Bearing these caveats in mind, selected surveys of practitioners demonstrate that:

• Most therapists who treat clients with eating disorders do not use scientifically supported treatments for these conditions (i.e., cognitive-behavioral, behavioral, interpersonal therapies; Mussell, Crosby, Crowe et al., 2001).

• A half or more of doctoral-level licensed therapists who treat obsessive-compulsive disorder (OCD) do not use the clear-cut scientific treatment of choice for this condition, namely exposure and response (or “ritual”) prevention (Freheit, Swann, Vye, & Cady, 2004).  Instead, increasing numbers are using energy therapies and eye movement desensitization and reprocessing, neither of which have been scientifically supported for OCD (Freheit et al., 2004).  Similarly, only a half of licensed and provisionally licensed psychotherapists who treat patients with posttraumatic stress disorder use imaginal exposure, which is the most scientifically established treatment for this condition (Becker, Zayfert, & Anderson, 2004).   Moreover, fewer than 30% of these psychologists have even been trained in exposure techniques (Becker et al., 2004).

• One third of children with autism and autism-spectrum disorders receive scientifically unsupported interventions, like sensory-motor integration therapy and facilitated communication (Levy & Hyman, 2003), the latter of which appears to be mounting a major comeback in the media, if not in actual clinical practice (Wick & Smith, 2009).

• Approximately 25% of U.S. doctoral-level licensed psychotherapists routinely use two or more suggestive techniques, like repeated prompting and cuing, journaling, guided imagery, body work, and symptom interpretation, to recover purported memories of early abuse [Poole, Lindsay, Memon, & Bull, 1995; see Polusny & Folette, 1996, for comparable results among members of American Psychological Association (APA) Divisions 12 and 16]. 

• Thirty-nine percent of APA members who conduct clinical assessments “always or frequently” use human figure drawings in their practice despite consistent evidence that such drawings are invalid for the overwhelming majority of diagnostic purposes; 43% “always or frequently” use the Rorschach Inkblot Test despite consistent evidence that only a handful of the clinical inferences derived from this measure are empirically supported (Watkins, Campbell, Nieberding, & Hallmark, 1995).

• Among Division 12 members, 98% use clinical prediction in contrast to only 31% who use actuarial (statistical or mechanical) prediction methods, despite the increasing availability of the latter methods and overwhelming research evidence that actuarial prediction is almost always equal or superior to – and far less expensive than – clinical prediction.  Moreover, when asked why they do not use actuarial prediction methods, many practitioners provide factually unsupportable or conceptually confused responses, claiming that such methods are less accurate (32%),  more expensive (27%), or even less efficient (23%) than clinical methods (Vrieze & Grove, 2009). 

Regrettably, some of these data derive from the mid 1990s, and more recent systematic data are unavailable.  In particular, updated information on clinicians’ use of recovered memory and projective techniques is sorely needed.  Nevertheless, the data presented here are clearly worrisome, and suggest that although many practitioners – including APA members - have been using scientifically supported methods (the good news), hefty pluralities of them are not (the bad news).  These and other survey data, some of which Baker et al. (2009) cited, raise troubling questions concerning the scientific basis of our discipline.   They strongly suggest that the research-practice gap is genuine, and that many Americans are receiving suboptimal mental health care. 

So how has the field, in particular the APA, reacted to the Baker et al. (2009) monograph and to survey data demonstrating the existence of a marked research-practice gap among its membership?  Disappointingly, the APA’s response has overwhelmingly been to circle the wagons.  Steven Breckler (2010), Executive Director of APA’s Science Directorate, wrote that “Clinicians do rely on the science” and suggested that “the claim by Baker et al. that clinicians eschew science in favor of clinical experience is not very well founded” (note, however, that Breckler’s statement oversimplifies Baker et al.’s position, as they did not apply this description to all clinicians).  In response to a Newsweek article discussing the Baker et al. monograph, Katherine Nordal (2009), APA’s Director of Professional Practice, wrote that the claim that many or most clinicians do not learn or practice effective treatments is “certainly unclear and not backed with (sic) good evidence.” She continued: “The American Psychological Association has a code of ethics for its members that dictates psychologists must base their clinical judgments on scientific and professional knowledge. Licensed psychologists practice within their areas of expertise as required by state regulations and our ethical principles.”  Nordal’s assertions are remarkable for what they do not inform readers: Namely, that this feature of the APA ethics code is virtually never enforced, and that APA rarely, if ever, sanctions practitioners who practice unscientifically. 

And, in a letter to the New York Times taking issue with research evidence that most patients with major depression receive inadequate care, James Brush, former president of the Ohio Psychological Association, voiced a different view.  According to Brush (2010), the debate concerning evidence-based therapies needlessly pits researchers against practitioners given that most of the latter are already relying on good science to inform their treatments.  Moreover, Brush wrote, “It is also untrue that psychologists do not learn about evidenced-based treatments.  Nearly all psychologists in all states must take continuing education and are thereby exposed to the current research about psychological conditions and treatments.”  Yet Brush did not inform readers that there is no requirement that continuing education (CE) courses are grounded in adequate science. Nor did he mention that CE courses offered by APA-approved sponsors have included training in crisis debriefing, rebirthing, imago relationship therapy, Jungian sandplay therapy, and a plethora of other therapeutic methods devoid of scientific support.   Crisis debriefing, for example, has been found to be either worthless or harmful in treating trauma-exposed victims. 

Inexplicably, Breckler, Nordal, and Brush all neglected to discuss, let alone address, the survey data reviewed here.  As a consequence, they failed to rebut the central evidence on which concerns regarding the research-practice gap are based.  Breckler, for example, criticized Baker et al.’s interpretation of a vignette study asking clinicians to make hypothetical judgments about evidence, but ignored survey data regarding clinicians’ actual practices. 

APA’s defensive attitude to the data presented in the Baker et al. report is ultimately counterproductive.   APA would instead be wise to follow the lead of companies that have implemented quality improvement (QI) approaches premised on the philosophy that acknowledging errors, and rooting out these errors, is the best route to effective practice.  One of Honda’s credos, for example, is “Our customers are satisfied because we never are.”  Or witness Toyota’s recent response to the problem afflicting its accelerator pedals: It swiftly acknowledged the problem, apologized unequivocally to its customers, and instituted an around-the-clock policy to fix it.  Or Dominos’ Pizza recent admission that its pizza crust tasted “like cardboard” and needed to be replaced by a superior recipe. 

Rather than cavalierly dismissing criticisms of the scientific quality of clinical psychology, APA could benefit from a humbler approach that embraces the view that “We agree that we can and should do better, and we’re going to try.”   Nevertheless, the first step toward QI is an open admission of the need for improvement, an admission that APA seems reluctant to make – probably because it lacks the courage to ruffle the feathers of a sizeable proportion of its membership.   APA’s priority should rest not with protecting the feelings of its members, but with the mental health of the general public. 

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If you would like to learn more about this or other topics discussed on the site, PBB recommends that you consult their online store for scientifically-based psychological resources.

Scott Lilienfeld is a professor of psychology at Emory University

Cognitive behavioral therapy and relapse prevention - December 2009 Psychotherapy Brown Bag featured article

by John Ludgate, Ph.D.

There is a good deal of support in the literature (see a review by Hollon et al; 2006 ) for the idea that cognitive-behavioral approaches appear to reduce relapse rates in some emotional disorders, especially depression and anxiety. While this might be a reason for some pride and self-congratulation amongst CBT researchers and practitioners, there is really little room for complacency since a significant percentage of patients (approximately 20% to 35%) still experience a recurrence of symptoms (Ludgate, 1994). This may be an even more significant problem for clinicians because it is usually the case that patients treated in clinical practice will have more severe psychopathology than patients meeting the inclusionary criteria for research studies and so the relapse rates may actually be higher.

Therefore, despite lower relapse rates compared to other treatment modalities, relapse is still a significant problem in CBT.  As a consequence, it behooves clinicians to refine and evaluate relapse-prevention methods to counter this problem. In the field of cognitive behavioral treatment of depression and anxiety, we have lagged behind in the development of CBT for addictions where there has been a great deal of research and clinical emphasis on relapse-prevention beginning several decades ago (Marlatt & Gordon, 1985).  A number of writers in the field of CBT with emotional disorders have more recently described how maintenance and relapse-prevention can be built into a comprehensive treatment of depression and other disorders. (Wilson, 1992; Anthony et al, 2005; Ludgate, 2009). Some concrete suggestions for improving longer term outcome may involve incorporating mindfulness into cognitive therapy (Segal et al, 2002) or including a continuation or a maintenance version of cognitive therapy (CT) after remission. (Jarrett et al, 2001)

Some studies that have looked at the effectiveness of adding a continuation phase following acute CT treatment or incorporating mindfulness into cognitive therapy practice have shown very encouraging results in the treatment of depression. For example; Hollon et al (2005) conducted a study in which acute phase CT was followed by three booster sessions during a 12 month follow up. This treatment had enduring effects at 2 year follow up with 30% of these patients relapsing versus 76.2% of clients who received medication continuation.  Similarly, Bockingetal (2005) found that treating depressed clients in remission who were at high risk for relapse with continuation pharmacotherapy plus CT reduced the risk of relapse compared to continuation pharmacotherapy alone. This effect was even more pronounced when the number of previous depressive episodes was 5 or more, where the risk was reduced from 72% down to 42% at 2 year follow up. 

With patients who are in partial remission following pharmacotherapy and have some residual symptoms Paykel et al, (1999) found that adding CT significantly reduces their relapse probability relative to standard clinical management (29% versus 47%). Similarly, Fava and colleagues (1998) found that treating residual symptoms of depression and anxiety with CT following successful pharmacotherapy greatly reduced the risk of relapse compared to clinical management at three different follow up points: 2nd ,4th, and 6th year.   They reported that the average number of relapses/recurrences per patient was 0.8 in the CT treated patients versus 1.7 in the clinical management group.  In a study where the continuation version of CT was significantly different from the acute phase of CT, with more of an emphasis on generalization of skills and relapse prevention and maintenance, Jarrett et al (2001) found that adding 10 sessions of Continuation CT over an eight months period after remission resulted in a 10% relapse rate at 2 year follow up compared to 31% with acute phase CT only. 

An interesting and stimulating development in clinical research into relapse prevention in CBT treatment has been the addition of mindfulness techniques, based on the work of Kabat-Zinn (1990), to standard cognitive therapy. Teasdale et al (2000) found that mindfulness based cognitive therapy (MBCT) reduced relapse by about half compared to treatment as usual. It was found to be especially effective in reducing relapse in patients with three or more previous episodes (36 and 37% versus 67 and 78%). 

Knowledge of predictors of relapse or sustained recovery can guide good clinical practice in terms of relapse-prevention.  For example, studies done on dysfunctional attitudes and relapse (Eaves & Rush, 1984; Ludgate, Reinecke, & A. T. Beck, 1987) suggest that, unless maladaptive attitudes or beliefs are identified and modified in therapy, patients who have improved symptomatically may still be at risk for relapse after treatment. Some research shows that psychotherapy that produces symptom relief only rather than also targeting belief-change may be a less than adequate treatment in terms of long term outcome (Ludgate, 1991). Again, in the same vein of incomplete or less than adequate treatment, the study mentioned earlier by Paykel and colleagues (1999) attests to the importance of dealing with residual depressive symptoms in ensuring good long term outcome.

Although no studies have addressed this issue empirically, it seems likely that inadequate conceptualization and the application of CBT in a rigid, over-technical manner is associated with a higher risk of relapse because core and idiosyncratic problems are not identified and addressed.  Consequently, there is a need for a comprehensive case assessment based on a biopsychosocial risk analysis to ensure well planned and appropriate treatment.  The importance of sophisticated case conceptualization as a means of maximizing treatment gains and preventing relapse needs to be underscored (Ludgate, 1994).

Research in depression treatment outcome has consistently found that adverse life events effect longer-term outcome negatively (Ludgate, 1991). Subsequently effective CBT should target skills for dealing with adverse life events and facilitating the setting up of a good resource system, including having emotional and social support available from others, which has also been found to act as a buffer to stress and relapse in these clients.

Finally, the focus on a skills training approach with the patient to become his or her own therapist would appear to be important in guiding clinical practice.  This emphasis is consistent with self efficacy research (Bandura, 1977) and with process research in CT (Barber & DeRubeis, 1989).  This research suggests that compensatory skills (i.e., skills to curtail negative thinking) are the process by which patients both overcome problems and prevent relapse.  Also, in keeping with this model, Ludgate (1991) found that patients' perception of their skill in using CT strategies on their own after therapy was the most powerful predictor of positive outcome over a 5-year period.

In summary, some of the following factors, which are considered important in the relapse process, can be targeted for intervention in a comprehensive cognitive behavioral treatment approach:

• The patient's personal resources and skills and his or her perception of these variables.

• External resources including support systems such as family, friends, community, and professional help, and the perception of these resources after treatment.

• Life events/stressors and the patient's perceptions of these events

• Residual symptoms that exist at the end of treatment

• Residual or continuing cognitive deficits or distortions such as dysfunctional beliefs or biased information processing

Although many writers in the CBT field stress the importance of building maintenance and relapse prevention into treatment, little specific information exists as to how this can be achieved in routine clinical practice. From a number of sources outlined earlier, the following appear to be the most promising strategies:

• Beginning early in therapy, stress the goal of making the client his/her own therapist

• Promote internal attributions of change

• Increase client activity level and responsibility more and more as therapy proceeds

• Place greater emphasis on between session activity as therapy enters middle and later stages  

• Work on a variety of targets

• Train in general skills and in vivo where possible

• Get the client to practice skills beyond criterion/overlearn

• Enlist significant others in therapy where possible and feasible

• Fade frequency of sessions later in therapy

• Help client plan a self-therapy program to be pursued after termination

• Educate regarding relapse and create realistic expectations regarding the future course of the disorder

• Discuss the need for and benefits of maintenance efforts

• Anticipate and plan for high risk situations

• Help client recognize early warning signals of possible relapse

• Generate and rehearse an emergency plan in the event of future setbacks

• Modify the environment, if possible to support new behaviors and set up a support system to buffer future adverse life events if they occur

• Use booster sessions

These and other therapeutic interventions aimed at relapse prevention are more fully described in Ludgate (2009) Cognitive-Behavioral Therapy and Relapse Prevention for Depression and Anxiety, published by Professional Resources Exchange.

If you would like to learn more about these topics, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.

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John Ludgate is a licensed psychologist who has practiced psychotherapy for over 30 years.  He was trained by and subsequently worked with Aaron Beck and has been an author on a number of books and peer-reviewed journal articles.  You can learn more about Dr.Ludgate and his North Carolina-based practice at his website: www.behaviortherapist.com.

November 2009 Psychotherapy Brown Bag Featured Article - Joan Cook and James Coyne discuss the dissemination of EMDR

 

by Joan Cook, Ph.D. and James Coyne, Ph.D.

The following is an e-interview by Joan Cook and James Coyne.  The two influential psychologists discuss the dissemination of EMDR, what it means for the proponents of other therapeutic approaches, and what their experience was in publishing a paper on these topics.

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You recently published an article in Professional Psychology that by its title alone is likely to attract controversy. What was your purpose in conducting the study and what were your most interesting results?

Cook: The title, “Comparative Case Study of Diffusion of Eye Movement Desensitization and Reprocessing in Two Clinical Settings: Empirically Supported Treatment Status Is Not Enough,” was intended to be a bit provocative. Interested readers of Psychotherapy Brown Bag can get a free PDF by dropping me an email at Joan.Cook@yale.edu. We were interested in the apparent popularity of EMDR, at least among non-academic psychologists and other practitioners, and how it seemed to take hold in some settings, while being thoroughly rejected in others. We chose two VA medical settings, one in which it had taken hold, and one in which it did not, despite free training being offered. We were certainly aware of the controversies surrounding EMDR, but chose to take a neutral stance in an effort to grasp whatever lessons that could be learned in terms of effective dissemination and implementation of a therapy approach with sustained use. Hopefully regardless of their attitudes to EMDR, readers can learn something about the poorly understood topic of how one obtains sustained use of the psychotherapy by frontline clinicians.

Perhaps our most interesting findings were clinicians adopting treatments because they personally perceived the positive effects of the therapy in their own lives, what we call “experiencing is believing,” and also that a psychotherapy being adopted in a setting can become part of that program’s deeply entrenched identity.

How do you explain the popularity of EMDR?

Cook: First, we have to be careful about the assumption that it is that popular. We have an unpublished survey of over 2,200 U.S. and Canadian non-academic psychotherapists (many of whom were master’s level social workers) who completed a web-based survey concerning their use of over 60 specific psychotherapy techniques. EMDR was one of the least frequently used practices.

I have to admit, however, when we began this study, I was sold on the popularity of EMDR and assumed it was more widely used in routine practice.

Coyne: I agree, when we started the study, I assumed that we were studying a populist phenomenon, a therapy widely adopted by front-line clinicians that had developed outside of and in the face of opposition from academia. I wanted to understand how it spread, almost virally. But in retrospect, I think I was too impressed by the antipathy of academic psychologists to EMDR to appreciate that EMDR was not actually widely practiced. In a paradoxical way, opponents of EMDR have contributed to whatever appearance of strength and popularity it has. I was certainly caught up in this illusion.

How you explain the antipathy towards EMDR?

Coyne:  I think EMDR poses an interesting dilemma for advocates of evidence-based treatments, particularly academics. Strictly speaking, it meets the criteria for an evidence-based treatment. But some of the explanations that are offered for the mechanism of effect are patently absurd and there are a lot of "off label" applications that do not have a basis in best evidence. I think just the notion of a therapist sitting in front of patient and waving a finger back and forth or using tappers is tough for a lot of therapists to accept, regardless of whether it is effective treatment. Personally, I would feel ridiculous doing this.

But the interesting dilemma for advocates of evidence-based treatment, who are offended by EMDR, is how they can exclude it from being classified as being evidence-based without being inconsistent and even hypocritical. One strategy is to point out that EMDR does not have a verifiable mechanism of effect and propose this as an additional criterion. The problem is that numerous effective biomedical interventions would fail to meet this criterion and arguably, some other treatments academics want to accept as being evidence-based are at least as controversial as those who do not share a particular theoretical orientation.

I find proponents of EMDR, somewhat embarrassing to the promotion of it as evidence-based treatments with their willful violation of the tenets of evidence-based psychology in their application of EMDR to other disorders and problems well beyond the evidence of its efficacy. Treatments are not evidence-based, you know, but the application of them to particular clinical problems is. Yet, I find the gyrations of those who would exclude it hypocritical. It is certainly an interesting case study in how we evaluate evidence and the factors other than evidence that come into play.

So where do you stand on EMDR?

Coyne: I don't think I could be clearer, even if my answer is complex. It works, the explanations about why it works are annoyingly silly, and its off label applications are certainly not justified. But then again, these criticisms are applicable, in whole or part to other treatments that don’t come under attack.

Cook: I try not to get my personal opinion in the way of trying to understand why psychotherapists choose to adopt and sustain their use of various therapies. I’ve been trained in all the evidence-based treatments for PTSD and I have recently received a Stimulus Package NIMH R01 to understand the implementation of two other evidence-based treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in a national rollout.

Have you encountered any flack in trying to get this paper published?

Cook: Surprisingly, this paper took three rounds of reviews and numerous rich quotes and insights had to be cut to meet paper length as well as to maintain neutrality. The reviewers clearly perceived that we were anti-EMDR folks and we are thankful to the editor for judiciously mediating between reviewers and us. It was at times quite frustrating, though. In the end, the paper was strengthened.

Do you have related follow-up projects?

Coyne: I think there's still lots be learned about the popularity of EMDR that could be applied in the dissemination of other treatments. However, I'm reluctant to get into too much controversy with the proponents of the EMDR, because I think it only serves to promote EMDR. A lot of the illusion of its widespread application comes in the conflict that is generated by people who don't like it.

Cook: As I mentioned, we have a paper under review in which we surveyed thousands of therapists as to what they do with patients. EMDR does not rank high on the list. This was a shocker to me as I had believed all the hype – EMDR’s use was quite low actually. Perhaps practitioners seek training in it but then don’t actually use it? 

I'm most excited about the receipt of the stimulus package R01 to investigate factors associated with successful rollout of PE and CPT for PTSD in VA residential settings. EMDR isn't one of the treatments in this rollout, and so we don't focus on it. Jim and I will again be working together on this.

Coyne: But Joan is the PI on this exciting project. I had actually counseled against submitting the application because I believed that the odds of getting stimulus package funding were so low. The odds were miserably low, but Joan got one. I guess now I would say no one gets a grant without applying, unless it is something like a MacArthur Award.

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If you are interested in learning more about the topics discussed on this site, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.

Joan Cook is an assistant professor in the department of psychiatry at Yale University

James Coyne is a professor of psychology in psychiatry at the University of Pennsylvania and an adjunct professor of health psychology at the University of Groningen.

The Quality and Content of Supervision Leads to Long-Term Benefits for Clients - October 2009 Psychotherapy Brown Bag Featured Article

by Kelly Cukrowicz, Ph.D.

My name is Kelly Cukrowicz and I am an Assistant Professor at Texas Tech University. My research focuses generally on emotional and interpersonal correlates of suicide ideation in older adults, as well as longitudinal predictors of change in suicide ideation. Instead of contributing a piece in this area, I’d like to focus on the topic of supervision. Being a supervisor is an important role for me and one that I really enjoy. I take pride in being able to assist graduate student therapists in their growth as therapists, as well as in sharing information with them about empirically supported treatments. This semester my supervision team is reading articles on this topic and gaining experience offering supervision within student dyads.

As such, I’ve given a lot of thought recently to questions such as, “What makes good supervision?” and “How do differences in supervision impact treatment implementation and outcomes?” The literature has provided us with more information pertinent to the first question, so I’ll focus here on the second one. Basically, what impact does supervision have on the client, through (presumably) increased skill in treatment delivery of the therapist? In 2005 I was the lead author on a manuscript that examined the impact of a shift to empirically supported treatments on client outcomes at the Florida State University Psychology Clinic (Cukrowicz, White, Reitzel, Burns, Driscoll, Kemper, & Joiner, 2005). This article was discussed previously on PBB, so I won’t repeat the details. The gist of the study was that requiring training and supervision on empirically supported treatments drastically improved client outcomes. 

A recent study published in Journal of Clinical and Consulting Psychology has also examined the impact of clinical supervision on treatment outcomes. Schoenwald, Sheidow, and Chapman (2009) examined the relations between clinical supervision, therapist adherence to the treatment protocol, and changes in youth behavior and functioning problems one-year post treatment in a sample of youth with serious antisocial behavior problems. In a review of the literature on this topic, the authors point out that some existing studies have examined the impact of supervision on client outcomes for trainees; however, there is a dearth of research examining whether supervision impacts treatment adherence and client outcomes in usual care settings.

Schoenwald et al. examined data from a National Institute of Mental Health-funded study on practice context factors that may impact the implementation and client outcomes for multisystemic therapy (MST). The authors predicted that therapist adherence would mediate the impact of supervisor adherence on outcomes over this one-year period. The participants in this study included 1,888 families, 429 therapists, and 122 supervisors. This intensive treatment (see Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) averaged 22.2 weeks for this sample and included a typical caseload of four to six families (youth and caregiver) per therapist. Treatment length averaged four to six months depending on the needs of the family. Supervision was offered to teams of three to four therapists by supervisors who devoted at least half of their time to offering supervision and obtaining consultation from experts in this treatment.

Therapist adherence to the treatment was assessed monthly via caregiver ratings on the MST Therapist Adherence Measure – Revised (TAM-R). This 28-item scale allows caregivers to rate therapist adherence to the nine principles of MST. Supervisor adherence was assessed via the Supervisor Adherence Measure (SAM), on which therapists rate their supervisor every two months.

Mixed effects regression models were used to test the primary prediction indicated above. The results of this study indicated that two of the four dimensions of MST supervision predicted one-year outcomes for youth behavior. These dimensions were adherence to structure and process and focus on clinician development. Another dimension, adherence to principles, predicted therapist adherence to the treatment protocol. Further, therapist adherence ratings completed by the caregiver were associated with reduction in youth behavior problems over the one-year time period. Due to a lack of support for the initial prediction that supervisor adherence would impact both therapist adherence and youth outcomes, the mediational model was not tested.

Taken together, the results of this study suggest that some aspects of the supervision process may be more important than others in their association with therapist adherence and client outcomes. In this study, adherence to the principles of the treatment by the supervisor was most important. This subscale assesses the extent to which the focus of supervision was on the consistent assessment and therapeutic principles of MST. Thus, the therapist’s actions in therapy that are observable to caregivers (and subsequently can be rated on the TAM-R) are most prominent. As such, it may be that this factor appeared most important in part due to the fact that it was easier to rate. It is interesting to note that this dimension was most associated with therapist adherence, but not to one-year outcomes in youth behavior. The most important dimensions of supervision for youth outcomes were adherence to structure and process and clinician development, suggesting that supervisory efforts to teach the specific skills of MST and to ensure that the therapist’s goals, skills, and competencies were addressed had the greatest impact of youth behavior outcomes.

The results of this study are very encouraging to me as a supervisor. This study finds that important elements of the supervision process impact not only therapist adherence to the treatment, but also client outcomes. This study did not find any factor that was jointly associated with both; however, it does suggest that high-quality supervision does have a strong impact on both the delivery of services, as well as the benefits experiences by clients. An incredibly important element of this study was the long-term nature of the follow-up period. It isn’t just that high quality supervision has short-term benefits for clients – it actually yields effects that are maintained a full year later. When significant psychopathology is the focus, as in this study, this is incredibly important.

As I consider how all this applies to my own work as a supervisor, I am reminded of just how important it is to stress the need to “stick to it” with regard to continued use of the techniques, principles, and associated assessment principles associated with the selected treatment.

If you would like to learn more about empirically supported treatments for mental illness in general or multisystemic therapy in particular, Psychotherapy Brown Bag recommends the following products, all of which are available through the site's online store:

• A Guide to Treatments that Work by Peter Nathan and Jack Gorman

• Science and Pseudoscience in Clinical Psychology by Scott Lilienfeld, Steven Lynn, and Jeffrey Lohr

• Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual by David Barlow
  

• Multisystemic Treatment of Antisocial Behavior in Children and Adolescents by Scott Henggeler, Sonja Schoenwald, Charles Borduin, Melissa Rowland, and Phillippe Cunningham

Kelly Cukrowicz is an assistant professor of psychology at Texas Tech University

Suicide in active duty military personnel - The September 2009 Psychotherapy Brown Bag Featured Article

by Chad Morrow, Psy.D.

            My name is Chad Morrow and I am a psychologist/Captain serving in the United States Air Force (USAF).  The USAF has one of the best suicide prevention programs in the entire world, which was one of the reasons I decided to accept a commission (and internship) into military service.  The USAF continues to revamp and improve their program through the use of distinguished visiting professors (e.g., David Rudd, David Jobes, Thomas Joiner) and the incorporation of new empirically supported assessments/treatments.  As you can see, the USAF is always concerned about reducing unnecessary deaths by suicide and preventing this any way possible.  As a resident, I was supervised by Craig Bryan – author of the April 2009 Psychotherapy Brown Bag featured article - who significantly increased my knowledge of newer, more current models of suicide.  As his supervisee, and eventually colleague, I have worked with Craig to continue the USAF tradition of understanding suicide, treating/assessing for suicidal behaviors, and improving the suicide prevention program through research and practice.   I would like to discuss a recent study we completed as an attempt to meet these objectives. 

 

Recently released data indicates that active duty (AD) males carry, for the first time in known history, a suicide risk greater than that of comparable males in the general population (Miles, 2008). This is particularly noteworthy considering that the military entrance process screens out serious mental illness prior to entry onto active duty, and that the rate of suicide in military males has historically been significantly lower than comparable civilian populations. To help prevent and reduce these alarming statistics, military psychologists and mental health professionals need a simple model for understanding suicide.  In line with the philosophy of PBB, a few researchers (Bryan, Morrow, Anestis, & Joiner, article under review) have begun this research to gain empirical support for a simple model to improve our assessment, treatment, and prevention of suicidal behaviors in AD military members. 

 

One model of suicide that has been discussed on PBB before and continues to establish a considerable empirical foundation is Joiner’s (2005) interpersonal-psychological theory (IPT) of suicidal behavior. To briefly recap, Joiner’s model proposes that three distinct variables must be present for an individual to die by suicide: perceived burdensomeness, thwarted belongingness, and acquired capability for suicide. Perceived burdensomeness is the sense that the individual is a burden to others, does not contribute to the group, and is a liability to the group’s well-being or safety. Thwarted belongingness is the sense that the individual lacks connections to others, and that previously meaningful relationships have been strained or lost. It is the combination of burdensomeness and thwarted belongingness that comprises the desire for suicide. The third variable, the acquired capability for suicide, is the degree to which an individual is able to enact a lethal suicide attempt. The IPT has garnered considerable empirical support among non-military populations (DeCantanzaro, 1995; Trout, 1980; Van Orden, Lynam, Hollar, & Joiner, 2006; Van Orden, Witte, Gordon, Bender, & Joiner, 2008; Woznica & Shapiro, 1990) and OIF/OEF veterans (Anestis, Bryan, Conette, & Joiner, 2009; Brenner at al, 2008).  However, there are currently no empirical tests among AD military groups.

 

The authors of the current study wanted to test two aspects of the IPT within a military population. First, they hypothesized that acquired capability would be higher within a military sample than in non-military samples (e.g., military training increases the acquired capability). Second, they hypothesized that burdensomeness and thwarted belongingness would be associated with suicidal history, and that the interaction of burdensomeness, thwarted belongingness, and acquired capability would predict suicidal history above and beyond the contribution of each variable independently.

 

 The current study tested the author’s hypotheses in a sample of 88 active duty U.S. Air Force personnel, which was compared to a non-military undergraduate sample and a non-military clinical sample (see Van Orden (2008) for a more detailed description of this sample). 

 

Participants completed the following measures; Suicidal Behaviors Questionnaire-Revised (SBQ-R; Osman, Bagge, Gutierrez, Konick, Kopper, & Barrios, 2001), which is a brief self-report measure of past suicidal behaviors; Positive and Negative Affect Schedule-Short Form (PANAS; Watson, Clark, & Tellegen, 1988), which is a widely-used measure of positive and negative emotional states and emotional reactivity; Interpersonal Needs Questionnaire (INQ), which was designed by Joiner’s research group to measure participants’ current beliefs about the extent to which they feel connected to others and the extent to which they feel like a burden on the people in their lives; Acquired Capability for Suicide Scale (ACSS), which is a 5-item measure also designed by Joiner’s group to assess one’s fearlessness about lethal self-injury.   The AD scores on the INQ and ACSS were compared to non-military samples (as reported in Van Orden et al, 2008) to test the author’s first hypothesis. 

In regards to hypothesis #1, results suggested that AD personnel demonstrated higher acquired capability when compared to a clinical non-military sample. This finding suggests that one potential factor contributing to these increased suicide trends might be the increased capability for suicide among military personnel. In other words, basic military training may increase individuals’ acquired capability for suicide. It is important to note, however, that although acquired capability is a necessary condition for suicidal behaviors, it is not sufficient in and of itself.  Further, this data cannot determine if the increase in acquired capability actually decreases over time.  While these are two important factors to address, it is still imperative to recognize that an increase in acquired capability may exist (e.g., this person may have the ability to carry out such an act) and psychologists and mental health professionals need to assess/intervene accordingly when interacting with an AD military member.

 

In regards to hypothesis #2, the interaction of burdensomeness and acquired capability significantly predicted suicidal history, but the three-way interaction between burdensomeness, belongingness, and acquired capability did not, providing partial support for the theory in a military sample. The finding that the burdensomeness-acquired capability interaction predicted suicidal history, but not the three-way burdensomeness-belongingness-acquired capability interaction, replicates Van Orden et al. (2008). Interestingly, the main effect of belongingness did not independently predict suicidal history in either this study or Van Orden et al’s, which might suggest that belongingness is less robustly related to suicidal desire than burdensomeness. If these finding are indeed valid (e.g., further research is clearly needed to better understand and replicate these findings), it would be imperative for psychologists and mental health professionals to be extremely vigilant towards any report of perceived burdensomeness when assessing/intervening with an AD military member.   

 

            It is important to note that there are several limitations to this study (e.g., sample consisted only of junior enlisted Air Force personnel, sample did not include more senior military members with deployment experiences, and the authors used a single time point for assessment, which made it impossible to determine how military training impacts risk factors for suicide over time).  However, this data is particularly relevant in light of recent reports of an alarming increase in suicides and suicide attempts among active duty personnel and veterans (Miles, 2008).  The current study provides preliminary support of Joiner’s (2005) IPT among a military population, and provides direction for future research that could inform suicide assessment, prevention, and treatment efforts within the AD military setting. 

If you would like to learn more about suicide and suicide prevention, we recommend the following resources, all of which are available through our online store:

• Why People Die by Suicide by Thomas Joiner
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, the Department of the Air Force, or the U.S. Government.

Chad Morrow is a captain in the United States Air Force and the chief of the mental health clinic and ECAC/SERE psych services.

 

Understanding and treating juvenile sexual offenders - August 2009 Psychotherapy Brown Bag Featured Article

by Therese Kemper, Ph.D.

          Seven years ago, as a third year graduate student, I began a clinical practicum at a university based treatment program that provides services to youth at a high security, residential juvenile justice facility. During this placement, I was to provide individual and group therapy to adjudicated juveniles, many of whom had committed sexual offenses. Although this was a new area for me, I already had limited but successful experience treating individuals with serious psychological disorders, such as depression, bulimia, and personality disorders. I expected that, once I adjusted to the anticipation of a new job and the idea of working with incarcerated and potentially dangerous adolescents, my approach to treating these youth would be no different from my approach with previous clients. Essentially, I’d familiarize myself with the latest research, read about the empirically supported treatments, and with some expert guidance from my supervisors and a treatment manual, I’d be ready to forge ahead. 

The good news, my supervisor shared, was that research was generally showing a positive effect of treatment on reducing sexual recidivism for adult offenders. The bad news was that whether treatment worked for juveniles was far less conclusive. Then the news became worse: it was not clear exactly what type of treatment worked, how it worked, for whom it worked, or what specifically was the target of treatment. My readiness to forge ahead was considerably lessened, but I was also curious given that treatment for sexual offenders was already ongoing in the facility. I wondered: if there was not a well-established treatment for juvenile sexual offenders, what were they doing here?

            It was clear at this facility, as it is in treatment programs across the country, that treatment providers cannot sit and wait for a “gold standard” of treatment to be available. Children and families are in dire need of our assistance and victims need protection. Judges are mandating youth to complete sexual offender specific treatment and legislation previously reserved for adult sexual offenders, such as community notification, sexual offender registration, residency restrictions, and civil commitment, is being widely applied to juveniles. As a result, critical decisions about a youth’s release from incarceration, placement with family, or need for further supervision are being made based on judgment of treatment outcomes and assessment of recidivism risk, which are imperfect at best for juveniles.

As a relative newcomer to the treatment and research of juvenile sexual offenders, these realizations about the high stakes of working with these youth are both distressing and exciting. The distress surfaces when I cannot provide families, youth, or judges with more definitive information about the role of treatment or future risk. On the other hand, because research and treatment of juvenile sexual offenders is relatively new compared to many other areas of psychological research, we have the unique opportunity to build knowledge about these youth from the ground up. Though it is a tedious task, the work currently being done will provide the foundation for the development of empirically validated and cost effective treatment and risk prediction for juvenile sexual offenders and, in fact, we are well on our way. Treatment, such as multisystemic therapy (Borduin, Henggeler, Blaske, & Stein, 1990; Letourneau, Schoenwald, & Sheidow, 2004), and risk assessment measures such as the Juvenile Sex Offender Assessment Protocol (J-SOAP; Righthand, Prentky, et al., 2005) and Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR; Worling, 2004), are showing promise and should leave us optimistic about what lies ahead. However, the fact remains that neither specific types of treatment nor risk assessment measures have empirical support to the level expected by scientifically minded practitioners.

            In the meantime, when treatment demands are high and the legal and social consequences for juvenile sexual offenders are serious, we as treatment providers have to pull ourselves up by our bootstraps and do the best we can with the resources and knowledge currently available. One bootstrapping strategy used with juvenile sexual offenders has been the application of what is known about and practiced with adult sexual offenders. This has both practical and clinical utility and is certainly a reasonable launching point for work with juveniles. However, while this approach may be used as a temporary guide, it is critical that the assumptions about juveniles and their similarity to adult sexual offenders be examined. One of these assumptions—that there are juvenile equivalents of child molesters and rapists—is one focus of research being conducted by many in the field, including at our facility. This is a particularly important assumption to examine because, with it may come several other assumptions: that juveniles will exhibit stability in victim choice if they continue to sexually offend; that the groups will show different patterns and levels of sexual deviance and criminal behavior; and that recidivism rates of the groups will differ. If these assumptions regarding juvenile sex offenders are erroneous, treatment effectiveness and risk prediction will be greatly diminished and application of legal and social policies to juveniles will be greatly misguided.

The issue of whether there are juvenile equivalents of child molesters and rapists is also important to examine because of the value a valid classification system will have in informing treatment, risk prediction, and possibly prevention. Specifically, a valid classification system for juvenile sexual offenders will identify different developmental correlates, specific offending patterns or symptomatic presentation, treatment needs, and outcomes for each specific subgroup. If these factors are identified for particular subgroups of juvenile sexual offenders, children at risk may be identified early and provided with preventative measures. Treatment may also be more cost effective because criminogenic needs unique to the individuals in each subgroup could be targeted and risk prediction and public policies could be improved so that the level of intervention and supervision matches the juvenile’s level of risk and dangerousness. 

            Whether victim age is as valid classification method for juvenile sexual offenders as it appears to be for adults remains an empirical question. The research thus far has been inconclusive as to whether juveniles who offend younger children (child offenders) or those who offend peers or adults (peer offenders) are truly distinct groups. Aside from differences in rates of sexual abuse (more common in child offenders) and victim characteristics (child offenders tend to victimize male and female relatives, whereas peer offenders tend to victimize female acquaintances; Worling, 1995), consistent differences between these subgroups have not been found, even on treatment outcomes or recidivism rates (Kahn & Chambers, 1991; Nisbet, Wilson, & Smallbone, 2004; Parks & Bard, 2006; Vandiver, 2006). Part of our research is focused on comparing subgroups of child and peer offenders on sexual and nonsexual offense history, abuse history, social skills, impulsivity, treatment outcomes, and recidivism. In addition, we include a group of mixed offenders—those who have a history of adjudicated sexual offenses against both children and peers. This group is of particular interest because, with few exceptions (see Parks & Bard, 2006), they are often combined with child offenders, are classified as either child or peer offenders based on their most recent offense, or are excluded from research samples. It is possible that this is a distinct group and that combining them with either child or peer offenders clouds true differences between those subgroups.

Our Research

            Our sample consisted of 198 child offenders (victims were age 12 or younger and 4 or more years younger than the offender), 77 peer offenders (victims did not meet child victim criteria), and 21 mixed offenders (at least one child and one peer victim) who were adjudicated for sexual offenses and court ordered to complete residential sex offender treatment. Some differences between child and peer offenders were found, as expected, on measures of sexual abuse and victim characteristics. However, the most noteworthy findings were for the mixed group. Admittedly, the mixed group is quite small and this likely constrains the interpretation of the results, but the mixed group is possibly a severe group and at the very least, worthy of further study.        

   Mixed Offenders

            Generally, the mixed offenders had a more extensive sexual offense history than other juvenile sexual offenders. Two sexual offense adjudications (against a child and peer) were necessary for classification as a mixed offender; however, many exceeded this criterion—48% of mixed offenders had three or more adjudicated offenses, compared to 9% of child and 4% of peer offenders. Compared to other sexual offenders with two or more sexual offense adjudications, the mixed offenders had more victims than both groups and more sexual offense adjudications than peer offenders. The mixed offenders were also characterized by high rates of abuse, with nearly two-thirds having been abused in some manner and half of them abused sexually.

            The mixed offenders were also noteworthy in terms of the details of their offending history, in that they had a varied and intrusive pattern of offending. Specifically, the mixed offenders were more varied in victim gender and relationship, and appeared to exhibit less discretion in their victim choice than other subgroups. They were the group most likely to victimize both boys and girls and the group most likely to victimize both inside and outside the family. They were also the most likely to abuse multiple victims at the same time, with one-third of the mixed offenders doing so, compared to 10% of child and 5% of peer offenders. Mixed offenders engaged in penile penetration of the victims more often than child offenders and engaged in oral sex more often than peer offenders. Finally, the mixed offenders had the greatest variety of sexual acts in their offense history, suggesting that they engaged in different types of sexual acts (e.g., fondling, penetration, oral sex) with different victims. The mixed offenders did not differ from the other sexual offenders on criminal history variables, including age at first arrest or number of nonsexual charges. It therefore appears that their versatility in offending sets them apart from other sexual offenders only in terms of sexual, and not nonsexual, crime.

Child Offenders

            The child offenders were the largest subgroup, accounting for two-thirds of the sample. Half of the child offenders were victims of abuse and, along with the mixed offenders, experienced higher rates of sexual abuse than did the peer offenders. Over 25% had multiple sexual offense adjudications and they were charged with offenses against an average 1.5 victims. These youth tended to victimize females and relatives; however, nearly one-third had an adjudicated offense against a male. Child offenders were the least likely to engage in penile penetration of the victims, but engaged in oral sex more often than the peer offenders. As a group the child offenders were just over 13 years old at first arrest and were among those with the fewest nonsexual charges in their history.

Peer Offenders

            Peer offenders represented the second largest subgroup, comprising one-quarter of the sample. Over one-third of peer offenders were victims of abuse and, although the rate of sexual abuse was higher than what is typical in the general population, it was lower than the rate of the other sexual offenders. Similar to child offenders, they averaged fewer than two victims but nearly 30% had multiple sexual offense adjudications. The overwhelming majority victimized females and they were the group most likely to victimize non-family members and to offend in a public place. Peer offenders were more likely than child offenders to engage in penile penetration of victims, but were least likely to engage in oral sex. Finally, this group was notable in terms of their nonsexual offense history. As a group, peer offenders were likely to have been first arrested before age 13 and had an average of over seven nonsexual charges, which was nearly one and a half times the nonsexual charges of the other subgroups and significantly more than the child offenders.

            Involvement in Treatment

            The vast majority (88%) of the sexual offenders in this study successfully completed the one year group treatment program at the facility. The mixed offenders had the highest proportion of treatment failures (29%), due to serious conduct problems within the facility or unsatisfactory progress in treatment after multiple attempts in the treatment program. Interestingly, treatment performance was not related to either sexual or nonsexual recidivism after a follow up period of approximately five years. Prior residents of the facility were tracked using a legal research database, Westlaw, which allowed for a nationwide search of adult criminal records. Rates of nonsexual convictions were high (40%) and rates of sexual convictions were relatively low (6%). Both of these rates are consistent with other published data on juveniles (Reitzel & Carbonell, 2006) and with research showing higher nonsexual than sexual recidivism rates in youthful sexual offenders (Freeman, 2007; Reitzel & Carbonell, 2006).

Groups in this study did not differ in their rates of nonsexual recidivism, which was somewhat surprising given that peer offenders had more extensive nonsexual criminal histories than child offenders and adult rapists generally show higher nonsexual (violent, general) recidivism than child molesters (Freeman, 2007; Hanson & Bussière, 1998). Also somewhat unexpectedly, groups did not differ on rates of sexual recidivism. Despite the mixed offenders’ extensive sexual offense history, they did not have unusually high rates of sexual recidivism. In fact, the child offenders accounted for 16 of the 18 sexual recidivists, with one sexual recidivist coming from each of the other groups. Though this difference was not statistically significant, it is clinically interesting. Child offenders were clearly overrepresented in the group of sexual recidivists, as they accounted for 89% of the sexual recidivists despite accounting for only 67% of the sample. 

Interpretations

Overall, this research offers some support for the validity and clinical utility of classifying juvenile sexual offenders on the basis of victim age. The mixed offenders appeared somewhat more severe in their sexual offense history and did more poorly in treatment than other groups. The child and peer offenders showed differences in sexual abuse history, victim choice, and nonsexual crime, similar to differences found between adult child molesters and rapists. The results are moderately consistent with the adult and juvenile literature and hint at further avenues for research. For example, mixed offenders may be more sexually deviant than other groups, which could result in extensive future sexual offending and resistance to treatment. Interventions aimed specifically at reducing sexual deviance may be indicated for this group. This research suggests that peer offenders may be similar to adult rapists in their propensity for nonsexual crime and, therefore, treatment targeting general criminal behavior may be most beneficial for them. Finally, child offenders may be at a higher risk for sexual recidivism and future research might focus on whether these offenders are more likely than others to continue victimizing others as they enter adulthood.

            In contrast to, and despite these important differences, some similarities between the groups make these subgroups appear somewhat arbitrary and suggest that victim age-based subgroups of juveniles may not be as distinct as are adult rapists and child molesters. No differences were found on measures of physical abuse, social skills, or impulsivity, and subgroups exhibited some commonalities in their patterns of sexual offending and recidivism. We therefore must closely examine, in future research, variables that are thought to be related to the etiology and maintenance of sexual offending in juveniles and determine whether there are differences between subgroups on those important variables. Furthermore, there are inherent difficulties in determining who constitutes a juvenile version of a child molester when, in reality, the offenders themselves are children. As a result, we must be cautious when making downward extensions of adult treatment methods and policies to juveniles. Our research findings also make it clear that detailed examination of a wide range of developmental factors, sexual deviance, criminal history, and long-term offending patterns will be necessary before we can validate juvenile sexual offender subgroups and identify their specific treatment needs.

Closing Thoughts

            Seven years ago, I began searching for answers about who to treat, what to treat, and how to treat juvenile sexual offenders. Although I was surprised to find that starting up in this area would not be as straightforward as familiarizing myself with the latest treatment manual, I have been rewarded with the opportunity to observe the rapid increase in knowledge about juvenile sexual offenders. Recently, I have been fortunate to have the opportunity to integrate research and clinical work in my dealings with youth. The combination of research and practice in a clinical setting maximizes our potential to improve the services we provide, while protecting victims and making a meaningful contribution to the knowledge of juvenile sexual offenders. It is my hope and expectation that our efforts in this line of work will result in fair and effective practices for juveniles who sexually offend.

Dr. Therese Kemper, Ph.D., is a post-doctoral fellow at Florida State University and an experienced clinician and researcher specializing in the understanding and treatment of sexual offenders.

The utility of diagnostic feedback - July 2009 Psychotherapy Brown Bag featured article

by Jill Holm-Denoma, Ph.D.

A few years ago, I experienced a nagging pain in my right hip. I was an active athlete who did not want to be slowed down by an injury, and therefore went to my physician to get checked out. After examining me, the physician said he was unable to determine what was causing my pain or give me a firm diagnosis, but that he suspected rest and ibuprofen would be helpful. I left his office feeling a bit frustrated that I did not have a good explanation about my hip pain and worried that I might not get well soon. Several weeks later, I ended up in an orthopedic’s office, and this time, after conducting a thorough assessment, the physician told me that I had Trochanteric Bursitis (a common problem that causes inflammation of the bursa over the outside of the hip joint) that could be treated with a specific type of physical therapy. I felt relieved to have an explanation for my pain and hopeful knowing that an effective treatment was available for my problem.

Around the same period of time, I began to think about the experiences that psychiatric patients might have when seeking diagnosis and treatment from a mental health provider. From working at various community sites, I knew that psychologists did not always give their patients candid diagnostic feedback. There are many well-intentioned reasons that mental health care providers have for not providing their patients with diagnostic information (discussed below), but I wondered if this felt frustrating, unsatisfactory, and/or confusing to the patients. If a psychologist failed to share his/her diagnostic conceptualization with a patient, would that patient feel like I did after seeing the first physician about my hip pain (i.e., frustrated, confused, worried, and a bit hopeless)?

It occurred to me and one of my labmates (Dr. Kathryn Gordon, who is now an assistant professor of psychology at North Dakota State University and co-author of the May 2009 Psychotherapy Brown Bag featured article) that this was an empirical question. That is, we could design a study to determine whether giving patients diagnostic feedback was useful or was harmful. Before conducting the study, we spent time familiarizing ourselves with published literature on the topic. I was shocked to learn about the low rate at which clinicians provide their patients with diagnostic feedback! For instance, in a study examining hypothetical diagnoses of fake patients, American clinicians stated they would disclose diagnostic information if the client met criteria for a mood or anxiety disorder 80% of the time, schizophrenia about 70% of the time, and borderline personality disorder about 55% of the time (McDonald-Scott, Machiwaza, & Satoh, 1992). When working with actual patients, fewer than half of psychiatrists reported that they routinely disclose dementia or personality disorders diagnoses (Clafferty, McCabe, & Brown, 2001; Pinner & Bouman, 2002), and almost 40% of psychiatrists said that they would not disclose diagnostic information for certain disorders to clients even if the client asked for it!

Why would clinicians withhold this type of information, I wondered? I believe that there are many well-intentioned reasons it happens. For instance, David Rosenhan, a psychologist, conducted a fascinating study entitled “On Being Sane in Insane Places” (1973). The results of this study led him to believe that diagnostic labels are not reliably applied in clinical settings and that client knowledge of their diagnosis leads to feelings of misunderstanding, powerlessness, and inadequacy. Clinicians may also withhold information about diagnoses because they are worried that providing a diagnosis may cause social stigma and labeling effects (Langer, & Abelson, 1974, Scheff, 1999; Sushinsky & Wener, 1975), fear that giving such feedback may diminish a patient’s morale and further compromise their mental health (Hassan & Hassan, 1998), and/or worry that diagnostic feedback provision may cause an uncomfortable therapeutic interaction.

Although I could understand the reasons that providing diagnostic feedback caused feelings of hesitation in some clinicians, I could not help but think that at least some patients actually feel worse when they are not told what is going on with them. Said differently, Dr. Gordon and I hypothesized that some patients would rather hear “bad” news from their mental health care provider (i.e., that they meet criteria for a mental illness) than hear no news (i.e., not be told what was going on with them).

Dr. Gordon and I therefore conducted a study at a community outpatient clinic in which we empirically evaluated whether patients perceived receiving clear, detailed diagnostic feedback as a positive or negative experience. We recruited 53 adult outpatients for the study, and asked them to report on how they were feeling during multiple points of the assessment process. Specifically, we assessed their mood with a brief self-report instrument (a visual analog scale) that consisted of alternating Positive (hope, optimism, validation, relief) and Negative (shame, fear, distress, discouragement) descriptors. Each descriptor was presented on a rating scale that let participants rate their level of agreement (e.g., “not validated at all,” “not very validated,” “somewhat validated,” “very validated”). By asking participants to fill out this instrument at many times during the assessment and diagnostic feedback process, we were able to determine what type of emotional experience patients have before, during, and after receiving diagnostic information about their mental health. In this study, less than half of the participants met criteria for a single psychiatric diagnosis. That is, most patients actually met criteria for >1 mental illness, which meant that they would perhaps be more likely to feel negative and/or upset by receiving diagnostic feedback than patients who only met criteria for 1 disorder.

The results of the study indicated that clients reported no change in negative emotions (such as shame and fear) and significant increases in positive emotions (such as hope and validation) following diagnostic feedback provision. Furthermore, this result held even when it was examined specifically in people who received multiple psychiatric diagnoses. Therefore, the results suggested that diagnostic feedback, when provided in a careful and constructive manner, tended to increase clients’ positive emotions and potentially their hope for treatment. The results clearly did not support the notion that provision of diagnostic feedback would lead to an increase in clients’ negative emotions. Based upon these results, we concluded that mental health care providers should give their patients clear diagnostic feedback in an empathic manner. But how does one go about doing that? In our study, we created a script that therapists used when providing feedback that seemed to be helpful:

Basic Steps:

1)    Introduce your agenda of providing diagnostic feedback

2)    Verbally reflect the main symptoms the patient has reported

3)    Tell client the name for their disorder and provide information about it

4)    Assure client that a lot is known about treatment for the disorder

5)    Advise client to guard against misinformation regarding the diagnosis

6)    Answer any diagnostic questions that the client has

Script:

1) Now that I have a sense of what has brought you here for treatment, I want to discuss your diagnosis. 2) You told me that recently you’ve been experiencing these symptoms ____ and that you’ve been feeling ____.  These symptoms and feelings cluster together into a syndrome. 3) There’s a name for the syndrome that you’ve described, and it’s called _____.  This syndrome typically consists of symptoms like ___.   People with this disorder typically feel like _____ [use the DSM for support during step 3]. We know a lot about this syndrome, both scientifically and clinically. 4) We also know a lot about how to treat this disorder effectively. 5) There is a lot of information available about this disorder.  However, I’d like to caution you that much of the information you will find about this disorder (online, from a friend, or in a bookstore) may be incorrect.  However, at this clinic, we know a lot about your syndrome, and I will be happy to give you as much information as you desire and help you to find good sources of information about the disorder. 6) Do you have any questions about your diagnosis?

It is my hope that clinicians will feel more comfortable providing diagnostic feedback to patients now that they have a) empirical results to show that diagnostic feedback is received positively by patients, and b) a framework with which to provide such feedback. It is also my hope that informed patients will be assertive in asking their providers for information about the diagnosis and its treatment implications.

Jill Holm-Denoma is an assistant professor in the department of psychology at the University of Denver and maintains a private practice providing assessment services and empirically supported treatments for mental illness in the Denver area.

Psychotherapy Brown Bag - Featured Articles

Those of you who read our site regularly are likely already familiar with our featured articles, but for those of you who are new to Psychotherapy Brown Bag, we would like to provide a summary resource to familiarize you with this feature.  Each month, we publish an article by a prominent professional on a topic within their area of expertise.  We feel fortunate to have been able to work with such accomplished professors and therapists and believe that their contributions provide significant value for readers. 

We hope you enjoy the articles, leave comments with your thoughts, and contact us with questions or concerns.

March 2009
Robert Leahy, Ph.D.
President, Association for Behavioral and Cognitive Therapies
Director, American Institute for Cognitive Therapy
Author of The Worry Cure: Seven Steps to Stop Worry from Stopping You

Robert Leahy's PBB Article: "Living with financial anxiety: Seven steps to dealing with your worries"


April 2009
Craig Bryan, Psy.D.
Captain, United States Air Force
Clinician, Wilford Hall Medical Center

Craig Bryan's PBB Article: "Bringing mental health treatment to the troops: An empirically based process improvement for veterans with PTSD symptoms in primary care"


May 2009
Katie Gordon, Ph.D.
Assistant Professor, North Dakota State University
and
Les Gordon, M.A., LMFT
Clinician, Private practice in Coral Springs, Florida

Katie and Les Gordon's PBB Article: "Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively"


June 2009
Sarah Fischer, Ph.D.
Assistant Professor, University of Geogia

Sarah Fischer's PBB Article: "Sexual trauma and bulimia nervosa: Potential mechanisms of action and new data"

The July 2009 featured article will be contributed by Jill Holm-Denoma, Ph.D, an assistant professor at the University of Denver.  Her article will discuss the utility of discussing diagnoses with clients in an effective manner that involves education and the provision of accurate reading materials.

Future contributors have been lined up for the coming months and we look forward to posting their contributions. 

Sexual trauma and bulimia nervosa: Possible mechanisms of action and new data - June 2009 Psychotherapy Brown Bag featured article

by Sarah Fischer, Ph.D.

Whenever I read about a consistent association between two types of psychopathology, such as bulimia nervosa (BN) and substance abuse, for example, I always wonder “Why?”  The ‘Why’ question is what really drives my interest in research on eating disorders and co-occurring conditions. Sexual trauma is one experience that is fairly consistently linked to eating disorder symptoms. Thus, I am delighted to have this opportunity to write about possible mechanisms of action linking trauma experiences to the development of eating disorder symptoms, and to share some new data testing these hypotheses.  First, I would like to share some hypotheses developed with a colleague, Erin Hartzell, about how childhood abuse may lead to later symptoms of bulimia nervosa. Next, I would like to share a hypothesis and some new data about how later sexual trauma experiences may affect BN symptom development.

Childhood Abuse and BN Symptom Development

Child abuse, most often sexual, is considered a non-specific risk factor for eating disorder symptoms.  It is considered a risk factor because there are elevated rates of child abuse in eating disordered samples, yet non-specific because those rates are similar to rates of child maltreatment in other samples of women with psychopathology (Thompson & Wonderlich, 2004;  Jacobi, Hayward, & de Zwaan, 2004).  A recent meta- analysis on this topic found that women who had been sexually abused had higher rates of eating disorder symptoms than those who had not, and that individuals with BN had higher rates of sexual abuse than those without BN (Smolak& Murnen, 2002). More recent data in a sample of women who had been sexually victimized as adults or children indicate that women with trauma histories had higher rates of eating disorder symptoms than did controls (Holzer, Uppala, Wonderlich, Crosby, & Simonich, 2008).  Researchers have only recently begun to describe specific models linking sexual or physical abuse to later eating disordered symptoms, rather than examining rates of co-occurrence of the two conditions (Thompson & Wonderlich, 2004). For example, some data indicate that Post Traumatic Stress Disorder symptoms mediate the link between childhood sexual abuse (CSA) and later eating disorder symptoms (Holzer et al., 2008). In other words, in this sample, the relationship between CSA and later eating disorder symptoms was explained statistically by PTSD, such that the reason that relationship existed was because those who experienced CSA developed PTSD, which in turn influenced the development of eating disorder symptoms.  Thus, the time appears ripe for specific mechanisms of action linking trauma to the development of eating disorder symptoms to be articulated and tested, as the field begins to move beyond descriptive data collection.

In contrast to CSA, emotional or psychological abuse is one form of child maltreatment that has received relatively little attention; however, it is also found in elevated rates in samples of women with obesity and eating disorder symptoms ( Grilo, Masheb, Brody, Toth, Burke-Martindale, & Rothschild, 2005; Grilo & Masheb, 2001). CSA does not likely occur in a vacuum; in families in which children are sexually or physically abused, the victims are also likely to be emotionally abused and neglected. Therefore, it seems likely that the overlooked factor of co-occurring emotional abuse may have a significant contribution to the development of psychopathology, including BN symptoms. In fact, most studies that examine CSA do not present data on emotional abuse.

The consequences of growing up in an emotionally abusive environment have several potential links to future eating disordered behavior, which can be incorporated into existing models of the development of BN symptoms. Bruch (1973) was the first to identify poor interoceptive awareness as a possible risk factor for disordered eating behavior, and to link this deficit to childhood environments.  She described poor interoceptive awareness as being associated with difficulties in recognizing hunger and satiety cues, resulting from an environment in which a child's needs are not sufficiently met. In this type of environment, skills to recognize and manage physiological signals are not taught. Poor interoceptive awareness is also associated with difficulties in correct emotion recognition and identification (van Strien & Ouwens, 2007; Garner, 1991) and emotional eating (Larsen, van Strien, Eisinga, & Engels, 2006). For example, individuals who have difficulty distinguishing emotions and physical sensations may perceive themselves as hungry when they are feeling anxiety or arousal. A number of studies have linked alexithymia (poor emotion identification) and interoceptive awareness to eating disorders (Mitchell & Mazzeo, 2004). One prospective study demonstrated that poor interoceptive awareness predicts the onset of disordered eating in girls (Leon, Fulkerson, Perry, & Early-Zald, 1995).

Emotional abuse may lead to BN symptoms by a second mechanism, which can be incorporated in the cognitive behavioral model of the development of eating disorders.  Individuals who are emotionally abused are often devalued, criticized, and belittled from a young age. This devaluation is likely to be integrated into the self concept of the victim of emotional abuse, resulting in the person believing that they are unlovable, or weak, or worthless. This low self esteem could lead to weight and shape concerns, and attempts to modify one's appearance through dieting. This cycle, of course, is the start of Fairburn’s Cognitive Behavioral model of the development of BN. While a discussion of dieting and the influence of dieting on BN symptoms is beyond the scope of this article, it does appear that severe caloric restriction, such as attempting to undereat as opposed to reduction of overeating (Herman, van Strien, & Polivy, 2008), cutting out food groups, and following food rules, leads to restraint that is almost impossible to sustain. This leaves one susceptible to breaking food rules and 'black and white thinking' about those rules, which causes individuals to overeat after a prolonged period of restraint.  The low self esteem that is hypothesized to lead to attempts to modify weight and shape through diet is one mechanism by which emotional abuse can influence later BN symptoms.

Finally, emotional abuse can lead to the development of BN symptoms by deficits in adaptive emotion regulation skills. Heatherton and Baumeister (1991) suggest that the function of binge eating is to distract from an abstract stimulus (negative thoughts about self; painful emotions) with a concrete stimulus (food). Several studies have been conducted with the use of EMA technology, and all consistently find that increases in negative affect precede binge eating behavior (Stein, Kenardy, Wiseman, Dounchis, Arnow, & Wilfley, 2007; Engelberg, Steiger, Gauvin, & Wonderlich, 2007; Smyth, et al., 2007).  Moreover, binge eating behavior may be negatively reinforced via this pathway because it acts to decrease or block negative affect, at least in the short term, by relieving the experience of painful emotions (Arnow, Kennedy, & Agras, 1992; Heatherton & Baumeister, 1991; Polivy & Herman, 1993; Whiteside, Chen, Neighbors, Hunter, Lo, & Larimer, 2007). Linehan’s (1993) conceptualization of Borderline Personality Disorder and the role of the invalidating environment provides theoretical support for the relationship between early abuse and disorders of emotion dysregulation.  While the role of the invalidating environment has not explicitly been described or studied in relation to later BN symptoms, we believe that this model provides a framework for describing one mechanism by which emotional abuse may lead to eating disorders. Only one study to date has attempted to examine the relationship of the invalidating environment and eating disordered behavior. In this study, women with eating disordered symptoms endorsed self report items indicating that their family environments had several features of the invalidating environment described by Linehan (Mountford, Corphostine, Tomlinson, & Waller, 2007).

Deficits in emotion identification and labeling, a consequence of the invalidating environment and emotional abuse, often then lead to deficits in emotion regulation skills. If one is not provided with modeling of healthy emotion regulation strategies, such as in an abusive home, then one may turn to immediately reinforcing, maladaptive strategies to alleviate distress or distract oneself from negative emotion.  As described previously, several studies have already linked BN symptoms to negative emotional antecedents and poor distress tolerance skills. We hypothesize that poor distress tolerance skills mediate the link between the experience of emotional abuse and later binge eating.  In short, emotional abuse leads to the development of poor emotion regulation skills, and these maladaptive skills lead to binge eating.

Testing These Models

So, where does sexual trauma fit in here? As previously stated, it is unlikely that CSA occurs without concurrent emotional abuse. Therefore, my colleagues and I hypothesize that it is actually the emotional abuse that co-occurs with CSA that leads to deficits in self esteem, interoceptive awareness, and especially emotion regulation skills, which mediate the link between child abuse and later ED symptoms. We had the opportunity to test one of these hypotheses in a large sample of undergraduate women (N = 1302).  Using a statistical technique known as structural equation modeling (SEM), we tested a mediational hypothesis.  Specifically, we first hypothesized that emotional abuse would contribute the most variance to BN symptoms when three types of childhood abuse were simultaneously modeled: emotional, sexual, and physical (Hartzell & Fischer, manuscript submitted for publication). Second, we hypothesized that deficits in emotion regulation skills would mediate the relationship between childhood abuse and BN symptoms. Overall, results indicated that the model fit the data well (CFI = .99, RMSEA = .03) and supported our hypotheses. However, we were surprised about one finding. When all three types of childhood abuse were simultaneously modeled, only emotional abuse had a significant direct effect on multiple eating disorder symptoms (restriction, binge eating, and weight and shape concerns). Sexual abuse, in fact, did not have a significant direct relationship to any of the ED symptoms in our sample. With regards to the mediation, all three types of abuse had significant, positive associations with deficits in emotion regulations skills, which in turn had significant positive associations with all ED symptoms modeled (Hartzell & Fischer, manuscript submitted). (Sobel tests of the significance of the mediation indicated that the indirect effects of emotional abuse through emotion dysregulation were significant, but not those of sexual abuse).

Adult Sexual Trauma and BN Symptoms

I would like to now turn to a discussion of some hypotheses of how personality can interact with trauma experiences to influence BN symptoms. Of course, genetic influences on temperament and personality are in place from birth, and are also constantly influenced by environmental events. Therefore, childhood trauma experiences may also influence personality development. For example, Borderline Personality Disorder symptoms in individuals with BN may be uniquely associated with childhood sexual abuse experiences (Dohm et al., 2002).

This aside, individuals often experience sexual trauma in adulthood as well as childhood.  The first few years of college may be a particularly high risk time for sexual trauma in young adult women. Therefore, I am interested in examining the interacting effects of personality and new trauma experiences on the development of BN. Cross sectional research has indicated that negative urgency, the tendency to act rashly in response to negative affect or distress, is positively associated with binge eating symptoms (Fischer & Smith, 2008; Fischer, et al., 2004; Anestis, et al., 2007). However, this trait is also positively associated with alcohol abuse (Whiteside & Lynam, 2003; Fischer & Smith, 2008; Miller, Flory, Lynam, & Leukefeld, 2003) risky sexual behavior (Miller, et al., 2003 ) and pathological gambling (Fischer & Smith, 2008). Theoretical models of personality risk for pathology hypothesize that personality traits are genetically heritable factors that increase vulnerability to several types of psychopathology.  However, environmental events may actually cause an individual to cross the 'liability threshold' into pathology (Bulik, Sullivan, & Kendler, 2003). Thus, genetic trait by environment interactions may be linked to bulimia nervosa and other eating disorders (Bulik, et al., 2003). 

My current research is testing hypotheses based on the idea that one such gene -environment transaction may exist between negative urgency and sexual trauma. Our hypothesis is that individuals with high levels of negative urgency, who act rashly or impulsively when distressed,  may not provide themselves with the opportunity to learn longer term, more adaptive strategies to cope with negative affect. They thus tend to turn to maladaptive emotion regulation strategies, such as binge eating, purging, and substance abuse. I hypothesize that individual differences in negative urgency may interact with the experience of sexual assault to influence the development of or increase in eating disorder symptoms. I had the opportunity to collect data to test this hypothesis in a longitudinal study of women across their first year of college (N = 550), a high risk time for the development of BN symptoms (Fischer, Stojek, & Collins, manuscript in preparation). My colleagues and I collected data on eating disorder symptoms, impulsivity related personality constructs, and sexual assault at three different time points across the year. Thus, we were able to capture pre-existing sexual assault, new occurrences of sexual assault, pre-existing BN symptoms, and the emergence or increase of BN symptoms over the year.

At time 1, we found that pre-existing sexual assault and negative urgency had unique direct positive effects on BN symptoms. We then controlled for the presence of BN symptoms at time 1, and tested the interaction effect of time 1 levels of negative urgency and new occurrences of sexual assault at both time 2 and time 3.  At both time points, the interaction effect was significant (Fischer, et al., manuscript in preparation). Thus, women who had been sexually assaulted in the interim between time 1 and time 2, and time 2 and time 3, and had high levels of negative urgency, experienced increases in BN symptoms at time 2 and time 3.  My colleagues and I are very excited about this data, as it is one of the only prospective studies demonstrating both the influence of sexual assault on the development of symptoms and testing a hypothesized mechanism of action.

Linking Adult Experiences and Symptoms, Childhood Abuse, and Personality

Of course, both childhood and adult experiences can interact to influence personality, interact with personality, and influence BN symptoms. The effect of an emotionally labile temperament may be mitigated when an individual grows up in an environment that puts forth effort to teach adaptive emotion regulation skills. However, when such an individual is placed in an emotionally abusive environment in which they are not taught adaptive emotion regulation tools, the result may be psychopathology such as bulimia nervosa. Of course, this interaction could lead to any of the pathways previously outlined. For example, high negative urgency individuals in an abusive environment may be more likely to develop weight and shape concerns as a result of low self esteem, or may be more likely to experience deficits in interoceptive awareness because of their tendency to quickly block negative emotions. Poor distress tolerance may be both a mediator and a moderator of emotional abuse to later binge eating. Sexual abuse experiences can also influence neurotransmitter and personality development itself. For example, the neurotransmitter that is hypothesized to play a key role in the development of eating disordered behavior is serotonin, or 5HT (Steiger, 2004). This neurotransmitter has been associated with satiety and disordered eating, but also with personality traits associated with BN, such as affective instability and impulsivity (Lesch, Bengel, Heils, et al., 1996; Steiger, Richardson, & Joober, 2007). Steiger and colleagues found increased levels of psychopathology in bulimic women who both had been abused and were a carrier of an allele that regulates serotonin reuptake (Steiger, et al., 2007). This indicated that a gene by environment interaction was present; that individuals who had a genetic vulnerability to personality instability had greater psychopathology when they had experienced abuse.  This is supportive of the notion that personality may interact with environmental events to influence the development of psychopathology. Overall, there are many avenues to be explored in this area of research, and it is an exciting time to study these transactions.

If you are interested in learning more about these topics, we recommend that you browse our newly redesigned online store.  Products are listed by category (e.g., eating disorders, ADHD) and are geared for both professionals and non-professionals.

Sarah Fischer is an assistant professor in the psychology department at the University of Georgia.

Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article

By Les Gordon, M.A., LMFT & Katie Gordon, Ph.D.

Part 1: Why It’s Important (Katie Gordon, Ph.D.)

Simply put, it’s important to include family members in the treatment of children and adolescents because it leads to better mental health outcomes. Parents are often valuable resources in therapy, and their active involvement in the treatment process can go a long way to reduce their child’s suffering and mental health problems. Multisystemic therapy (MST) for adolescent conduct disorder is a clear example of the potentially powerful and positive impact family members can have on clinical outcomes. In one particularly impressive MST study, Schaeffer and Borduin (2005) followed up adolescent felons who were randomly assigned to either MST or individual therapy 14 years prior. They found that those who received MST were 4 times less likely to be re-arrested, 2.5 times less likely to be arrested for a violent crime, and averaged ~62 less incarcerated days per year than those who received individual therapy.
    In a review article on the status of treatments with family components (e.g., parental psychoeducation, parent training), Diamond and Josephson (2005) presented evidence that including parents in treatment for other childhood/adolescent mental health problems, including substance-use related problems, anxiety disorders (particularly if one or both parents have anxiety also) and attention-deficit/hyperactivity disorder (ADHD) tends to lead to better outcomes than treatments that do not include parents (note: parental involvement does not appear to affect core symptoms of ADHD, but reduces associated behavior problems) . Since the 2005 review, more evidence has emerged that a specific type of family-based treatment (FBT) is superior to supportive individual therapy for bulimia nervosa in adolescents (le Grange, Crosby, Rathouz, & Leventhal, 2007), findings that are in line with those that Mike Anestis presented on FBT for adolescents with anorexia nervosa earlier this week. Involving family in the treatment of adults is beyond the scope of this article, but it is worth mentioning that there is empirical support for manual-based family treatments for adults with substance use disorders (e.g., Fals-Stewar & O’Farrell, 2003), bipolar disorder (Rea et al., 2003), and schizophrenia (Pharoah et al., 2006).
    Despite the evidence that including family members in treatment can be very beneficial, some clinicians may still feel reluctant, and parents may fear that they will be blamed if they participate. This may be due, in part, to historical or even folk explanations of mental disorders. For example, beliefs that certain mental illnesses are caused by having an absentee father (e.g., having “dad issues”) or an uncaring mother (e.g., “the refrigerator mother” or “the schizophrenogenic mother”) may linger in the minds of parents and even clinicians, despite a lack of evidence to support these theories. Part 2 of this article highlights the importance of directly addressing these types of issues by assuring parents that the purpose of their involvement is not to place blame, but rather, to enlist them as essential, helpful collaborators in their child’s treatment. It may be particularly important to assure parents of this early on, given evidence that parental therapeutic alliance predicts retention rates and outcomes in therapy for children and adolescents (e.g., Shelef et al., 2005). A second, perhaps more common, reason clinicians may feel reluctant to include families in therapy might be that they feel unsure about having the appropriate skills and/or feel intimidated about being “outnumbered” by clients in the therapy room. The purpose of Part 2 of this article is to normalize these feelings of uncertainty, and to outline some practical tips for including family members in treatment.

Part 2: How to Do It Effectively (Les Gordon, M.A., LMFT)

As a family therapist for 25 years, I can’t imagine any conceptualization of child or adolescent psychological problems that does not include careful examination of the family process. The assessment of family dynamics throughout treatment allows for deeper understanding of the presenting problem, and the factors that maintain it. With this in mind, I hope that these hints will be helpful to clinicians working with children, adolescents and their families.

1.  Start early by asking family members to attend the initial assessment session. Set up a 1.5-2 hour meeting for an initial assessment, not counting any paperwork you’ll have them fill out. I usually set up an initial session fee that is somewhat less than two hours but more than the one hour standard fee. Introduce yourself to each member of the family in the waiting room, making a bit of small talk. Depending on the age of the child(ren), I also make sure to have some toys or games ready for them as well, as it can help with engaging the client and building rapport. Notice the affect, attitudes, and body language of all member of the family. I try to gather basic information, such as the child’s age, presenting problems, and the family member names prior to the first session. This is done through a 10-minute phone consultation when the clients first seek out your professional services. Although a good office manager can save you the trouble of this conversation, I believe it is highly beneficial to actually speak to the family and establish some initial rapport and connection. You may also be able to determine whether this is a case that you are qualified to accept. I have referred prospective clients out at this point due to my lack of expertise with their particular problems, insurance issues, and/or some other issue.

2.  Appreciate the differences between assessment and treatment. The first few sessions are primarily assessment, and therefore clinicians need to avoid jumping in to the rescue of the family. This is the time to observe, ask questions, and detail how the family functions.  The family dynamics will quickly appear without much prompting. For example, if there is a toddler who is playing while the clinician is speaking with the parents, you can observe who redirects the child, the patience levels, and the type of words and physical actions used during interactions with the child. With older children and adolescents, you can observe where they sit, how close to either parent they are, how active they are in conversation, how affectionate, along with mood and communication patterns. If clinicians interrupt and direct too tightly at this point, you could miss important observations into the family’s true form and style.

3.  Set the rules up immediately. After you introduce yourself and explain a little bit about how you work and your philosophy, encourage them to ask any questions they may have at that point. This is the time to disclose a bit more about your experience as a therapist.  Did you work in schools? Hospitals? What brought you into the counseling profession? If you have any sense of humor (hopefully) this is the time to be wise, gentle, and humorous.  If you have no sense of humor, then perhaps a political science major may have been more appropriate. I usually state at this time that I was a childrearing expert at one time-- immediately after graduate school and prior to the births of my three children. I want them to know that I am a parent and have experienced the full effects of having a job, being in a relationship, and raising children who were all not perfect every moment of every day (except my co-author).  This builds an alliance of immeasurable importance with the parents because they feel that they will be understood rather than judged.
    Explain how therapy works and in general what they can expect. I usually say that I will meet with the child/adolescent alone some to most of the time, go through confidentiality, and leave some time at the end of each session for parents to join us. As some occasions warrant – we may spend a whole session together as a family.

4.  Practice helps a family therapist more than anything. If you are an intern or student, or a newly supervised licensee, then seek out as much family work as you can. Avoid that feeling in the pit of your stomach that you may be outnumbered or overwhelmed in session. Embrace the unknown - understanding that expertise is the result of hundreds of hours of practice. Find a supervisor who likes systemic and family therapy and get their assistance. Read a Satir or Minuchin book or article. I am reminded that when I did workshops in my thirties with these esteemed family therapy pioneers, I went immediately back into my practice and attempted one of Satir’s techniques with a very dysfunctional family. It was a total flop except for the insight I gained about myself as a young family therapist. Of course, I missed the point that these famous family therapists had years of experience in conducting family therapy!

5.  After assessment is complete, and the clinician has established a respectful and workable relationship with the family it is time to actually do what they are paying you to do… provide treatment. Of course, treatment recommendations depend on your observations and conclusions regarding family and individual diagnosis(es). Clinicians may find it helpful to devote a part of a session to review their opinions with the family, outline treatment protocols, and get consent for treatment. The consenting family is a less problematic family. Some disorders (e.g., anxiety disorders) may require less family involvement than others (e.g., oppositional-defiant disorder, which typically has a greater impact on the entire family’s functioning).  At times, sibling conflict may be so important that I’ll decide to have a separate meeting with the siblings.

6.  With regards to treatment considerations, families typically have developed a series of rigid responses to disciplinary situations without really understanding that there are other ways to interact. Many clinicians use the react vs. response techniques to educate families. I basically tell parents that any strategic and planned response is superior to simply reacting, so it’s imperative to discuss how to handle conflict. During this period of introducing new patterns of responses, clinicians are likely to find different degrees of unwillingness or inability to make changes. We often think the clients are being resistant and treat it as such. However, most failure at this point is due to parental insecurity and the results of years of habitualized reactions. The gentle, supportive, and educational approach is usually more successful, and may keep the client engaged at a time when they want to give up. Most importantly- go slowly and pick only one behavior to change at a time. This may be as simple as disengagement, time-out, or rehearsed verbalizations such as “I’m too upset now to decide what to do, let me go chill for 15 minutes, and we’ll meet back here to finish our discussion.” Remind parents that change is difficult, but simply making the attempt sends a message of support and love to their children.
A most valuable therapeutic technique in family therapy is positive practice.  This is when the client and/or their family role play the new response to repetitious conflicts first in the clinician’s office then at home.  Remember-- it is highly unlikely for an individual to apply a new technique in the middle of the apex of a stressful moment when they have reacted to it in the same way for months or years. Our brains just don’t function that way. The more they rehearse the responses in times of calm the greater the likelihood of success when they really need it. This also builds up rapport and teamwork within the family.

7.  To paraphrase Virginia Satir, “There is only one argument that ever exists- and that is whose definition of what is going on is going to be accepted”. Family therapists the world over have found such wisdom in this simple proclamation which has profound effects on how we view psychotherapeutic treatment. We clinicians often get drawn into conflicts with families about who is right--they actually present their arguments to us and ask us to make a decision after all the evidence is presented! I usually comment that I forgot to wear my robes this day, and therefore I cannot judge effectively. Unless it’s allowing children to play with matches or play in traffic, I try to encourage parent-oriented solutions.
    As a result, family therapists often teach communication skills as a vital part of therapy.  Remember, parents have almost no training in parenting, and the communications skills that feel natural to many clinicians do not feel natural at all for some families. The basics of communication skills training include: using “I feel...” rather than “you…” statements, timing the discussion of problems right (e.g., not while watching TV or in the middle of the night), and how we to divide time between listening and speaking. It also may help to highlight the goal of effective communication-- do we want to be right or be happy (and resolve the problem)?  There are many effective communication programs available. A couple that I prefer are Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training and The Parent's Handbook: Systematic Training for Effective Parenting .
    It is also essential to teach parents to listen to children and adolescents during non-crisis times. Sometimes, direct interaction between parents and children only occurs when something is going wrong. Of course, this is upside down. The more we listen to our children in non-conflict situations, the better the communication is during the conflict situations. Perhaps the most efficacious time for practicing good communication is during therapy, because there is a supportive, experienced person to assist them and because most people, even children, know that therapy is a time for sharing important thoughts and feelings.  I often joke that it’s my sofa that does everything- as soon as their bottom hits the cushion they start emoting! Outside of the office the best times to communicate with children is away from distractions and for short periods of 5- 15 minutes.  I believe short walks are also effective times for communication because, symbolically, both people are walking in the same direction, towards the same goal. Communicating while walking can also reduce the amount of eye contact and body language being negatively interpreted by the other person (which can lead to conflict).

8.  There are some common problems which tend to derail effective treatment if the clinician does not respond effectively:

-   Adolescents (ages 15-19) do not always want their parents involved in treatment. They may feel that their confidentiality and trust in the clinician is compromised, because they feel that the clinician sides with parents during conflicts. In this situation, referring the parents to another clinician for parent skills training may be appropriate. It is particularly convenient if they see a clinician in the same practice, or you have established a good working relationship with the clinician, so that you can work together to treat the family. Every once in a while a family session can be more effective with the two clinicians conducting co-therapy.

-   Parents may expect quick results and improvements despite presenting with serious problems. This is best dealt with by reminding parents that these problems didn’t develop overnight, and therefore cannot be solved easily. Also, remind parents of the treatment plan and highlight the small improvements that they may not have noticed or remember. Also, if too much time has passed with little or no positive results, it’s prudent to meet with the family, and admit that the current treatment plan does not seem to be effective. Developing additional or alternate plans is advised in this situation. This may include increasing the number of sessions per week, referral for further psychological testing, a medication consult, etc.

-   One or more individuals may take over the session and diminish the clinicians’ ability to direct traffic effectively. This may include excessive arguing, aggression, and threats or physical attacks towards each other. This almost always occurs because the clinician tries to get the family to use a level of communication that they are not ready or skilled enough to use. An experienced family therapist practices smaller and less emotionally-laden topics before moving onto the big issues. It is also necessary to carefully consider the mood of the client or their family on that particular day. If the clinician reads significant disturbance or aggression, it may be better to speak with that person individually and ask them if they are okay with a family session that day.
    Humor and empathy are usually effective in discharging anger. No one can truly be angry with someone who clearly understands and articulates their perspective.  Often, it is the job of the family therapist to rephrase a family member’s statement in a way that is less threatening and more accurate. Asking permission to do this and asking if you spoke correctly allows the client to still feel in control. If a conflict starts to accelerate I may say “ Oops, I’m sorry I forgot to wear my striped referee’s jersey today” or “Folks, if you wait about an hour then you can argue for free once you go home- it’s too expensive to fight here.” Sometimes you might just have to insist that one or all the parties take a time out in another room or outside.  Many times, I have had an adolescent or parent storm out of session and come back on their own within five minutes, because they really want to be a part of treatment.

-   Seldom, a parent, due to his or her own issues (e.g., a diagnosable mental disorder), is unable to improve much of their skill set, and does not contribute in a positive way to their child’s treatment. A clinician may then employ “damage control,” and try to teach the son or daughter how to responsibly and functionally get their needs met in their lives, even if that parent is unable to assist them.

-   In some situations, a clinician may feel that a family or one of its members display such callous and obstructive behaviors that it is necessary to discharge them from treatment. Make the discharge in compliance with the ethics of your license and/or practice, making sure to provide them with referrals for treatment elsewhere (it’s best not to refer them to colleagues that you like!).

    In conclusion, family therapy can be a vital and effective assessment and treatment modality that requires a certain set of skills. There are a number of workshops, books, classes, and supervision experiences that can assist you in acquiring these skills once you have determined the value of family therapy as it fits into your practice.

If you are interested in learning more about integrating family into the treatment of children and adolescents, we recommend the following products, all of which are available through the Psychotherapy Brown Bag online store:

• The Parent's Handbook: Systematic Training for Effective Parenting
  

• Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training

• Bipolar Disorder, Second Edition: A Family-Focused Treatment Approach

• Treating Bulimia in Adolescents: A Family-Based Approach
  

• Multisystemic Treatment of Antisocial Behavior in Children and Adolescents

Les Gordon, M.A., has been a Licensed Marriage & Family Therapist and an educator for over 25 years, and currently has a private practice in Coral Springs, Florida.
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Katie Gordon, Ph.D. is an Assistant Professor of Psychology at North Dakota State University. She received a year of training in family-based treatments for eating disorders at the University of Chicago.