Evidence Based Treatments. Society of Clinical Psychology Div 12 2014

Cognitive Behavioral Therapy for adult ADHD

Status: Strong Research Support

What does this mean?

Description

Cognitive behavioral therapy (CBT) for adult ADHD provides concrete strategies and skills for coping with the core symptoms of ADHD (inattention, hyperactivity, impulsivity) and associated impairment in social, occupational, educational, and other domains. Components of CBT for ADHD include psychoeducation, training in organization, planning, and time management, problem solving skills, techniques for reducing distractivity and increasing attention span, and cognitive restructuring particularly around situations that cause distress.

Bipolar Disorder

Section Authors: Sheri L. Johnson and Daniel Fulford (University of Miami)

Description

The defining feature of bipolar I disorder is the presence of at least one lifetime manic episodes. Mania is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a distinct period of abnormally and persistently euphoric or irritable mood that lasts at least 1 week (or any duration if hospitalized). According to the DSM, mood changes are accompanied by at least 3 (4 if mood is only irritable) of the following symptoms: overly confident self-esteem, racing thoughts, distractibility, excessive involvement in pleasurable activities that can result in negative consequences, excessive talkativeness, decreased need for sleep, and increases in goal-directed activity. DSM criteria specify that the symptoms lead to clear impairment. The DSM includes several milder forms of bipolar disorder, including bipolar II disorder and cyclothymia, but psychological treatment research has focused on bipolar I disorder.

Although bipolar I disorder is defined by at least one lifetime episode of mania, at least two-thirds of diagnosed persons report a history of major depressive episodes (Karkowski & Kendler, 1997; Kessler, Rubinow, Holmes, Abelson, & Zhao, 1997; Weissman & Myers, 1978). Longitudinal data suggests that subsyndromal symptoms are present during at least 47% of weeks among persons with bipolar I disorder, and that subsyndromal depressive symptoms are particularly common (Judd et al, 2002). Given these symptom patterns, there is a need for psychosocial treatments that can provide relief for mania as well as treatments that can provide relief for depression.

Treatment outcomes for mania and depression are reviewed separately. It is worth noting that some trials provided evidence that treatments could produce better medication adherence, lower relapse rates, or improvements in social domains, but did not measure or obtain effects specifically for mania versus depression (Cochran, 1984; van Gent & Zwart, 1991; Fristad et al., 2003; Volkmar et al., 1981).

Psychological Treatments

Treatment Research Support for Mania

Research Support for Depression

Psychoeducation Strong Research Support

Modest Research Support

Systematic Care Strong Research Support

No Research Support

Cognitive Therapy (CT) Modest Research Support

Modest Research Support*

Family-Focused Therapy (FFT) No Research Support Strong Research SupportInterpersonal and Social Rhythm Therapy (IPSRT)

No Research Support Modest Research Support*

*Although findings of two trials indicated that these treatments lead to reduced depression, they have been labeled as having modest research support due to mixed findings.

Psychoeducation for Bipolar Disorder

Status: Strong Research Support for mania and Modest Research Support for depression


Description

Psychoeducation treatment involves providing patients with information about bipolar disorder and its treatment, with a primary goal being to improve adherence to pharmacological treatment by helping patients understand the biological roots of the disorder and the rationale for pharmacological treatments. Patients are also taught the early warning signs for episodes, and common triggers for symptoms. Psychoeducation interventions are typically—but not always—held in group format. The best tested approach consists of 21 group sessions (Colom & Vieta, 2006).

Systematic Care for Bipolar Disorder

Status: Strong Research Support for Mania


Description

Systematic care consists of a system-level intervention and a group therapy component. At the system level, care for bipolar patents is provided by an outpatient specialty team comprised of a nurse care coordinator and a psychiatrist, with staff-patient ratios at a level that provides clients with regular appointments and easily available telephone consultations. Small specialist teams are emphasized to provide for enhanced flow of information, a strategy that might be particularly helpful in complex medical systems such as the VA. A second system-level intervention consists of support offered to the treatment providers to help maintain evidence-based pharmacological treatment, such as clear treatment guidelines and ongoing feedback about the

care provided. Beyond the system-level intervention, group psychoeducation is provided using the Life Goals Program manual to teach patients about their symptoms, the need for medications, and to provide support in achieving occupational and social goals. Participants also create personal self-management plans detailing coping strategies for early warning signs. The Life Goals part of the program consists of 5 weekly group sessions followed by twice-monthly sessions for up to 43 sessions.

Cognitive Therapy (CT) for Bipolar Disorder

Status: Modest Research Support for depression* and Modest Research Support for mania


Description

It is important to note that there are many manuals of cognitive therapy for bipolar disorder, including group and individual approaches. Of these, the findings based on the manual by D. Lam and others have been particularly positive, as have those from the one-year report of the Systematic Treatment Enhancement Program for bipolar disorder (STEP; Miklowitz et al., 2007). Findings from other manuals have not achieved strong research support to date (Patelis-Siotis et al., 2001; Scott et al., 2006). All cognitive therapy manuals include a psychoeducational component regarding the biological basis of the illness, the need for medications, and the early warning signs of symptoms. They also include a focus on identifying maladaptively negative thoughts about the self, and teaching clients skills to challenge these overly negative thoughts. Many also include ideas about how to target the overly positive thoughts that might be present during mania. The Lam manual is distinguished by an integration of cognitive interventions with more extensive focus on promoting regular sleep and regulating extreme goal striving. The Lam manual is designed for 12 to 18 individual weekly sessions, followed by 2 booster sessions over the next 6 months, and only the randomized controlled trials that used this particular manual have shown effects in diminishing manic symptoms over time.

Family Focused Therapy (FFT) for Bipolar Disorder

Status: Strong Research Support for depression


Description

Family Focused Therapy (FFT) is a modification of the family-focused therapy originally developed for the treatment of schizophrenia (Goldstein & Miklowitz, 1995). All immediate family members are included, and therapy consists of several stages, beginning with psychoeducation about the symptoms and etiology of bipolar disorder and the need for medication adherence. Families are taught to respond early to emergent symptoms, and provided with training about the best coping responses. Then, drawing on the evidence that overly negative family interactions (expressed emotion) can trigger relapse of bipolar disorder, families learn communication and problem-solving skills for reducing conflict and resolving family problems. Treatment typically consists of 21 sessions over 9 months and was conducted in patient homes during the initial studies.

It is important to note that forms of family therapy other than FFT have not been shown to produce changes in manic or depressive symptoms (Clarkin, Carpenter, Hull, Wilner, & Glick, 1998; Miller, Solomon, Ryan, & Keitner, 2004). The FFT approach is distinguished from these other approaches by more structured exercises concerning family communication, more education about bipolar disorder, and more specific strategies for responding to symptoms.

Interpersonal and Social Rhythm Therapy (IPSRT) for Bipolar Disorder

Status: Modest Research Support for depression


Description

Interpersonal and Social Rhythm Therapy (IPSRT) is a modification of the Klerman and Weisman Interpersonal Therapy for Depression approach. Drawing on research demonstrating that sleep and schedule disruption is an important component of bipolar disorder, the original interpersonal psychotherapy approach has been expanded to provide techniques for enhancing the regularity of daily routines and schedules. The treatment also includes a focus on mourning the losses associated with bipolar disorder. The interpersonal components of therapy involve focusing on resolution of current interpersonal problems, such as unresolved grief, interpersonal disputes, role transitions, and interpersonal isolation. In the Frank et al. (2005) study, participants were randomly assigned to receive IPSRT in two forms: acute therapy (weekly sessions for several months) or maintenance sessions (monthly for two years). Of note, acute treatment lead to significant improvements in symptoms; maintenance sessions did not.

Borderline Personality Disorder

Section Author: E. David Klonsky (University of British Columbia)

Description

Borderline personality disorder refers to a longstanding pattern of unstable self-image, moods, relationships, and impulsive behaviors that usually begins in early adulthood. People with this disorder are typically unable to tolerate being alone, and their relationships tend to be unstable and intense. They also engage in risky and impulsive behaviors such as dramatic over-spending, having unsafe sex, or having sex with people they hardly know, abusing drugs or alcohol, driving recklessly, or binge-eating. It is not uncommon for people with this problem to physically hurt themselves (by cutting themselves, for example) or to try repeatedly to kill themselves. Individuals with borderline personality disorder also often experience severe mood swings, feelings of emptiness, and intense anger.


Dialectical Behavior Therapy (strong research support) Mentalization-Based Treatment (modest research support) Schema-Focused Therapy (modest research support)

Transference-Focused Therapy (strong/controversial research support)

Dialectical Behavior Therapy for Borderline Personality Disorder



Description

Dialectical Behavior Therapy (DBT) was originally developed as an intervention for chronically suicidal individuals. DBT blends behavioral and crises intervention theories with an emphasis on acceptance and tolerance drawn both from Western contemplative and Eastern meditation practice. The theoretical framework emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence the term "dialectical"). Treatment targets are agreed upon, with self-harm taking priority. The learning of new skills is a core component - including mindfulness (e.g., non-judgmental awareness of one’s own feelings and actions), interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises, and identifying and regulating emotional reactions. DBT involves both individual and group therapy.

Mentalization-Based Treatment for Borderline Personality Disorder

Status: Modest Research Support


Description

Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. Patients with BPD show reduced capacities to mentalize, which leads to problems with emotional regulation and difficulties in managing impulsivity, especially in the context of interpersonal interactions. Mentalization based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalizing.

Schema-Focused Therapy for Borderline Personality Disorder



Description

Schema Focused-Therapy (SFT) is an integrative approach founded on the principles of cognitive-behavioral therapy and then expanded to include techniques and concepts from other psychotherapies. Schema therapists help patients to change their entrenched, self-defeating life

patterns - or schemas - using cognitive, behavioral, and emotion-focused techniques. The treatment focuses on the relationship with the therapist, daily life outside of therapy, and the traumatic childhood experiences that are common in borderline personality disorder. Participants in the first study of SFT for borderline personality disorder received therapy for three years.

Transference-Focused Therapy for Borderline Personality Disorder

Status: Strong/Controversial Research Support


Description

Transference-Focused Therapy (TFP) focuses on revealing the underlying causes of a patient's borderline condition and working to build new, healthier ways for the patient to think and behave. From the perspective of TFP, the borderline patient's perceptions of self and of others are split into unrealistic extremes of bad and good. These conflicting dyads are thought to be expressed through the specific self-destructive symptoms of BPD. The term “transference” refers to the patent’s experience of his or her moment-to-moment relationship with the therapist. The treatment focuses on transference, because it is believed that patients will display their unhealthy dyadic perceptions not only in day-to-day life, but also in the interactions they have with their therapist. TFP focuses on using patient-therapist communications to help the patient integrate these different representations of self and, in the process, develop better methods of self-control.

TFP has the unusual designation of strong/controversial research support because of mixed findings. TFP performed favorably in two randomized controlled trials (Clarkin et al., 2007; Doering et al., 2010), but performed less well than a comparison treatment in another (Giesen-Bloo et al., 2006). More research is needed to clarify the research status of TFP.

Disorders in Childhood and Adolescence

The Society of Clinical Child and Adolescent Psychology (Division 53, American Psychological Association) has developed a list of evidence-based treatments for children and adolescents. Rather than duplicate efforts, we are working together with Division 53 on evidence-based practice initiatives and direct you to their Website on Evidence-Based Practice for Children and Adolescents.

Chronic or Persistent Pain

Current Section Author: Mark A. Lumley (Wayne State University)

Original Section Author 2008-2009: David A. Williams (University of Michigan)

Description

There are many forms of chronic pain and many ways to classify or subtype it. Chronic pain may be classified according to an underlying disease process (e.g., cancer pain, rheumatoid

arthritis), a region of the body (e.g., low back pain, headaches, neck pain), a specific bodily system or medical specialty (e.g., gastrointestinal pain, urogenital pain, musculoskeletal pain, rheumatologic pain), a presumed environmental cause (e.g., whiplash-related pain, repetitive movement pain), and even a period of life (e.g., pediatric pain). Furthermore, patients evaluated and treated in practice settings, such as pain clinics, typically have a wide range of pain types and causes. Some studies of treatments of chronic pain focus on only a specific subtype, and other studies include patients with a wide range of pain types. This makes matching research-supported treatments to specific types of pain rather complicated.

Whereas acute pain acts as a warning signal of actual or imminent damage to the body, chronic pain appears to have no inherent value for survival and is best thought of as a disorder. Interventions for acute pain often fail for chronic pain, which suggests that there are different underlying pathophysiologic mechanisms and the need for distinct approaches to treatment. Pain perception is an integration of nociceptive (neural sensory system), emotional, and cognitive evaluation. Any aspect of this integrated experience can become aberrant and contribute to the maintenance and/or exacerbation of pain. Interventions for acute pain tend to target the nociceptive system; successful interventions for chronic pain tend to be those that address affective, cognitive, and behavioral factors as well. Although some psychological interventions may be effectively applied to all types of chronic pain, other psychological interventions may have greater effectiveness if targeted towards specific pain types or specific aspects of chronic pain conditions.

Chronic Pain Conditions

Fibromyalgia Chronic Low Back Pain Rheumatologic Pain Headache Chronic or Persistent Pain in General (including the conditions listed above)

Fibromyalgia

Description

Fibromyalgia (FM) is a generalized chronic pain condition affecting 2-4% of the adult US population with women being more commonly affected than men. Hypothesized mechanisms involved in both the triggering and maintenance of symptoms include sleep disturbance, predisposing activity in the autonomic nervous system and the hypothalamic-pituitary adrenal (HPA) axes, and central amplification of nociceptive, affective, and cognitive processing of sensory information. Symptom domains of concern to patients with FM include persistent pain and tenderness, stiffness, fatigue, sleep disturbance, cognitive problems, problems with mood, and decreased functional status. No treatments are consistently effective for FM; however the strongest evidence currently supports the use of several pharmacological approaches, aerobic exercise, and Cognitive Behavioral Therapy (CBT).


Multi-Component Cognitive Behavioral Therapy for FM (Strong Research Support)

Multi-Component Cognitive Behavioral Therapy for Fibromyalgia



Description

Cognitive Behavioral Therapy (CBT) for FM can be tailored to target many of the symptom domains associated with FM. CBT emphasizes the learning of adaptive behavioral responses to illness and in so doing, alters thinking styles, experiences, and emotional responses that can maintain or worsen the illness. Given FM is a multifaceted disorder; unimodal treatment (i.e. focusing just on pain) is unlikely to lead to maximum positive outcomes. Thus CBT for FM often includes the following components: (1) education about FM including the nature of the disorder and the role patients can play in its management, (2) Symptom self-management skills targeting pain, fatigue, sleep, cognition, mood, and functional status (e.g. relaxation techniques, graded activation, pleasant activity scheduling, sleep hygiene), and (3) Life style change promoting skills targeting barriers to change, unhelpful thinking styles, and long term maintenance of change (e.g. stress management, goal setting, structured problem solving, reframing, and communication skills). In order to better learn and integrate skills into one’s life style, CBT relies upon self-monitoring, skill rehearsal, and social reinforcement. CBT for fibromyalgia can be administered either individually or in small groups over 6 to 10 sessions.

Chronic Low Back Pain

Description

Acute low back pain affects roughly a quarter of the adult U.S. population at any given time. Most cases are self-limited and medical attention is not sought. Up to a third of cases annually persist for longer than 1-3 months and are considered to have transitioned into chronic low back pain (CLBP). Chronic low back pain is associated not only with pain, but also with decreased functionality, work loss, and disability. Pain and disability are influenced not only by injury and structural abnormalities; but also by patients’ attitudes and beliefs, psychosocial factors, and behavioral patterns. Treatment is often composed of multidisciplinary efforts to remove the underlying organic problem (if identified) and by efforts to reduce disability by focusing on environmental factors, central pain processing mechanisms, de-conditioning, fear of re-injury, and other affective, cognitive-evaluative, social, and behavioral factors.


Behavioral and Cognitive Behavioral Therapy (Strong Research Support)

Behavioral and Cognitive Behavioral Therapy for Chronic Low Back Pain


http://www.div12.org/PsychologicalTreatments/treatments/chronicpain_bct_clbp.html


Description

Behavioral Therapy (BT) and Cognitive Behavioral Therapy (CBT) for CLBP are terms for psychological interventions that often get applied inter-changeably in the CLBP literature. Therapies based upon these principles seek to help the patient with pain reduce symptom intensity, regain functioning, and reduce suffering. Many techniques get incorporated into this form of therapy and rarely are single components applied in actual practice. Techniques can include time-contingent pacing, spouse involvement and reinforcement of adaptive responding, use of quotas and goals for gradual return of functioning, reframing of affective and cognitive responses, learning of coping skills, and learning of the relaxation response (e.g. progressive muscle relaxation, biofeedback). In order to better learn and integrate skills into one’s life style, CBT relies upon self-monitoring, skill rehearsal, and social reinforcement. CBT for CLBP is most often administered either individually or in small groups over 8-12 sessions and is often incorporated into a broader medical and/or physical therapeutic program.

Rheumatologic Pain

Description

Rheumatologic pain conditions include such diagnoses as Osteoarthritis (OA) and Rheumatoid Arthritis (RA). OA and RA appear to have a prevalence of 7% and 1% of the population in the U.S. respectively. OA is considered to be a degenerative form of arthritis involving low grade inflammation of the joints, wearing of the cartilage, and diminished ability of synovial fluid to lubricate joints. The resultant pain is associated with avoidance of weight bearing, walking and standing behaviors that contribute to secondary complications including muscle atrophy and lax ligaments. While any joint can be affected by OA, the most common are joints in the hands, feet, spine, hips, and knees. RA also involves inflammation of the joints but includes soft tissue swelling as well. It is considered an autoimmune disorder (in this case, a disorder where the immune system turns upon its own joints resulting in pain). Pain is a consequence of the biological mechanisms underlying each of these Rheumatological disorders and needs to be considered in the overall management of the disorder. While psychological processes are not considered central to the development of OA or RA, psychological factors can play critical roles in the management of the chronic pain and quality of life issues associated with these conditions.


Multi-Component Cognitive Behavioral Therapy for Rheumatologic Pain (Strong Research Support)

Multi-Component Cognitive Behavioral Therapyfor Rheumatologic Pain

http://www.div12.org/PsychologicalTreatments/treatments/chronicpain_ct_rp.html



Description

Cognitive Behavioral Therapy (CBT) for Rheumatologic pain conditions is based upon the idea that adaptation to persistent pain involves personal control over nociceptive, affective, cognitive, and behavioral aspects of the pain experience. Typically CBT for Rheumatologic pain involves three components. The first is education about chronic pain. Through education, the patient and clinician share a common knowledge base upon which to discuss the nature of pain, options for treatment, and the importance of patients playing an active role in pain management. The second component is symptom self-management skills targeting pain, affect, cognition, and functional status (e.g. relaxation techniques, graded activation, and pleasant activity scheduling. The third component involves the promotion of life style change, maintenance of benefit, and relapse prevention. Such skills involve stress management, goal setting, structured problem solving, reframing, and communication skills. In order to better learn and integrate skills into one’s life style, CBT relies upon self-monitoring, skill rehearsal, and social reinforcement. CBT for Rheumatologic conditions can be administered either individually or in small groups over 8-12 sessions.

Chronic Headache

Description

While the brain itself is not sensitive to pain; there are networks of nerves (e.g. meninges), blood vessels, and muscles extending over the scalp, face, and neck that can become quite painful. While most headaches are benign and self-limiting, 16% of Americans experience some form of chronic headache. Headaches have a number of causes including, high blood pressure, fever, inflammation, infection, substance use, structural abnormalities, and as symptoms of other disorders. Some forms of headache are predominantly associated with muscular tension in the face or neck (e.g. tension headache) or with sustained awkward neck movements (e.g. cervicogenic headache). Other headaches are driven neurologically and are associated with vascular changes, nausea, and at times visual disturbances (e.g. migraine). A thorough diagnostic exam helps to determine the most appropriate treatment options for the different kinds of headaches.


Cognitive-behavioral treatment for Chronic Headaches (Strong Research Support)

Cognitive Behavioral Therapy for Chronic Headache

http://www.div12.org/PsychologicalTreatments/treatments/chronicpain_cbt_ch.html



Description

When a stressor is perceived, the human body adjusts by having its autonomic nervous systeminitiate changes in muscle tension, heart rate, blood blow, brainwave patterns, and other neurochemical responses. While such a response can be helpful in the short run, chronic adjustments like this can be hard on the body producing secondary unwanted symptoms. The relaxation response is a method of calming the body’s physiological response to stress. It is a learned behavioral strategy where through skill and practice, the individual takes conscious control over his/her own body’s physiological response to stressors. There are a number of methods for teaching the relaxation response including progressive muscle relaxation, visual imagery, and mindfulness meditation. Biofeedback modalities support the learning of the relaxation response through the use of electrodes placed over muscles (e.g. EMG-assisted relaxation) which then provides immediate feedback to individuals regarding the success of their attempts to alter muscle tension. Related biofeedback techniques can be used to monitor bloodflow and sweating responses (i.e. other indicators of physiological arousal). In multi-component CBT for chronic headache, cognitive coping skills for pain are taught in addition to the relaxation response so as to provide the individual several skills for managing headache pain. The combination of cognitive therapy with the relaxation response has been shown to produce more headache relief than relaxation alone for tension headache. For vascular headache (e.g migraine) the value of adding the cognitive therapy to the relaxation response is less clear.

Chronic or Persistent Pain in General (including numerous conditions)

Description

There are numerous sources of chronic or persistent pain such as fibromyalgia, headache, back problems, and rheumatological conditions among many others. Some treatments are being examined as interventions for chronic or persistent pain regardless of the source of the pain. Research on such treatments will be presented on this page.


Acceptance and Commitment Therapy for Chronic Pain (Strong Research Support)

Acceptance and Commitment Therapy for Chronic Pain Status: Strong Research Support

http://www.div12.org/PsychologicalTreatments/treatments/chronicpain_act.html


Description

Acceptance and Commitment Therapy (pronounced "ACT" as one word) is a type of cognitive-behavioral therapy that stems from research and theory on experiential avoidance-the idea that private experiences (emotions, thoughts, and symptoms including pain) that are routinely avoided lead to various disorders. ACT also is based on Relational Frame Theory, a theory of how human language influences experience and behavior. ACT aims to change the relationship individuals have with their own feared or avoided thoughts, feelings, memories, and physical sensations. Acceptance and mindfulness strategies are most commonly used to teach patients to decrease avoidance, to disconnect their thoughts from their actions, and to behave according to their broader life values. Acceptance of one's experience, rather than change or control of symptoms, is emphasized. Patients learn to clarify their goals and values and to commit to behave accordingly. ACT is a model of therapy, not a specific protocol, and there are variations in how ACT is conducted, particularly its format but sometimes the specific techniques. Most protocols include mindfulness, for example, but some do not; however, the overarching approach of specific techniques is to help people to be intensely present-focused. With respect to chronic pain, the expressed goal of ACT is not to reduce symptoms or pain, but to improve functioning by increasing psychological flexibility, or the ability to act effectively according to personal values, even in the presence of negative experiences such as pain.

Depression

Section Author: Dan Strunk (Ohio State University)

Original Section Author 2008-2010: Adele Hayes (University of Delaware)

Description

Clinical depression is more than just feeling blue or down. People who are clinically depressed feel down, sad, and hopeless most of the time, for weeks on end. They often become disinterested in things they used to enjoy. In addition to feeling low all the time, those suffering from depression often have trouble sleeping or eating. They find that they have trouble with their thinking; they may not be able to concentrate well enough to read or even watch television. Those who are depressed often spend a lot of time thinking about death, or thinking that they would be better off dead. The symptoms of depression can be similar to those experienced by someone who is grieving the death of a loved one. However, in depression, these feelings can arise without such a loss, and they last much longer than normal grief.

According to the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of Major Depressive Disorder is given when five or more of the following symptoms have been present during a consecutive two-week period:

Depressed mood most of the day, nearly every day. Markedly diminished interest or pleasure in all or almost all activities most of the day,

nearly every day. Significant weight loss when not dieting or a decrease or increase in appetite nearly

every day. Difficulty sleeping, or sleeping too much nearly every day.

Noticeably physically agitated or slowed down, as observed by others nearly every day. Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive guilt nearly every day. Diminished ability to concentrate or make decisions nearly every day. Recurrent thoughts of death or suicide.


Behavior Therapy/Behavioral Activation (strong research support) Cognitive Therapy (strong research support) Cognitive Behavioral Analysis System of Psychotherapy (strong research support) Interpersonal Therapy (strong research support) Problem-Solving Therapy (strong research support) Self-Management/Self-Control Therapy (strong research support) Acceptance and Commitment Therapy (modest research support) Behavioral Couple Therapy (modest research support) Emotion-Focused Therapy (Process-Experiential) (modest research support) Rational Emotive Behavioral Therapy (modest research support) Reminiscence/Life Review Therapy (modest research support) Self-System Therapy (modest research support) Short-Term Psychodynamic Therapy (modest research support)

For more information on depression and its treatment, please visit the National Institute of Mental Health website.

Behavior Therapy/Behavioral Activation for Depression



Description

A central assumption of most behavioral therapies for depression is that this disorder is associated with problematic behavior-environmental relationships. These therapies are based on early behavioral social learning theories of depression (e.g., Ferster 1973, 1981; Lewinsohn, 1974). According to these theories, depression is associated with low levels of positive reinforcement and high levels of aversive control, which can be due to problems in the environment or to skill deficits. When people get depressed, they increasingly withdraw from their environment, engage in escape behaviors, and disengage from their routines. Over time, this avoidance exacerbates depressed mood, as individuals lose opportunities to be positively reinforced through experiences, social activity, or experiences of mastery. Behavior therapies focus on increasing the frequency and quality of pleasant activities, increasing one's sense of mastery, decreasing aversive consequences, and improving mood. Behavior therapies usually involve techniques such as activity scheduling, ongoing monitoring of pleasant activities and feelings of mastery, gradual exposure to more challenging activities, and if needed, social skills and self-control training (e.g., Rehm, 1977).

http://www.div12.org/PsychologicalTreatments/faq.html#support

A number of therapies for depression have grown out of this behavioral tradition. The Coping with Depression Course (Antonuccio, 1998; Lewinsohn, Youngren, & Zeiss, A. Z., 1992) is a psychoeducational group that includes behavioral and cognitive skills training. Muñoz and colleagues have developed programs for low-income and minority populations, such as the Reality Management group (Muñoz, Ippen, Rao, &. Dwyer,2000), which builds on behavioral principles and also includes cognitive and interpersonal components. These manuals are available in Spanish. Behavioral Activation (BA) is the most recent iteration of these early behavioral therapies. BA increases activation systematically with graded exercises to increase the patient's contact with sources of reward, identify processes that inhibit activation, teach skills to solve life problems, and improve one's life context (Martell, Addis, & Jacobson, 2001). BA does not include cognitive components. A version of behavioral activation has also been applied to a depressed inpatient sample in an initial pilot study (Hopko, LeJuez, LePage, Hopko, & McNeil, 2003). Cognitive-Behavioral Therapy for Late Life Depression applies behavioral principles to geriatric depression (Thompson, Gallagher-Thompson, & Dick, 1995, Revised, 2005) and also includes some cognitive components.

Cognitive Therapy for Depression



Description

Cognitive therapy (CT) for depression evolved from Beck's (1967) cognitive theory that depression is maintained by negatively biased information processing and dysfunctional beliefs. CT is a structured, problem-focused, and time-limited therapy. Patients are taught to monitor and record their negative thoughts so that they can recognize the associations between their thoughts, feelings, physiology, and behavior. They learn to evaluate the validity and utility of these cognitions, test them out empirically, and change dysfunctional cognitions to a more adaptive viewpoint. As therapy progresses, patients learn to identify, evaluate, and modify underlying assumptions and dysfunctional beliefs that can put them at risk for relapse. Behavioral techniques such as activity scheduling, self-monitoring of mastery and pleasure, and graded task assignments are used early in therapy to help patients overcome inertia and expose themselves to potentially rewarding experiences. Patients also learn adaptive coping and problem-solving skills. Cognitive therapists use a variety of strategies and techniques to help depressed patients address their thinking, including psychoeducation, guided discovery, socratic questioning, role playing, imagery, and behavioral experiments. CT is typically 14 to 16 sessions, although therapy can take longer if symptoms are more severe and chronic. Cognitive therapy can be delivered individual and group formats, and it has been applied to geriatric populations.

Maintenance of treatment gains is enhanced by booster sessions during the first year after termination. Several variants of cognitive therapy have been developed as more structured relapse prevention programs. Cognitive Therapy- Continuation (Jarrett & Kraft, 1997) provides 8 to 10 monthly sessions. Patients learn to use emotional distress and depressive symptoms to


practice the coping and other skills learned in the acute phase of therapy and to enhance generalization of these skills. Well-Being Therapy (Fava & Riuni, 2003) provides 8 to 12 sessions designed to facilitate well-being after recovery from depression and reduce the risk of relapse. This therapy is not symptom-focused but rather focuses on building the components of mental health in Ryff's (1989) model: autonomy, personal growth, environmental mastery, purpose, positive relations, self-acceptance. Cognitive restructuring, activity scheduling, assertiveness training, and problem solving skills are used. Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2001) is an eight-session relapse prevention program that combines mindfulness meditation with cognitive therapy techniques. Patients learn to recognize the negative thought processes associated with depression and to change their relationship with these thoughts. By unhooking from these thoughts and recognizing their transient nature, patients can learn to prevent the downward spiral from negative mood to rumination to depression. MBCT is especially helpful to reduce the risk of relapse in those with chronic depression.

Cognitive Behavioral Analysis System of Psychotherapy for Depression



Description

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCollough, 2000) is an integrative therapy for chronically depressed adults that combines components of cognitive, behavioral, interpersonal, and psychodynamic therapies. According to this model, those with chronic depression experience disconnectedness from their environment and therefore have decreased access to important feedback on problematic interpersonal patterns and relationships. The therapeutic relationship is actively used to help patients generate empathic behavior, identify and change interpersonal patterns related to depression, and heal interpersonal trauma. CBASP consists of three techniques: 1) Situational Analysis, a problem-solving technique designed to help the patient realize the consequences of his/her behavior on others and modify it, 2) Interpersonal Discrimination Exercises, examination of past traumatic experiences with others and differentiation of those from healthier relationships, and 3) Behavioral Skill Training/Rehearsal, such as assertiveness training, to further help depressed individuals modify maladaptive behavior. McCollough (2000) strongly recommends that all patients who begin CBASP therapy also begin a regime of antidepressant medication.

Interpersonal Therapy for Depression




Description

Interpersonal Therapy (IPT) for depression was developed by the late Gerald Klerman and Myrna Weissman. IPT recognizes that depression arises from multiple influences, but the emphasis is placed on understanding and treating depression within an interpersonal context. Patients are taught to view depression as a medical disorder rather than a characterological problem and at the same time are motivated to work toward change and symptom reduction. The initial sessions are devoted to taking a detailed interpersonal inventory and formulating the patient's depression in interpersonal terms related to four main interpersonal domains: 1) complicated grief, 2) interpersonal disputes, 3) role transitions, and 4) interpersonal deficits. Therapist interventions include clarification, supportive listening, encouragement of affect, role playing, and communication analysis. IPT is structured and manualized but is less directive than cognitive and behavioral therapies. IPT typically includes 12 to 16 sessions. It is available in individual and group formats and has been applied to geriatric populations.

Problem-Solving Therapy for Depression



Description

Problem-solving therapy (PST) teaches patients to more effectively generate solutions for problems, such as interpersonal conflicts or the pursuit of goals. Therapists help patients learn and effectively apply the steps of problem solving, including: 1) identifying problems, 2) generating multiple alternative solutions, 3) selecting the best solution from the alternatives, 4) developing a plan, 5) implementing the problem solving tactic, and 6) evaluating the efficacy of problem solving. According to Cuijpers, van Straten, and Warmerdam (2007) there are three general types of problem-solving therapy: social problem-solving therapy, problem-solving for primary care settings (which can be conducted by paraprofessionals), and self-examination problem-solving therapy, which helps patients determine their major goals, evaluate problems that are blocking those goals, and engage in problem-solving and acceptance of uncontrollable problems. PST is a short-term therapy (8-16 sessions) that can be provided in individual or group format. PST for primary care settings is briefer and consists of 4 to 6 sessions. PST has also been applied to geriatric and medical populations. PST has received empirical support as a treatment for depression, but some findings are mixed. Nezu (2004) notes that outcomes are best when the problem-solving orientation component of PST is included in addition to the skills training.

Self-Management/Self-Control Therapy for Depression





Description

Self-Management/Self-Control Therapy is a behavioral therapy that is based on Kanfer's (1970) model of self-control. This model characterizes depression as involving selective attention to negative events and immediate consequences of events; stringent self-evaluative standards; negative, inaccurate attributions of responsibility for events; insufficient self-reinforcement; and excessive self-punishment. The therapy, developed by Rehm (1997; Fuchs & Rehm, 1977), involves didactic presentations, instructional exercises to teach concepts and skills, and the application of these skills to the day-to-day lives of participants through homework assignments. This 10-session program can be delivered in group or individual formats, and it has been applied to the treatment of depression in children and adolescents, adults, and geriatric populations.

Rational Emotive Behavioral Therapy for Depression



Description

Rational emotive behavioral therapy (REBT) is a form of CBT developed by Albert Ellis (Ellis, 1994). Like other forms of CBT, REBT is a present-focused, short-term therapy. In REBT, therapists work with their clients to help them make changes in those aspects of their thinking hypothesized to contribute to emotional and behavioural problems. REBT is distinct from other forms of CBT in its greater emphasis on: (1) unconditional self-acceptance; (2) reducing secondary problems, such as depression about depression; and (3) efforts to reduce demanding beliefs (David, Szentagotai, Lupu, & Cosman, 2008).

Short-Term Psychodynamic Therapy for Depression



Description

In general, brief dynamic therapies for depression focus on increasing patients' awareness and insight about problematic patterns and core relational themes related to depression. Different types of psychodynamic therapy have been studied in clinical trials, but all do not use treatment manuals and some of the therapies are not designed specifically to treat depression. However, data are accumulating to suggest that short-term therapies in this class are efficacious. Some common themes across the different forms of brief dynamic therapy for depression include a focus on: 1) how past experiences influence current functioning, 2) affect and the expression of emotion, 3) the therapeutic relationship, 4) facilitation of insight, 5) avoidance of uncomfortable topics, and 6) the identification of core conflictual relationship themes. Therapy is time-limited




and includes approximately 16 to 20 sessions. These therapies have also been developed for geriatric populations.

Eating Disorders and Obesity

Section Author: Katharine L. Loeb, Ph.D. (Fairleigh Dickinson University, and Mount Sinai School of Medicine)

Description

This webpage reviews scientifically-evaluated psychological treatments for eating disorders and obesity. Many medications are also helpful for these problems, but we do not cover medications in this website. Of course, we recommend a consultation with a mental health professional for an accurate diagnosis and discussion of various treatment options. When you meet with a professional, be sure to work together to establish clear treatment goals and to monitor progress toward those goals. Feel free to print this information and take it with you to discuss your treatment plan with your therapist.

Eating Disorders:

Anorexia Nervosa

Bulimia Nervosa

Binge Eating Disorder

Obesity And Pediatric Overweight

Anorexia Nervosa


Description

Anorexia nervosa is a serious disorder characterized by a persistent refusal to maintain a normal body weight, extreme fear of gaining weight, disturbance in the experience of shape and weight, denial of the seriousness of one’s low body weight, and, in post-pubertal females, sustained absence of menstrual cycles. Anorexia nervosa carries significant medical risk as well as the highest risk of death of the psychological disorders. Individuals with anorexia nervosa frequently experience co-occurring depression, and half the deaths in anorexia nervosa result from suicide. In most cases, the fear of weight gain is sufficiently strong to deter people with this problem from engaging in treatment. There are two subtypes of anorexia nervosa: restricting type, in which individuals achieve and maintain their low weight exclusively via dieting, fasting,

http://www.div12.org/PsychologicalTreatments/disorders/obesity_main.php

http://www.div12.org/PsychologicalTreatments/disorders/binge_main.php

http://www.div12.org/PsychologicalTreatments/disorders/bulimia_main.php

http://www.div12.org/PsychologicalTreatments/disorders/anorexia_main.php

and/or excessive exercise, and binge eating/purging type, in which individuals also engage in one or both of these problematic behaviors.


Family-Based Treatment (strong research support)

Cognitive Behavioral Therapy (modest/controversial research support)

Family-Based Treatment for Anorexia Nervosa



Description

Family-Based Treatment (FBT) for anorexia nervosa is an outpatient intervention for adolescents designed to restore weight without hospitalization; however, if a patient is medically unstable, a brief stay in an inpatient unit to resolve the medical concerns may be warranted, followed by a course of FBT. While there are many types of family therapy, FBT specifically refers to a treatment modality developed at the Maudsley Hospital in London, England or its adaptations. FBT is typically conducted in 20 sessions over 12 months, although a shorter course is sufficient for many cases while additional sessions may be necessary for others. FBT consists of three phases. In the first phase, parents are placed in charge of the process of nutritional rehabilitation and weight restoration with the help of the therapist. The adolescent’s autonomy in other domains (friendships, school) is kept intact, at a level consistent with the patient’s stage of development. In the second phase of treatment, once the acute starvation is reversed, control over eating is returned to the adolescent. The third phase of treatment addresses termination and issues of family structure and normal adolescent development. FBT views the parents of adolescents with anorexia nervosa as a resource for resolving the problem, and corrects misperceptions of blame directed to the parents and to the ill adolescent. Siblings play a supportive role in treatment, and are protected from the job assigned to the parents. The focus of FBT is not on what caused the anorexia nervosa, but on what can be done to treat it with as little reliance on hospitalization as possible.

Cognitive Behavioral Therapy for Anorexia Nervosa

Status: Modest Research Support for Post-Hospitalization Relapse Prevention Status: Controversial for Acute Weight Gain


Description


http://www.div12.org/PsychologicalTreatments/treatments/anorexia_cognitive.html

http://www.div12.org/PsychologicalTreatments/treatments/anorexia_family.html

Cognitive Behavioral Therapy (CBT) as a post-hospitalization outpatient intervention for anorexia nervosa is designed to prevent relapse once a patient has gained weight in the context of inpatient treatment. CBT for acute weight gain is designed to restore weight on an outpatient basis. CBT for anorexia nervosa, designed for late adolescents and adults with this disorder, is typically conducted on an individual basis over the course of one year. Biweekly session are recommended initially while weekly sessions are sufficient once weight is stable. This treatment is explicitly focused on the achievement and maintenance of a healthy weight, particularly one at which (for females) return of menses is possible. CBT for anorexia nervosa employs behavioral strategies including the establishment of a regular pattern of eating and systematic exposure to forbidden foods, while simultaneously addressing cognitive aspects of the disorder such as motivation for change and disturbance in the experience of shape and weight. CBT for anorexia nervosa also emphasizes schema-level change and challenges the seemingly inextricable tie between personal identity and the illness.

Bulimia Nervosa


Description

Bulimia nervosa is characterized by frequent episodes of binge eating, defined as the uncontrolled consumption of abnormally large amounts of food in a discrete period of time, as well as problematic attempts to counteract the effects of overeating. Most commonly, the compensatory mechanisms take the form of self-induced vomiting, although individuals with bulimia nervosa can also engage in other forms of purging (e.g., laxative or diuretic misuse) as well as fasting and excessive exercise. If someone with this problem exclusively fasts and/or exercises excessively following binge eating episodes without purging, they are considered to have a non-purging subtype of the disorder. The self-concept of individuals with bulimia nervosa is disproportionately influenced by their shape and weight. Individuals with bulimia nervosa are normal to overweight; if someone is underweight and binge eats and purges, s/he would likely be diagnosed with anorexia nervosa, binge/purge type.


Cognitive Behavioral Therapy (strong research support)

Interpersonal Psychotherapy (strong research support)

Family-Based Treatment (modest research support)

Healthy-Weight Program (controversial research support)

Cognitive Behavioral Therapy for Bulimia Nervosa

http://www.div12.org/PsychologicalTreatments/treatments/bulimia_healthyweight.html

http://www.div12.org/PsychologicalTreatments/treatments/bulimia_family.html

http://www.div12.org/PsychologicalTreatments/treatments/bulimia_interpersonal.html

http://www.div12.org/PsychologicalTreatments/treatments/bulimia_cognitive.html



Description

Cognitive Behavioral Therapy (CBT) for bulimia nervosa directly targets the core features of this disorder, namely binge eating, inappropriate compensatory behaviors, and excessive concern with body shape and weight. This treatment focuses on how these symptoms cycle to perpetuate themselves in the present, as opposed to why they originally developed in the past. CBT for bulimia nervosa is conducted in approximately twenty weekly sessions, which encompass three phases. The first phase includes psychoeducation regarding weight and the adverse physiological effects of binge eating, purging, and extreme dieting, and helps the patient establish a regular pattern of eating and an appropriate weight monitoring schedule. In the second phase, the focus shifts to reducing shape and weight concerns and dieting behavior, and identifying precipitants to any remaining binge-purge episodes. The third phase is devoted to maintenance planning and the prevention of relapse in the future. In CBT, the therapist works collaboratively with the patient to disrupt the factors maintaining the binge-purge cycle with the goal to achieve abstinence from these behaviors. This treatment is typically administered individually, but it can be delivered in group format. Therapists can also guide patients in a self-help version of CBT for bulimia nervosa. CBT has the strongest scientific evidence of all the tested psychological treatments for bulimia nervosa. An enhanced version of CBT has recently been developed and tested at Oxford University to treat the spectrum of eating disorders, including bulimia nervosa.

Interpersonal Psychotherapy for Bulimia Nervosa



Description

Interpersonal Psychotherapy (IPT) for bulimia nervosa is based on an intervention originally developed for the treatment of depression. In IPT, the focus is on interpersonal difficulties in the patient’s life. The connection between these problems and the development and maintenance of the eating disorder is identified at the beginning of treatment, but only implied thereafter; for the majority of the therapy, the symptoms of bulimia nervosa are never explicitly addressed. IPT for bulimia nervosa is conducted in approximately twenty weekly sessions, which encompass three phases. The first phase of IPT is devoted to identifying specific interpersonal problems areas currently affecting the patient, and choosing which of these areas to focus on for the remainder of treatment. The four typical interpersonal problem domains are role disputes, role transitions, interpersonal deficits, and unresolved grief. Interpersonal precipitants of current binge eating episodes are highlighted during this phase. In the second phase of IPT for bulimia nervosa, the therapist encourages the patient to take the lead in facilitating change in the interpersonal realm. The therapist’s role involves keeping the patient aware of the time frame of treatment and focused on the problem areas, clarifying issues raised by the patient, and encouraging change. The third phase covers maintenance of interpersonal gains and relapse prevention. This


treatment is typically administered individually, but it can be delivered in group format. In clinical trials, IPT for bulimia nervosa has been shown to have a slower effect than CBT in achieving symptom improvement and resolution.

Family-Based Treatment for Bulimia Nervosa



Description

Family-Based Treatment (FBT) for bulimia nervosa is adapted from FBT for anorexia nervosa and like its predecessor, is designed for adolescents. While there are many types of family therapy, FBT specifically refers to a treatment modality originally developed at the Maudsley Hospital in London, England. FBT for bulimia nervosa is an outpatient intervention typically conducted in 20 sessions over 6 months, although a shorter course is sufficient for some cases while additional sessions may be necessary for others. FBT consists of three phases. In the first phase, parents are placed in charge of helping their child reestablish healthy eating patterns and prevent binge eating and purging episodes from occurring. While this process is collaborative in nature, parental authority is mobilized as necessary in response to the health crisis that the eating disorder poses. The adolescent’s autonomy in other domains (friendships, school) is kept intact, at a level consistent with the patient’s stage of development. In the second phase of treatment, once the acute symptoms have abated and a regular pattern of eating a variety of foods is established, control over eating is returned to the adolescent. The third phase of treatment addresses termination and issues of family structure and normal adolescent development. FBT views the parents of adolescents with bulimia nervosa as a resource for resolving the problem, and corrects misperceptions of blame directed to the parents and to the ill adolescent. Siblings play a supportive role in treatment, and are protected from the job assigned to the parents. The focus of FBT is not on what caused the bulimia nervosa, but on what can be done to resolve this serious disorder.

Binge Eating Disorder


Description

Binge eating disorder is characterized by frequent episodes of binge eating, defined as the uncontrolled consumption of abnormally large amounts of food in a discrete period of time. During these episodes, individuals with binge eating disorder often eat more quickly than usual, eat beyond fullness, eat when not physically hungry, eat alone out of embarrassment, and feel disgusted, depressed, guilty, and distressed. Unlike bulimia nervosa, binge eating disorder is not associated with problematic attempts to immediately counteract the effects of binge eating, such as purging, fasting, and excessive exercise. However, most individuals with this disorder are overweight and engage in ongoing attempts to diet successfully. Binge eating disorder,


which is recognized by patients, clinicians, and researchers as a clinically significant problem, is currently under consideration as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000).



Interpersonal Psychotherapy (strong research support)

Cognitive Behavioral Therapy for Binge Eating Disorder



Description

Cognitive Behavioral Therapy (CBT) for binge eating disorder directly targets the cardinal features of the disorder, namely binge eating and its associated loss of control and distress. Importantly, this treatment aims to resolve the maladaptive eating patterns that maintain the binge eating. CBT for binge eating disorder is conducted in approximately twenty weekly sessions, which encompass three phases. For obese individuals with binge eating disorder, the first phase of treatment explicitly addresses the need to prioritize cessation of binge eating over immediate weight loss, and helps the patient establish a regular pattern of eating and an appropriate weight monitoring schedule. Nutritional education is provided and regular exercise is encouraged. In the second phase, the focus shifts to reducing shape and weight concerns and expanding one’s definition of self-worth, and challenging notions of food addiction or other cognitions that may perpetuate the binge eating. The third phase is devoted to maintenance planning and the prevention of relapse in the future. In CBT, the therapist works collaboratively with the patient to disrupt the factors maintaining the binge eating with the goal to achieve abstinence from this behavior. This treatment can be delivered in either individual or group formats. Therapists can also guide patients in a self-help version of CBT for binge eating disorder.

Interpersonal Psychotherapy for Binge Eating Disorder



Description

Interpersonal Psychotherapy (IPT) for binge eating disorder is based on an intervention originally developed for the treatment of depression. In IPT, the focus is on interpersonal difficulties in the patient’s life. The connection between these problems and the development and maintenance of the eating disorder is identified at the beginning of treatment, but only implied thereafter. IPT for binge eating disorder is administered in either group or individual


http://www.div12.org/PsychologicalTreatments/treatments/binge_interpersonal.html

http://www.div12.org/PsychologicalTreatments/treatments/binge_cognitive.html

format, and is conducted in approximately twenty weekly sessions, which encompass three phases. The first phase of IPT is devoted to identifying specific interpersonal problems areas currently affecting the patient, and choosing which of these areas to focus on for the remainder of treatment. The four typical interpersonal problem domains are role disputes, role transitions, interpersonal deficits, and unresolved grief. Interpersonal precipitants of current binge eating episodes are highlighted during this phase. In the second phase of IPT for binge eating disorder, the therapist encourages the patient to take the lead in facilitating change in the interpersonal realm. The therapist’s role involves keeping the patient aware of the time frame of treatment and focused on the problem areas, clarifying issues raised by the patient, and encouraging change. The third phase covers maintenance of interpersonal gains and relapse prevention.

Obesity And Pediatric Overweight


Description

Obesity is defined as an excess of body weight, relative to height, that is attributed to an abnormally high proportion of body fat. A common metric to calculate presence and degree of obesity is body mass index (BMI). The mathematical formula is for BMI is weight in kilograms / (height in meters)². For adults, a BMI of 25-29.9 represents an overweight status, and a BMI over 30 corresponds to obesity. While there is no scientifically accepted definition of obesity in children and adolescents, pediatric overweight is defined as a BMI-for-age meeting or exceeding the 95th percentile; the 85th percentile marks the point at which a child or adolescent becomes at risk for overweight. Overweight and obesity, which are alarmingly on the rise among children, adolescents, and adults, are established risk factors for a number of medical complications and diseases including diabetes, coronary heart disease, stroke, and sleep apnea. Obesity is not an eating disorder, but it can be associated with maladaptive eating patterns.


Behavioral Weight Loss Treatment (strong research support)

Behavioral Weight Loss Treatment for Obesity and Pediatric Overweight



Description

http://www.div12.org/PsychologicalTreatments/treatments/obesity_behavioral.html

Behavioral Weight Loss Treatment (BWL) for obesity is a short-term intervention designed to achieve acute weight reduction as well as establish new behavioral patterns to increase the likelihood of sustained maintenance of weight loss. A well-studied version of BWL for adults is the LEARN (Lifestyle, Exercise, Attitudes, Relationships, and Nutrition) Program. As the components of its acronym suggest, LEARN promotes change in multiple domains to synergistically yield weight loss. An emphasis of LEARN is the benefit of small, lifestyle-oriented changes (e.g., getting off a bus at an earlier stop and walking the remainder of the distance to one’s destination) that can cumulatively achieve a negative energy balance. LEARN encourages reasonable weight goals and moderation in food choices (no food is completely forbidden). LEARN consists of 12 lessons, which can be conducted in individual or group therapy sessions. BWL for children similarly corrects maladaptive eating and activity patterns and food choices by targeting nutrition, diet, and exercise, and a reduction in sedentary activities such as television viewing. In most adaptations of BWL for children, parents are enlisted to facilitate and support family-level lifestyle changes that promote healthy weight. The development of better problem solving skills for children and parents is an additional part of some protocols. For children, weight loss is frequently less of a goal than weight maintenance during a period of growth, the net effect of which is a reduction in BMI-for-age percentile. BWL typically yields modest short-term weight loss or BMI-for-age percentile reduction in adults and children, respectively. Children typically maintain their weight loss following BWL while adults often experience weight regain, consistent with the data from other weight loss interventions for the adult population.

Generalized Anxiety Disorder

Section Author: Bethany A. Teachman (University of Virginia)

Description

Generalized Anxiety Disorder refers to difficulties controlling anxious apprehension and worry about life events. The anxiety and worry are excessive and unproductive (i.e., it is not problem solving), and concern multiple life domains or activities, such as work or school performance, health of family members, etc. The uncontrollable worry must last for at least six months, and is accompanied by various somatic symptoms, such as muscle tension, restlessness, sleep disturbance or fatigue, as well as difficulties concentrating or irritability. Importantly, the intensity and duration of the anxiety and worry must be out of proportion to the objective likelihood or negative consequences of the feared events. Further, the worry interferes with functioning, making it difficult to focus on tasks.


Cognitive and Behavioral Therapies (strong research support)

Cognitive and Behavioral Therapies for Generalized Anxiety Disorder



Description

http://www.div12.org/PsychologicalTreatments/treatments/anxiety_cbt.html

Cognitive and behavioral therapies for generalized anxiety disorder (GAD) refer to a variety of techniques that can be provided individually or in combination. The basic premise underlying the therapy approaches is that thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate problems in another (e.g., changing negative thinking will lead to less anxiety). The excessive, uncontrollable worry that is the hallmark of GAD is thought to be maintained through maladaptive thinking about the utility of worrying, a tendency to repeat worries instead of problem-solving, difficulties relaxing, and unhealthy behaviors, including attempted avoidance of negative thoughts and images, as well as situations that might provoke worry. The cognitive therapy techniques focus on modifying the catastrophic thinking patterns and beliefs that worrying is serving a useful function (termed cognitive restructuring). The behavioral techniques include relaxation training, scheduling specific ‘worry time’ as well as planning pleasurable activities, and controlled exposure to thoughts and situations that are being avoided. The purpose of these exposures is to help the person learn that their feared outcomes do not come true, and to experience a reduction in anxiety over time.

The research evidence suggests that both cognitive or behavior therapy on their own can be helpful for GAD (especially cognitive restructuring or applied relaxation). However, there may be some advantage to combining the approaches, with some studies finding that the treatment is more powerful when therapy involves cognitive work, exposures and relaxation. Cognitive Behavior Therapy (CBT) typically refers to a combination of the various cognitive and behavioral approaches, and ‘Anxiety Management Training’ usually refers to the particular combination of relaxation and cognitive restructuring. The therapies can be conducted individually or with a group, and CBT is helpful for older adults with GAD as well. Typically, CBT will be conducted in weekly sessions of 1–2 hours over the course of approximately 4 months, for a total of 16–20 hours of treatment.

Insomnia

Section Authors: Lee M. Ritterband and Elise M. Clerkin* (University of Virginia)

Description

Insomnia involves a subjective complaint of problems initiating and/or maintaining sleep, or nonrestorative sleep. There are four main types of sleep problems that can occur in the context of insomnia: 1) Sleep Onset (difficulty falling asleep); 2) Sleep Maintenance (wakening during the night and having difficulty falling back to sleep); 3) Terminal Early Awakening (waking early in the morning and being unable to fall back to sleep); and 4) Mixed Sleep Problems (combination of difficulties initiating and sustaining sleep). Insomnia is associated with a range of problems, including clinically significant impairment or distress in social, occupational, and other important areas of functioning.

Although Cognitive Behavior Therapy (CBT) is widley regarded as one of the most effective treatments for insomnia, some of CBT’s component techniques are also independent treatments for insomnia (e.g., Sleep Restriction, Stimulus Control, etc.). As of yet, there has not been a complete dismanteling of CBT to isolate the relative efficacy of each component within the same study. Therefore, we have included research status information for CBT generally, as well as research status information for some of the techniques comprising CBT.

Psychological Treatments:

Cognitive Behavior Therapy (strong research support)

Sleep Restriction Therapy (strong research support)

Stimulus Control Therapy (strong research support)

Relaxation Training (strong research support)

Paradoxical Intention (strong research support)

Electromyograph (EMG) Biofeedback (modest research support)

Cognitive Behavior Therapy for Insomnia



Description

Cognitive-behavioral treatment (CBT) for insomnia focuses on maladaptive behaviors and dysfunctional thoughts that perpetuate sleep problems. The main components of therapy include behavioral, cognitive, and educational interventions. Behavioral interventions focus on a variety of ‘guidelines’ that patients must follow in order to retrain their bodies to associate sleep with bed. Behavioral techniques include stimulus control and sleep restriction (see descriptions below). Cognitive interventions attempt to address and change the many negative beliefs and thoughts about sleep that may exacerbate sleeping difficulties. Finally, educational interventions focus on understanding the different types of sleep and sleep cycles, as well as improving sleep hygiene and other maladaptive behaviors (e.g., establishing regular sleeping schedules, eliminateing napping, and avoiding stimulunts, exercise, and alcohol before bedtime).

Sleep Restriction Therapy for Insomnia



Description

Sleep restriction therapy utilizes a form of systematic sleep deprivation in which a sleep window is established and maintained to allow the body to (re)learn proper sleeping dynamics and increase sleep efficiency. For example, if a patient reports spending about 8 hours per night in bed, but only sleeps 6 of those hours, the amount of time in bed would be reduced to closely match the amount of time the patient typically sleeps in bed (in this case, 6 hours). Periodic adjustments to this sleep window are made contingent upon sleep efficiency, until an optimal sleep duration is reached.

Stimulus Control Therapy for Insomnia


http://www.div12.org/PsychologicalTreatments/treatments/insomnia_emg.html

http://www.div12.org/PsychologicalTreatments/treatments/insomnia_paradoxical.html

http://www.div12.org/PsychologicalTreatments/treatments/insomnia_relaxation.html

http://www.div12.org/PsychologicalTreatments/treatments/insomnia_stimulus.html

http://www.div12.org/PsychologicalTreatments/treatments/insomnia_sleep.html

http://www.div12.org/PsychologicalTreatments/treatments/insomnia_cognitive.html



Description

The main goal in stimulus control therapy is to reduce the anxiety or conditioned arousal individuals may feel when attempting to go to bed. Specifically, a set of instructions designed to reassociate the bed/bedroom with sleep and to re-establish a consistent sleep schedule are implimented. These include: 1) Going to bed only when sleepy; 2) Getting out of bed when unable to sleep; 3) Using the bed/bedroom only for sleep and sex (i.e., no reading, watching TV, etc); 4) Arising at the same time every morning; and 5) Avoiding naps.

Relaxation Training for Insomnia



Description

In relaxation-based treatments, patients are taught formal exercises focused on reducing somatic tension (e.g., progressive muscle relaxation, autogenic training) or intrusive thoughts at bedtime (e.g., imagery training, meditation). Multiple weekly or biweekly sessions are typically required to adequately teach relaxation skills. Practice at home is also encouraged, so patients can gain mastery of the relaxation techniques. Although relaxation therapy is demonstrably effective, there is little evidence suggesting differential effectiveness across the range of relaxation modalities.

Paradoxical Intention for Insomnia



Description

Paradoxical intention is a cognitive technique that consists of persuading a patient to engage in his or her most feared behavior. In the context of insomnia, this type of therapy is premised on the idea that performance anxiety inhibits sleep onset. Paradoxically, if a patient stops trying to fall asleep and instead stays awake for as long as possible, the performance anxiety is expected to diminish; thus, sleep may occur more easily. In clinical practice, some patients are fairly reluctant to use this procedure, and compliance is often problematic. Sleep restriction therapy, a similar technique with a different rationale, may be more readily accepted by patients.

Biofeedback-Based Treatments for Insomnia






Description

Biofeedback is a training technique that conveys information about a patients’ bodily functions that are typically considered outside conscious control. For instance, EMG biofeedback provides information about muscular activity. When treating insomnia, biofeedback is often used in conjunction with relaxation training or other behavioral approaches. The goal is to help raise patients’ awareness of their physiological processes, so that they might gain control over them. For instance, biofeedback may help people recognize both when they are having an exaggerated physical stress response, and well as to what they are responding. Eventually, this is thought to help people learn to control and minimize their stress response, thus leading to healthier sleep.

Mixed Anxiety Conditions

Description

There are numerous types of anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety, and phobias among many others. Some treatments are being examined as interventions for anxiety regardless of the particular type of anxiety disorder. Research on such treatments will be presented on this page.


Acceptance and Commitment Therapy for Mixed Anxiety Conditions (Modest Research Support)

Acceptance and Commitment Therapy for Mixed Anxiety



Description

Acceptance and Commitment Therapy (ACT) is a behavioral therapy that is based on Relational Frame Theory, a theory of how human language influences experience and behavior. ACT aims to change the relationship individuals have with their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Acceptance and mindfulness strategies are used to teach patients to decrease avoidance, attachment to cognitions, and increase focus on the present. Patients learn to clarify their goals and values and to commit to behavioral change strategies. This treatment has been applied to a number of conditions, including anxiety.

Obsessive-Compulsive Disorder

http://www.div12.org/PsychologicalTreatments/treatments/anxietymixed_act.html


Acting Section Author: E. David Klonsky (University of British Columbia) Original Section Authors 2008-2011: Greg Hajcak and Lisa Starr (Stony Brook University)

Description

Obsessive-compulsive disorder, or OCD, is defined by the presence of either obsessions or compulsions (typically both occur). Obsessions are defined as recurrent thoughts, images, or impulses that are viewed by the person as intrusive or inappropriate and that invoke anxiety. Obsessions are not simply amplified worries about real life problems; in fact, the person may view them as silly or unrealistic. Examples include worries about being contaminated with dirt or germs, having something awful happen to a loved one, or having made a terrible mistake. The person attempts to ignore, suppress, or neutralize these obsessions, often through compulsions. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform. These may include actions such as counting, hand-washing, checking (e.g., locks), ordering, or hoarding things with no sentimental or monetary value.


Exposure and Response Prevention (strong research support)

Cognitive Therapy (strong research support)

Acceptance and Commitment Therapy (modest research support)

Exposure and Response Prevention for Obsessive-Compulsive Disorder



Description

Exposure and Response Prevention (EX/RP) involves two components: 1) provoking obsessions and maintaining the subsequent anxiety, and 2) refraining from engaging in rituals. The purpose of this process is to allow the patient to habituate to the obsession-related anxiety; thus, the contingency between the obsessions and compulsions is weakened, and the patient learns that anxiety resulting from the obsession will habituate on its own. Exposures are conducted hierarchically, with less feared stimuli presented first. Exposure may be conducted imaginally or in vivo. Imaginal exposure often focuses on the feared consequences of obsessions. For example, a woman who performs counting rituals to neutralize obsessions about accidentally killing her husband may be asked to vividly imagine killing her husband, while refraining from counting. In vivo exposure involves bringing the patient into the actual presence of feared stimuli. For example, a patient with contamination fears may be asked to sit on the bathroom floor for a specified amount of time, without washing his/her hands or taking a shower. EX/RP is often conducted in conjunction with cognitive therapy techniques. EX/RP typically lasts 12 to 16 sessions; although it is probably often provided on a once-weekly basis, it can be delivered more frequently (e.g., daily or twice-weekly).

http://www.div12.org/PsychologicalTreatments/treatments/ocd_act.html

http://www.div12.org/PsychologicalTreatments/treatments/ocd_cognitive.html

http://www.div12.org/PsychologicalTreatments/treatments/ocd_exposure.html

Cognitive Therapy for Obsessive-Compulsive Disorder



Description

The underlying premise of cognitive therapy assumes that anxious patients experience distorted, dysfunctional thoughts about themselves, the world, and the future, which produce and maintain their anxiety. OCD has been hypothesized to relate to an inflated sense of personal responsibility related to events that may cause harm to either the self or others; Cognitive therapy aims to help the person identify, challenge, and modify these dysfunctional ideas. This is often achieved through Socratic dialogue with the therapist, and through homework assignments in which the patient is instructed to identify and challenge negative automatic thoughts. Cognitive therapy techniques are often used in conjunction with exposure and response prevention.

Acceptance and Commitment Therapy for Obsessive-Compulsive Disorder



Description

Acceptance and Commitment Therapy (ACT) is a behavioral therapy that is based on Relational Frame Theory, a theory of how human language influences experience and behavior. ACT aims to change the relationship individuals have with their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Acceptance and mindfulness strategies are used to teach patients to decrease avoidance, attachment to cognitions, and increase focus on the present. Patients learn to clarify their goals and values and to commit to behavioral change strategies. This treatment has been applied to a number of conditions, including OCD.

Panic Disorder

Section Author: Greg Hajcak (Stony Brook University)

Description

Panic disorder is characterized by unexpected periods of intense anxiety or fear that generally peak within 10 minutes (i.e., panic attacks). Physical symptoms characteristic of panic attacks include: racing or pounding heart, shortness of breath or difficulty breathing, dizziness, nausea, feelings of unreality; individuals may report that they fear they are dying, losing control, or going crazy during panic attacks. Individuals with panic disorder experience persistent fear about subsequent panic attacks and/or the consequences of having a panic attacks. Treatments for



panic disorder are appropriate regardless of whether the panic is accompanied by agoraphobia, or avoidance of places where panic attacks seem likely.



Applied Relaxation (modest research support)

Psychoanalytic Treatment (modest research support/controversial)

Also, see findings from the Division 12 clinical survey on the use of research-supported treatments for Panic Disorder.

Cognitive Behavioral Therapy for Panic Disorder



Description

Many cognitive-behavioral treatments for panic disorder have strong research support; these tend to include both cognitive and exposure-based components. The underlying premise of cognitive therapy assumes that anxious patients experience distorted, dysfunctional thoughts, especially about the catastrophic consequences of certain bodily sensations. Cognitive therapy aims to help the person identify, challenge, and modify dysfunctional ideas related to panic symptoms. This is often achieved through Socratic dialogue with the therapist, and through homework assignments in which the patient is instructed to identify and challenge negative automatic thoughts. Avoidance of panic and panic-cues is targeted through exposure-based components of CBT for panic disorder, including both in vivo (e.g., going to crowded places or driving in traffic) and interoceptive (e.g., bodily sensations) exposures. Interoceptive exposure refers to exposure to bodily sensations and feelings; thus, during interoceptive exposure, patients will deliberately simulate and experience physical sensations such as dizziness, a racing heart, and difficulty breathing. Through interoceptive exposure, patients learn that these physical experiences are aversive, but not dangerous, and do not lead to feared consequences (e.g., death, losing control, going crazy). Patients habituate to their anxiety surrounding these sensations after repeated interoceptive exposures. Most CBT protocols include in-depth psychoeducation about fear and panic attacks, and these treatments tend to last 12 – 16 sessions total; CBT for panic can be delivered in individual and group formats. Many CBT treatments include a relaxation component, although there is some controversy over whether to focus on breathing retraining (cf. Meuret, Wilhelm, Ritz, & Roth, 2003; Schmidt, Woolaway-Bickel, Trakowski, et al., 2000; Taylor, 2001).


http://www.div12.org/panicsurvey

http://www.div12.org/PsychologicalTreatments/treatments/panic_psychoanalytic.html

http://www.div12.org/PsychologicalTreatments/treatments/panic_appliedrelax.html

http://www.div12.org/PsychologicalTreatments/treatments/panic_cbt.html

Applied Relaxation for Panic Disorder



Description

Applied relaxation involves first identifying situations in which panic is likely, as well as early panic cues; next, individuals are taught progressive muscle relaxation, and learn to become relaxed more and more quickly over the course of treatment. Finally, patients are taught to relax in the presence of panic cues, and then in real-world situations in which panic is likely. Thus, applied relaxation teaches patients to quickly relax in increasingly stressful situations.

Psychoanalytic Treatment for Panic Disorder

Status: Modest Research Support/Controversial


Description

Psychoanalytic treatment for panic disorder attempts to uncover the unconscious psychological meaning of panic; the treatment often focuses on psychodynamic conflicts that include separation/autonomy and anger expression/management. Psychoanalytic treatment for panic disorder also utilizes transference to work through unconscious conflicts.

The evidence for psychoanalytic treatment for panic disorder is somewhat controversial, insofar as the conceptual basis for this treatment has not been tested. That is, although psychoanalytic psychotherapy appears to work, it is not yet clear that the treatment works via the reduction of unconscious conflicts – the proposed mechanisms of change.

For a brief commentary on psychoanalytic psychotherapy for panic, see: McKay, D., Abramowitz, J., & Taylor, S., & Deacon, B. (2007). Evolving treatments for Panic Disorder, American Journal of Psychiatry, 164, 976-977.

Post-Traumatic Stress Disorder

Section Authors: Greg Hajcak and Lisa Starr (Stony Brook University)

Description

Post-Traumatic Stress Disorder, or PTSD, sometimes develops following a traumatic event in which the person experienced intense fear, helplessness, or horror. Such events can include rape, assault, combat, kidnapping, or other experiences in which the person was threatened with death or serious injury, or in which the person witnessed someone else experiencing a traumatic event. People who develop PTSD following a trauma often "re-experience" the trauma, through intrusive images, thoughts, and dreams relating to the event, and sometimes feel or act as if the event is recurring. Often people with PTSD become very frightened,



distressed, and/or physiologically reactive in response to cues in the environment that remind them of the event. People with PTSD avoid people, places, and/or activities that remind them of the trauma, and try to avoid thinking about the trauma. Sometimes people with PTSD cannot remember aspects of the trauma. PTSD is also associated with lowered enjoyment of/ participation in activities, feelings of detachment from others, difficulty experiencing certain emotions or being affectionate, and a sense that one's future is foreshortened. In addition, individuals with PTSD tend to be easily aroused, including difficulty sleeping or concentrating, irritability, hypervigilance, and exaggerated startle response. To be diagnosed with PTSD, the person must have experienced these symptoms for at least one month. Individuals who experience these symptoms for less than one month are sometimes given a diagnosis of Acute Stress Disorder, which often develops into PTSD. PTSD often co-occurs with other psychological disorders, such as major depression and substance-related disorders.


Prolonged Exposure (strong research support)

Present-Centered Therapy (strong research support)

Cognitive Processing Therapy (strong research support)

Seeking Safety (for PTSD with co-morbid Substance Use Disorder) (strong research support)

Stress Inoculation Therapy (modest research support)

Eye Movement Desensitization and Reprocessing (strong research support/controversial)

Psychological Debriefing (no research support/potentially harmful)

Prolonged Exposure for Post-Traumatic Stress Disorder



Description

Prolonged exposure therapy involves the gradual confrontation of the traumatic memory, including thoughts, objects, environments, and situations that remind the patient of the trauma. Typically, exposure to the traumatic memory begins in session, and the patient is asked to listen to their traumatic memory for homework. The purpose of this imaginal exposure is to allow the patient to fully process the traumatic event, and to teach the patient that 1) memories/ reminders the trauma are not in themselves dangerous, and are not the same as experiencing the trauma again, 2) anxiety can be controlled without escaping or avoiding the feared stimuli, and 3) anxiety and PTSD symptoms can be experienced without the loss of control. Typically,

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_debriefing.html

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_emdr.html

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_stress.html

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_safety.html

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_cognitive.html

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_present.html

http://www.div12.org/PsychologicalTreatments/treatments/ptsd_exposure.html

hierarchical in vivo (i.e., in person) exposures are also part of prolonged exposure therapy, which involves confronting trauma reminders, including people, places, and objects. Prolonged exposure therapy last approximately 16 sessions and is often delivered twice-weekly or weekly; it is often used alongside other cognitive-behavioral techniques.

Present-Centered Therapy for Post-Traumatic Stress Disorder



Description

Present-Centered Therapy is a non-trauma focused treatment for PTSD. The primary mechanisms of change from a present centered perspective are grounded in (a) altering present maladaptive relation patterns/behaviors, (b) providing psycho-education regarding the impact of trauma on the client's life, and (c) teaching the use of problem solving strategies that focus on current issues (Mcdonagh et al., 2005; Classen et al., 2011; Schnurr et al., 2003). The treatment omits the use of exposure and cognitive restructuring techniques.

Cognitive Processing Therapy for Post-Traumatic Stress Disorder



Description

Cognitive Processing Therapy, or CPT, is designed to challenge and change distorted beliefs and self-blame through Socratic questioning. CPT also contains an exposure component, through writing about the traumatic event; however, the primary focus of therapy is to modify beliefs about the meaning and implications of the traumatic event.

Seeking Safety for PTSD with Substance Use Disorder



Description

Seeking Safety is a present-focused therapy to help people attain safety from trauma/PTSD and substance abuse. The treatment is available as a book, providing both client handouts and guidance for clinicians. The treatment was designed for flexible use. It has been conducted in group and individual format; for women, men, and mixed-gender; using all topics or fewer topics; in a variety of settings (outpatient, inpatient, residential); and for both substance abuse and dependence. It has also been used with people who have a trauma history, but do not meet criteria for PTSD. The key principles of Seeking Safety are:




1) Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions).

2) Integrated treatment (working on both PTSD and substance abuse at the same time)

3) A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse

4) Four content areas: cognitive, behavioral, interpersonal, case management

5) Attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues)

Stress Inoculation Training for Post-Traumatic Stress Disorder



Description

Stress Inoculation Training involves teaching coping skills to manage stress and anxiety. This may include training in deep muscle relaxation, cognitive restructuring, breathing exercises, assertiveness skills, thought stopping, role playing, and guided self-dialogue. Stress Inoculation Training is often used in conjunction with other therapy techniques, such as cognitive behavioral therapies.

Eye Movement Desensitization and Reprocessing for Post-Traumatic Stress Disorder

Status: Strong Research Support/Controversial


Description

Eye Movement Desensitization Reprocessing, or EMDR, pairs eye movements with cognitive processing of the traumatic memories. The initial phases of EMDR involve affect management techniques, such as relaxation. During the processing stage of therapy, the patient describes the traumatic memory and identifies and labels the images, beliefs, and physiological symptoms elicited by it. The patient is instructed to focus on these aspects of the traumatic memory while moving his/her eyes back and forth by tracking the therapists' finger (although other bilateral stimulation, such as finger-tapping, is used). The theoretical basis for EMDR is that PTSD symptoms result from insufficient processing/integration of sensory, cognitive, and affective elements of the traumatic memory. The bilateral eye movements are proposed to facilitate information processing and integration, allowing clients to fully process traumatic memories.

The efficacy of EMDR for PTSD is an extremely controversial subject among researchers, as the available evidence can be interpreted in several ways. On one hand, studies have shown that EMDR produces greater reduction in PTSD symptoms compared to control groups


receiving no treatment. On the other hand, the existing methodologically sound research comparing EMDR to exposure therapy without eye movements has found no difference in outcomes. Thus, it appears that while EMDR is effective, the mechanism of change may be exposure - and the eye movements may be an unnecessary addition. If EMDR is indeed simply exposure therapy with a superfluous addition, it brings to question whether the dissemination of EMDR is beneficial for patients and the field. However, proponents of EMDR insist that it is empirically supported and more efficient than traditional treatments for PTSD. In any case, more concrete, scientific evidence supporting the proposed mechanisms is necessary before the controversy surrounding EMDR will lift.

For a review of the controversy surrounding EMDR, see:

Davidson, P.R. & Parker, K.C. (2001). Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316. [link]

Herbert, J. D., Lilienfeld, S. O., Lohr, J. M., Montgomery, R. W., O'Donohue, W. T., Rosen, G. M., et al. (2000). Science and pseudoscience in the development of eye movement desensitization and reprocessing: Implications for clinical psychology. Clinical Psychology Review, 20, 945-971. [link]

Schizophrenia and Other Severe Mental Illnesses

Interim Section Author: E. David Klonsky (University of British Columbia)Original Section Author 2008-2011: Wendy N. Tenhula (VISN 5 Mental Illness Research, Education and Clinical Center, and University of Maryland School of Medicine)

Description

Schizophrenia is a serious and typically chronic mental illness characterized by psychotic symptoms (hallucinations & delusions), negative symptoms (e.g. flat affect, anhedonia, amotivation), impairments in social / role functioning, and cognitive deficits. Schizophrenia affects approximately 1% of the population and affects men and women in equal numbers. Symptoms typically begin in adolescence or early adulthood. Medication is generally effective in reducing symptoms and relapse, but even on optimized medication regimens, many individuals with schizophrenia continue to experience psychotic symptoms. In addition, current medications have little, if any, benefit for the negative symptoms, social disability and cognitive deficits associated with schizophrenia. Optimal treatment for schizophrenia includes both medication and specific psychosocial interventions. Which psychosocial interventions would be best for a given individual depends on their stage of illness, current clinical status, personal goals, and social needs.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VB8-41V34P6-1&_user=334567&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000017318&_version=1&_urlVersion=0&_userid=334567&md5=714afb0be54095067a3743ac398cbe8f

http://content.apa.org/journals/ccp/69/2/305

Psychological Treatments:

Social Skills Training (SST) (strong research support) Cognitive Behavioral Therapy (CBT) (strong research support) Assertive Community Treatment (ACT) (strong research support) Family Psychoeducation (strong research support) Supported Employment (strong research support) Social Learning / Token Economy Programs (strong research support) Cognitive Remediation (strong research support) Acceptance and Commitment Therapy (ACT) for Psychosis (modest research support) Cognitive Adaptation Training (CAT) (modest research support) Illness Management and Recovery (IMR) (modest research support)

Social Skills Training (SST) for Schizophrenia



Description

SST uses the principles of behavior therapy to teach communication skills, assertiveness skills, and other skills related to disease management and independent living. SST is usually conducted in small groups that are ideally led by two co-therapists. Skills are broken down into several discrete steps. After reviewing the steps of the skill, the therapist models the skill by demonstrating a role play. Participants then do role-plays to learn and practice the skill. Therapists and group members provide constructive feedback to the individual after each role play and each participant is given an opportunity to practice the skill several times. Repeated practice and “overlearning” of skills are important aspects of SST. Duration, frequency, and exact content of SST interventions depends on the needs of the client(s) and the treatment setting. SST may be even more helpful when supplemented with community-based practice opportunities and support.

Cognitive Behavioral Therapy (CBT) for Schizophrenia



Description

Similar to Cognitive-Behavioral Therapy (CBT) for other types of problems, CBT for schizophrenia involves establishing a collaborative therapeutic relationship, developing a shared understanding of the problem, setting goals, and teaching the person techniques or strategies to reduce or manage their symptoms. Therapy is usually conducted in individual sessions and is time-limited (typically several months). The goal is not to “cure” schizophrenia, but rather to improve the person’s ability to function independently, manage their schizophrenia, and to reduce the distress they experience in their daily life. Specific CBT approaches used in treating schizophrenia include cognitive restructuring, behavioral experiments / reality testing, self-


http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_illness.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_cognitive_adapt.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_acceptance.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_cognitive_rem.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_sociallearning.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_supported.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_family.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_assertive.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_cognitive_beh.html

http://www.div12.org/PsychologicalTreatments/treatments/schizophrenia_socialskills.html

monitoring and coping skills training. Unique considerations in treating schizophrenia include emphases on being non-confrontational and on normalizing psychotic experiences insomuch as they are on a continuum with non-psychotic experiences. CBT for schizophrenia can focus specifically on psychotic symptoms (i.e. hallucinations or delusional beliefs) but has also been shown to be helpful for addressing depression and / or anxiety associated with psychotic symptoms and their impact on the person’s life.

Assertive Community Treatment (ACT) for Schizophrenia



Description

ACT is a multidisciplinary team approach to intensive case management in which the team members share a caseload, have a high frequency of patient contact (typically at least once a week), low patient to staff ratios, and provide outreach to patients in the community. ACT teams include psychiatrists as well as other mental health clinicians. This team approach allows for integration of medication management, rehabilitation, and social services. ACT treatment is typically ongoing rather than time-limited, available 24 hours a day, and highly individualized to each client’s changing needs. The goals of ACT are to reduce hospitalization rates and help clients adapt to life in the community. ACT is most appropriate for individuals who are at high risk for repeated hospitalizations and have difficulty remaining in traditional mental health treatment.

Family Psychoeducation for Schizophrenia



Description

Family Psychoeducation (FP) for schizophrenia refers broadly to several different models of treatment in which the family members of a person with schizophrenia participate in and are the focus of the intervention. This is not based on the assumption that family members cause schizophrenia but rather on a recognition that families can have a significant impact on their relative’s recovery and functioning. The patient-centered goals of FP include reduced relapse, fewer hospitalizations, and improved outcomes for the person with schizophrenia. Family-centered goals are to reduce the distress of dealing with a family member’s mental illness, improve patient-family relations and decrease the burden of mental illness on family members. FP incorporates education about schizophrenia, assistance with crisis intervention, problem solving training, emotional support, and communication skills training. FP interventions typically last at least 9 months, can be conducted with individual families or in multi-family groups, and include a focus on the family’s strengths and resiliency.



Supported Employment for Schizophrenia



Description

Supported Employment (SE; also known as Individual Placement and Support) is an approach to vocational rehabilitation (VR) adapted for individuals with serious mental illness. Supported employment emphasizes the integration of employment and mental health services, rapid placement of individuals into jobs in the community, individualized job development, and ongoing job supports. Rather than segregating vocational rehabilitation and mental health services, supported employment specialists are part of the client’s treatment team. The goal of supported employment is to assist the person with schizophrenia in attaining competitive, community-based employment. As compared to more traditional VR approaches for this population (e.g. clubhouse models, transitional employment), the community-based nature of SE facilitates transfer of skills into real-world work settings, directly builds relationships with employers, and provides more naturalistic opportunities to identify the client’s interests and strengths.

Social Learning/Token Economy Programs for Schizophrenia



Description

Token economy programs are generally used in long-term care setting such as long-stay inpatient units and residential care settings, but can be adapted for shorter stay and less intensive treatment programs as well. They are comprehensive behavioral programs, based on social learning principles, in which participants receive reinforcers (such as tokens or points) for performing clearly defined target behaviors. These reinforcers are provided immediately after a desired behavior and then exchanged at a later time for tangible goods or desired privileges. The focus of a token economy is on shaping and positively reinforcing desired behaviors and NOT on punishing undesirable behaviors. Examples of typical target behaviors include self-care, medication adherence, work skills, and treatment participation. The primary goals of a token economy program are to increase the presence of adaptive behaviors and reduce the frequency of maladaptive or inappropriate behaviors, with the ultimate goal of preparing each participant for greater independence and improved functioning. Token economy programs appear to be most effective when implemented in the context of appropriate medication management, individualized treatment planning, and other evidence-based psychosocial treatments.



Cognitive Remediation for Schizophrenia



Description

Cognitive functions such as executive function, learning & memory, processing speed, and sustained attention are frequently impaired and play an important role in the functional impairments seen in schizophrenia. Cognitive remediation (CR) or cognitive rehabilitation interventions are designed to improve cognitive function through repeated practice of cognitive tasks and / or strategy training. CR interventions are typically time-limited. They can be conducted individually or in groups. Some involve extensive use of computers while others focus primarily on paper-and-pencil tasks. Most CR interventions take into account the motivational and emotional deficits that are often present in schizophrenia as well. The goal of CR is to improve cognitive function. Research has shown small to medium effects of CR on neuropsychological measures of cognition, but whether these improvements are sustained or whether they translate into improved functioning remains unclear.

Social Phobia and Public Speaking Anxiety


Description

Social phobia, also known as social anxiety disorder, reflects intense and persistent fear in social or performance situations where embarrassment or negative evaluation by others can occur. This disorder is quite common (up to 13% estimated lifetime prevalence), and leads to significant impairment because socially anxious individuals may avoid a broad range of situations where they fear they will be socially inept and/or scrutinized by others. Commonly feared situations include social gatherings, such as parties, as well as dating, initiating conversations, and interacting with persons in positions of authority. In some cases, the situations are endured with extreme distress (rather than avoided), even leading to panic attacks. Importantly, adults with this disorder must recognize that their fears are excessive or unreasonable. While some social anxiety and shyness are normative, individuals who meet criteria for social phobia experience these fears more frequently and intensely, such that they interfere with occupational or academic functioning, social activities or relationships. Some individuals with social phobia have impaired social skills, but this is not necessarily the case. Further, while some individuals fear almost all social situations (known as Generalized subtype), others fear only a single or a few performance and interpersonal situations.

Public speaking fear is a particular form of social anxiety, which typically involves concerns that the audience will think that one's performance is inadequate (e.g., fears the audience will think the speaker is stupid, boring, appears overly anxious, etc.). Given that public speaking fears are extremely common and normative, it is critical that the fears be excessive relative to the general


population and that they interfere with normal routines or significantly impair functioning in order to meet diagnostic criteria.


Cognitive and Behavioral Therapies (strong research support)

Cognitive and Behavioral Therapies for Social Phobia and Public Speaking Anxiety



Description

Cognitive and behavioral therapies for social phobia and public speaking fears refer to a variety of techniques that can be provided individually or in combination. The basic premise underlying the therapy approaches is that thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate problems in another (e.g., changing thoughts about fears of negative evaluation will lead to less anxiety). From a cognitive perspective, the excessive fear in social and performance situations is thought to be maintained by negative beliefs about the likelihood and catastrophic nature of embarrassing oneself and performing inadequately, and the probability and seriousness of negative scrutiny by others. The cognitive therapy techniques thus focus on modifying the catastrophic thinking patterns and beliefs that social failure and rejection are likely (termed cognitive restructuring). From a behavioral perspective, social anxiety is maintained by avoiding anxiety-provoking situations so that the individual does not have the opportunity to learn that they can tolerate the anxiety, that the anxiety will come down on its own without avoiding or escaping, and that their feared outcomes often do not come true or are not as terrible as they imagine. Avoidance can occur either by not entering a situation at all or by entering the situation but not experiencing it fully (e.g., because of consuming alcohol). Exposure therapies are thus designed to gradually encourage the individual to enter feared social situations and try to remain in those situations. The selection of situations to try follows an individually-tailored fear hierarchy that starts with situations that are only mildly anxiety-provoking and builds up to the most feared encounters.

Other common cognitive and behavioral techniques include behavioral experiments, applied relaxation, and social skills training. Behavioral experiments involve testing out predictions about the likelihood and consequences of social disappointments to see whether the feared outcomes actually occur, thereby challenging the distorted predictions. Anxiety symptoms can also be reduced through relaxation exercises, including progressive muscle relaxation and diaphragmatic breathing. Social skills training is recommended for those individuals who lack basic abilities in initiating and maintaining positive interpersonal interactions (more common among individuals who have the Generalized subtype of social phobia), and involves behavior rehearsal of social interactions and training in communication skills.

The research evidence suggests that combining cognitive therapy and exposure techniques, which is typical of most Cognitive Behavior Therapy (CBT) packages, is recommended. Therapy usually lasts from 12-16 sessions (though there is evidence that briefer therapies lasting 4-8

http://www.div12.org/PsychologicalTreatments/treatments/socialphobia_cbt.html

sessions can also be effective), and can be conducted in individual and group formats. The research literature also suggests that exposure therapy on its own can be an efficacious treatment. Cognitive therapy often adds to the effectiveness of behavioral interventions, but may be most consistently helpful when it is combined with behavioral approaches, rather than delivered as a stand-alone intervention. There is also some evidence that relaxation training on its own can be helpful, but like cognitive therapy, it seems to work most effectively as a component of CBT. Similarly, social skills training on its own is sometimes found to be equal to other established therapies (e.g., cognitive therapy, exposure), but rarely more effective than these other treatments. It is recommended that social skills training be used as an additional component of CBT for individuals who need it. (Many individuals with social phobia have adequate social skills, and do not require this component.)

Finally, early behavioral approaches used systematic desensitization (exposing participants to anxiety provoking images and thoughts, while pairing the exposure with relaxation to decrease the normal anxiety response). While there was some initial support for the utility of this technique, these studies typically had small samples or lacked rigorous control groups, and there is little recent evidence to suggest this approach should be selected over other exposure approaches that have stronger research support for treating social phobia and public speaking anxiety. Notwithstanding, given that this approach has been defined as probably efficacious in previous reviews (see Chambless et al., 1998), references supporting this technique are listed below.

Specific Phobias


Description

Specific phobias, formerly known as simple phobias, reflect excessive, irrational fears of a specific object or situation. The focus of the phobia almost invariably provokes an immediate anxiety response and the phobic stimuli are typically avoided, or endured with extreme distress. Importantly, to meet diagnostic criteria, the fear must cause some kind of impairment in the individual's functioning, and the fear must be greater than others would likely experience. Specific phobias can involve animals (e.g., spiders, snakes), natural environmental (e.g., heights, water), situations (e.g., flying, closed spaces), and blood/injection/injury (e.g., blood, dentist), among others. Specific phobias are extremely common, with a lifetime prevalence in the United States of about 12.5%.


Exposure Therapies (strong research support)

Exposure Therapies for Specific Phobias



http://www.div12.org/PsychologicalTreatments/treatments/specificphobia_exposure.html

Description

Exposure-based therapies reflect a variety of behavioral approaches that are all based on exposing the phobic individuals to the stimuli that frighten them. From a behavioral perspective, specific phobias are maintained because of avoidance of the phobic stimuli so that the individual does not have the opportunity to learn that they can tolerate the fear, that the fear will come down on its own without avoiding or escaping, and that their feared outcomes often do not come true or are not as terrible as they imagine. Avoidance can occur either by not entering a situation at all or by entering the situation but not experiencing it fully (e.g., because of consuming alcohol before taking a flight for a person with flying phobia). Exposure therapies are thus designed to encourage the individual to enter feared situations (either in reality or through imaginal exercises) and to try to remain in those situations. The selection of situations to try typically follows an individually-tailored fear hierarchy that starts with situations that are only mildly anxiety-provoking and builds up to the most feared encounters, though in some forms of exposure therapy (e.g., implosion therapy), the individual starts out being exposed to a very anxiety-provoking stimulus rather than building up to that point more gradually.

There are a number of variations of exposure therapy that work effectively in the treatment of specific phobias, so to some extent the specific approach selected may depend on the nature of the phobia and therapist and client preferences. Notwithstanding, the research evidence does provide more substantial support for some exposure therapies (i.e., in vivo exposure) over others (e.g., systematic desensitization).

In vivo exposure involves actually confronting the feared stimuli, usually in a graduated fashion (e.g., in spider phobia, a person might first look at a picture of a spider and eventually work up to touching a large tarantula; in flying phobia, a person might first read a story about a plane crash and then work up to taking an actual flight). The treatment usually last a number of hours, and can be administered in one very long session (e.g., one 3-hour session for spider phobia) or across multiple sessions (e.g., three to eight 1-1.5-hour-long sessions). A range of specific phobias respond well to in vivo treatment, although treatment acceptance and dropout can be a problem. Further, treatment gains tend to be well maintained up to a year following the end of treatment, particularly for animal phobias (though follow-up data is less impressive for blood-injection-injury phobia). When the therapist is actively modeling each step of the exposure and teaching the phobic individual how to interact with the feared stimulus, this type of exposure therapy can also be called Participant modeling or Guided mastery.

Applied muscle tension is a special variant of in vivo exposure for the treatment of blood-injection-injury phobia. This treatment uses standard exposure techniques but also incorporates muscle tension exercises to respond to decreases in blood pressure that can lead to fainting.

Virtual reality exposure uses a computer program to generate the phobic situation (e.g., being on a plane that is taking off, encountering a large tarantula, looking over a tall balcony ledge), and integrates real-time computer graphics with various body tracking devices so that the individual can interact in the environment. This therapy appears to be useful for phobias that may be difficult to treat in vivo; namely, flying phobias (where repeated plane flights are impractical) and height phobias, but more studies are needed to demonstrate its efficacy for a broader range of phobia subtypes.

Systematic desensitization involves exposing phobic individuals to fear-evoking images and thoughts (i.e., imaginal exposure) or to actual phobic stimuli, while pairing the exposure with

relaxation (or another response that is incompatible with fear) to decrease the normal fear response. Treatment using systematic desensitization tends to take longer than in vivo exposure, and appears to be more effective at changing subjective anxiety than at reducing avoidance. Thus, it is not recommended as the first line of treatment if a client is willing to try in vivo or an alternate form of exposure therapy.

Note that many exposure therapies also include a cognitive component that involves cognitive restructuring to challenge distorted or irrational thoughts related to the phobic object or response (e.g., I am going to fall, The dog is going to attack me, I can't tolerate this fear, etc.). Further, there is some evidence that either adding cognitive therapy to in vivo exposure or administering cognitive therapy alone can be helpful for claustrophobia, and it may also be useful for dental phobia. Evidence regarding the utility of cognitive therapy for flying phobia is mixed, and it is not clear that adding cognitive therapy to exposure therapy for other phobia types improves outcomes.

Substance and Alcohol Use Disorders

Section Authors: Lisa Najavits (Chair, Division 50 EST Workgroup) Nancy Piotrowski (Workgroup member), Greg Brigham (former Workgroup member) Ashley Hampton (Workgroup student coordinator), Matthew Worley (former Workgroup student coordinator)

Description

Substance use disorders (SUDs) are classified into two main categories: abuse and dependence, per the American Psychiatric Association Diagnostic and Statistical Manual, 4th edition, Text Revision (DSM-IV-TR; 2000). The DSM-IV-TR also identifies different classes of substances. These are alcohol; amphetamine; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; phencyclidine; and sedatives, hypnotics, or anxiolytics; and polysubstance (the latter referring to use of at least three classes of substances, but not including caffeine or nicotine, with no one substance predominating). The DSM-IV-TR also describes various important phenomena related to SUD diagnoses, including intoxication, withdrawal, tolerance, and remission. A current diagnosis refers to past-year timeframe; a lifetime diagnosis refers to having met criteria during some one-year period prior to the past year.

Criteria for SUD address various important impacts of substance use. Substance abuse criteria focus on substance-related problems at work or school; in dangerous situations, such as driving; with family and other important relationships; and with the legal system. Substance dependence criteria focus on tolerance, withdrawal; substance-related worsening of physical and/or mental health concerns; inability to control use of the substance; spending large amounts of time finding, using, and recovering from the substance; giving up other activities to use the substance; and continuing to use despite a strong desire to quit. See the DSM-IV-TR for more information.

Substance and Alcohol Disorders

Mixed Substance Abuse/Dependence

Alcohol

Cocaine

Smoking

Mixed Substance Abuse/Dependence

Section Authors: Lisa Najavits (Chair, Division 50 EST Workgroup) Nancy Piotrowski (Workgroup member), Greg Brigham (former Workgroup member) Ashley Hampton (Workgroup student coordinator), Matthew Worley (former Workgroup student coordinator)


Motivational Interviewing, Motivational Enhancement Therapy (MET), and MET plus Cognitive Behavior Therapy (strong research support)

Prize-Based Contingency Management (strong research support) Seeking Safety (strong research support for adults, modest research support for

adolescents) Friends Care (modest research support) Guided Self-Change (modest research support)

Motivational Interviewing, Motivational Enhancement Therapy (MET), and MET plus CBT for Mixed Substance Abuse/Dependence



Description

Motivational interviewing (MI) is a brief person-centered clinical method for strengthening clients' motivation for and commitment to change. First described by Miller (1983), it was originally designed for working with people with substance use disorders, but has since been more widely applied in health care, corrections, mental health and social work. It is particularly indicated for clients who are reluctant, ambivalent or defensive about change. Strongly rooted in the work of Carl Rogers, MI is nevertheless strategically goal-directed to facilitate an identified change. The overall spirit or style of MI is collaborative and empathic, and the course of MI is normally 1-4 sessions. Rather than working from a deficit model in which the therapist provides what the client is missing (e.g., skills, insight, knowledge), MI seeks to evoke the client's own motivations, strengths and resources. Drawing on the psycholinguistics of change, particular attention is paid in MI to specific aspects of client speech that predict subsequent change. The therapist elicits

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and explores the client's own reasons for change within an atmosphere of acceptance to minimize resistance and defensiveness.

MI therapists use a variety of strategies to evoke and strengthen clients' "change talk." There are specific guidelines for deciding what questions to ask, and what content to reflect and summarize. Studies have demonstrated that therapists adhering to MI-consistent skills are able to significantly increase client change talk, which in turn predicts behavior change outcomes. Therapists learning MI typically begin by developing a strong foundation of client-centered counseling skills (reflective listening, open questions, affirmation, summaries), then learn to identify, evoke, and strengthen client change talk using these skills strategically.

Motivational Enhancement Therapy (MET) combines the clinical style of MI with individual assessment feedback that may be particularly helpful for less-ready clients, where the initial task is to develop ambivalence about change. It was originally developed as a manual-guided intervention (Miller et al, 1992) for the multisite Project MATCH, a randomized clinical trial in which the 4-session MET yielded long-term reductions in alcohol consumption and problems comparable to those from 12-session cognitive-behavioral or twelve-step facilitation therapies (Project MATCH Research Group, 1997). MI and MET can be combined with other approaches such as cognitive-behavioral treatment (CBT), as tested in the multisite COMBINE study (Anton et al., 2006; Miller, 2004).

Prize-Based Contingency Management for Mixed Substance Abuse/Dependence



Description

Contingency management (CM) treatments evolved from basic behavioral research demonstrating that a behavior that is reinforced will increase in frequency. CM is a structured behavioral therapy that involves: (1) frequently monitoring the behavior targeted for change, and (2) reinforcing the behavior each time it occurs using tangible and escalating reinforcers. Often, the behavior targeted for change is drug use behavior, but other behaviors such as attendance at treatment, can also be reinforced. Patients are reinforced for submission of drug negative urine samples or attendance at treatment by earning the chance to win prizes ranging from $1 to $100 in value, and chances to win prizes increase with sustained abstinence or attendance.

Usually, CM treatments are in effect for 8-24 weeks, and CM is typically provided as an adjunct to other treatment. It can be integrated with virtually any form of therapy, including eclectic/standard group treatment, 12-step therapy, cognitive-behavioral therapy, community reinforcement approach therapy, motivational enhancement therapy, and others.

If abstinence is reinforced, the best outcomes of CM are generally achieved if abstinence from a single drug is reinforced (as opposed to requiring abstinence from multiple substances concurrently to receive reinforcement), if urine testing monitoring is conducted at least twice weekly, if onsite (as opposed to offsite) testing procedures are used, and if reinforcement magnitude is high. The prize CM system was designed to enhance patient outcomes while minimizing reinforcement and administrative costs.


Seeking Safety for Mixed Substance Abuse/Dependence

Status: Strong Research Support for Adults, Modest Research Support for Adolescents


Description

Seeking Safety is a present-focused, coping skills therapy to help people attain safety from trauma/PTSD and substance use disorder (SUD). It embodies a compassionate tone that honors what clients have survived and respects their strengths. It was designed for flexible use. It is a first-stage model that can be used from the start of treatment.

The key principles of Seeking Safety are: (1) Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions). (2) Integrated treatment (working on both trauma and substance abuse at the same time). (3) A focus on ideals to counteract the loss of ideals in both trauma and substance abuse. (4) Four content areas: cognitive, behavioral, interpersonal, and case management. (5) Attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues). Seeking Safety offers 25 treatment topics, each with a clinician guide and client handouts. The topics that can be conducted in any order and number, and the pacing and length of sessions can be determined by the clinician. Examples of topics are Safety, Asking for Help, Setting Boundaries in Relationships, Healthy Relationships, Community Resources, Compassion, Creating Meaning, Discovery, Recovery Thinking, Taking Good Care of Yourself, Commitment, Integrating the Split Self, Self-Nurturing, Red and Green Flags, and Life Choices.

Seeking Safety has a strong public health emphasis: low cost to implement, with emphasis on engagement and concrete strategies. The model has been used with a broad range of vulnerable populations, including those who are severe and chronic, adolescents, military and veterans, homeless, domestic violence, criminal justice, racially/ethically diverse, mild traumatic brain injury or other cognitive impairment, serious and persistent mental illness, low-reading or illiterate clients, and others. It is also used for individuals with PTSD or SUD disorder alone, subthreshold, or a history of the either disorder. Seeking Safety has been translated into Spanish, French, German, Dutch, Swedish, Polish, and Chinese. The model has been conducted by a broad range of clinicians, including social workers, psychologists, nurses, case managers, mental health counselors, substance abuse counselors, emergency workers, domestic violence advocates, as well as paraprofessionals, and peer-led.

Friends Care for Mixed Substance Abuse/Dependence



Description

Friends Care is a 6 month aftercare program conducted in stand-alone community facilities. The structure and components of Friends Care are grounded in the findings from earlier continuing



care studies and of community influences found to promote positive treatment outcomes. Individuals exiting substance abuse treatment programs are contacted up to one month prior to planned discharge to orient them to Friends Care, introduce them to aftercare staff with whom they will be working, and jointly develop preliminary aftercare plans. Services are offered by counselors under the direction of a supervisory case manager and place an emphasis on building community supports to drug free living.

In accord with procedures described in a detailed implementation manual (see below), all or some of the following services are provided at a frequency specified in the aftercare plan: (a) supportive counseling with review and strengthening of risk reduction behaviors and prosocial functioning; (b) case management services including skills building for obtaining needed resources; (c) work with client's spouse/ partner and relevant family; (d) obtaining/ maintaining employment through skills building in job finding and workplace demeanor; (e) affiliation with supportive community groups and organizations; (f) review of HIV prevention behaviors; and (g) crisis intervention, i.e., on-demand counseling for emergency situations.

Guided Self-Change for Mixed Substance Abuse/Dependence



Description

Guided Self-Change (GSC) Treatment for substance use disorders integrates cognitive-behavioral, motivational interviewing, and relapse prevention techniques to help individuals functionally analyze their alcohol or other drug problems and develop their own plans for changing. It can be delivered in individual or group formats, and has been evaluated in Spanish and English. Guided Self-Change is especially applicable for persons whose alcohol or drug problems are not severe. The GSC clinic website contains a host of printable materials in English and Spanish, including Therapist and Client Handouts, homework assignments for clients, other clinical and motivational handouts and forms, clinical tips and tools, and Timeline Followback (TLFB) forms, instructions, calendars, and excel computerized programs.

http://www.nova.edu/gsc


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Evidence Based Treatments. Society of Clinical Psychology Div 12 2014

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