Alternative Modes of Alternative Modes of Clinical InterventionClinical Intervention

Alternative Modes of Alternative Modes of Clinical InterventionClinical Intervention

Dr. KlineDr. Kline

FSU-PCFSU-PC

Socially Oriented Intervention TherapiesSocially Oriented Intervention TherapiesSocially Oriented Intervention TherapiesSocially Oriented Intervention Therapies

• The traditional view of psychotherapy is a one-to-one The traditional view of psychotherapy is a one-to-one relationship between a therapist & client. This model is still relationship between a therapist & client. This model is still very popular & effective for individual counseling.very popular & effective for individual counseling.

• However, it many circumstances, counseling requires However, it many circumstances, counseling requires treating more than one person simultaneously for a given treating more than one person simultaneously for a given problem (or multiple problems).problem (or multiple problems).

• Therefore, the need for therapies designed to treat multiple Therefore, the need for therapies designed to treat multiple individuals (group therapy, family counseling) has increased individuals (group therapy, family counseling) has increased substantially in the past 30 years. substantially in the past 30 years.

Socially Oriented Clinical InterventionsSocially Oriented Clinical InterventionsSocially Oriented Clinical InterventionsSocially Oriented Clinical Interventions

Intervention type Emphasis

Group Therapy Understand/alleviate problems in interpersonal relationships in a group setting.

Couples Therapy Facilitate problem solving of intimate problems in couples.

Family Therapy Change maladaptive & dysfunctional patterns in family systems to improve functioning.

Psychosocial Improve clients’ abilities to cope with mental Rehabilitation disorders, live in the community, gain independence

Group TherapyGroup TherapyGroup TherapyGroup Therapy• Focuses on treating multiple individuals in a group setting Focuses on treating multiple individuals in a group setting

with a special emphasis on interpersonal relationships of with a special emphasis on interpersonal relationships of the clients involvedthe clients involved..

E.g., Weight-control groups, assertiveness groups, alcoholics E.g., Weight-control groups, assertiveness groups, alcoholics anonymousanonymous

• Originally practiced at the turn of the 20Originally practiced at the turn of the 20thth century (early century (early 1900s), group therapy became a more common form of 1900s), group therapy became a more common form of therapy therapy due to a shortage of clinical personnel during WWIIdue to a shortage of clinical personnel during WWII. .

• Its popularity skyrocketed in the 60s & 70s & is now Its popularity skyrocketed in the 60s & 70s & is now considered a valid & well respected form of therapy. considered a valid & well respected form of therapy.

Therapeutic Factors in Group TherapyTherapeutic Factors in Group TherapyTherapeutic Factors in Group TherapyTherapeutic Factors in Group Therapy• 1. 1. Sharing New InformationSharing New Information: more information about a given problem is : more information about a given problem is

available (and shared) in a group therapy setting than a one-on-one setting.available (and shared) in a group therapy setting than a one-on-one setting.

This information comes from two sources:This information comes from two sources:

******The leader of the group (i.e., the counselor)The leader of the group (i.e., the counselor)

***The other members of the group***The other members of the group

Because multiple viewpoints are available & shared in this setting, aBecause multiple viewpoints are available & shared in this setting, a

more more comprehensive picture of the problem emergescomprehensive picture of the problem emerges. .

Moreover, Moreover, a given member of the group will have more difficulty dismissing the a given member of the group will have more difficulty dismissing the opinions of the group members compared with the sole opinion of the group opinions of the group members compared with the sole opinion of the group leaderleader. (. (Power in numbers!!!!)Power in numbers!!!!)

2. 2. Instilling HopeInstilling Hope:: • In group therapy, In group therapy, individual members may be “optimistic” individual members may be “optimistic”

they will progress in their treatment, because they are they will progress in their treatment, because they are encouraged by the progress other group members have encouraged by the progress other group members have mademade..

• Additionally, a given member of the group Additionally, a given member of the group may discover he or may discover he or she has made improvements in their treatment because such she has made improvements in their treatment because such progress has been pointed out to them from other group progress has been pointed out to them from other group membersmembers. .

• Evidence of the progress either one has made or the progress Evidence of the progress either one has made or the progress that has been made by other members both work to that has been made by other members both work to increase increase motivation & commitment to the group therapy sessionsmotivation & commitment to the group therapy sessions..

3. 3. Universality:Universality:

• Because individual members in group therapy have the Because individual members in group therapy have the opportunity to see other members experiencing the same or opportunity to see other members experiencing the same or similar problems, similar problems, a sense of cohesion develops among the a sense of cohesion develops among the membersmembers..

• That is, an individual member doesn’t have to feel isolated, alone, That is, an individual member doesn’t have to feel isolated, alone, and “uniquely” the only person to have dealt with this problem and “uniquely” the only person to have dealt with this problem before.before.

• Seeing other individuals struggling with the same issues offers Seeing other individuals struggling with the same issues offers comfort to clients who thought this was something only they comfort to clients who thought this was something only they had the burden of experiencinghad the burden of experiencing (e.g., bereavement, parents of (e.g., bereavement, parents of children with problems, etc.). children with problems, etc.).

4. 4. AltruismAltruism: :

• Individual group members may play the role of Individual group members may play the role of therapist to other group members.therapist to other group members.

• This offers each individual member an opportunity to This offers each individual member an opportunity to facilitate another members progress.facilitate another members progress.

• Being able to promote the well-being of other group Being able to promote the well-being of other group members, improves the self-esteem of the individual members, improves the self-esteem of the individual members who contribute to such positive events.members who contribute to such positive events.

5. 5. Interpersonal learningInterpersonal learning::

• An interesting by-product of the group An interesting by-product of the group therapy setting is the opportunity for therapy setting is the opportunity for individual members to practice their social individual members to practice their social skills.skills.

• Given that social skills may be part of a given Given that social skills may be part of a given client’s problems, this “client’s problems, this “safesafe” setting offers ” setting offers members the chance to “members the chance to “practicepractice” their ” their responses to others with constructive feedback.responses to others with constructive feedback.

6. 6. Recapitulation of the Primary FamilyRecapitulation of the Primary Family::

• The therapist leading the group may view the group The therapist leading the group may view the group therapy dynamic as a model for the clients’ familiestherapy dynamic as a model for the clients’ families. .

• This dynamic provides the therapist & members with This dynamic provides the therapist & members with an opportunity to “an opportunity to “reenactreenact” the problems/dysfunctions ” the problems/dysfunctions found in the clients’ family backgrounds.found in the clients’ family backgrounds.

• This concept is the group therapy version of This concept is the group therapy version of transferencetransference which is found in the one-one-one which is found in the one-one-one counseling settingscounseling settings (Neitzel et al., 2003). (Neitzel et al., 2003).

7. 7. Group CohesivenessGroup Cohesiveness::

• As groups develop and grow, the members become As groups develop and grow, the members become more cohesive.more cohesive.

• Cohesiveness (the strength of the bond among the Cohesiveness (the strength of the bond among the group members) promotes more disclosure, group members) promotes more disclosure, acceptance of other members, & counteracts the acceptance of other members, & counteracts the feelings of inadequacy & anxiety many individual feelings of inadequacy & anxiety many individual members experience.members experience.

• Cohesiveness appears to be the most important Cohesiveness appears to be the most important factor in the positive effects of the groupfactor in the positive effects of the group. .

Practicing Group Therapy: How it works!!Practicing Group Therapy: How it works!!Practicing Group Therapy: How it works!!Practicing Group Therapy: How it works!!• 1. 1. Number of membersNumber of members: Generally groups will consist of 6 -12 : Generally groups will consist of 6 -12

members.members.

• 2. 2. Variability of group membersVariability of group members: may be small or large : may be small or large depending on the group format:depending on the group format:

****HomogenousHomogenous groups have members who are similar in age, sex, groups have members who are similar in age, sex, type of problem, etc. (e.g., WWII Veteran’s group). This is in type of problem, etc. (e.g., WWII Veteran’s group). This is in contrast to contrast to heterogeneousheterogeneous groups who differ in these & other groups who differ in these & other characteristics (e.g., AA members). characteristics (e.g., AA members).

3. 3. Length of MeetingsLength of Meetings: meetings for group therapy tend to be : meetings for group therapy tend to be longer than individual counseling (e.g., 2 hours or more) because longer than individual counseling (e.g., 2 hours or more) because more time is needed for individual members to talk during the more time is needed for individual members to talk during the meetings. Also more time is needed for significant progress to meetings. Also more time is needed for significant progress to occur.occur.

Marital and Family TherapyMarital and Family TherapyMarital and Family TherapyMarital and Family Therapy

• Both marital & family counseling settings focus on Both marital & family counseling settings focus on dysfunctional relationships in couples, marriages, & dysfunctional relationships in couples, marriages, & families. families.

• Couples therapy focuses on dyads and the Couples therapy focuses on dyads and the interactions that occur within the relationship of interactions that occur within the relationship of two peopletwo people..

• Family therapy treats some or all the members of a Family therapy treats some or all the members of a given family unit (often goes hand-in-hand with given family unit (often goes hand-in-hand with couples therapy). couples therapy).

Couples TherapyCouples TherapyCouples TherapyCouples Therapy

Reasons why couples seek counselingReasons why couples seek counseling

Sexual Dissatisfaction

Personal autonomy/identity issues

Dominance-Submission issues

Communication issues

Financial problems

Child care responsibility issues

Intimacy problems

Fidelity

Argument style

Couples Therapy-Why & How it worksCouples Therapy-Why & How it worksCouples Therapy-Why & How it worksCouples Therapy-Why & How it works

Although couples therapy may be the main form of therapy for helping couples Although couples therapy may be the main form of therapy for helping couples with relationship difficulties, it can also be combined with other treatment with relationship difficulties, it can also be combined with other treatment techniques to address other issues.techniques to address other issues.

For instance, a couple may go to counseling, when one of the partner’s is having For instance, a couple may go to counseling, when one of the partner’s is having “other” problems in their life “other” problems in their life (e.g., alcohol/drug use, depression, anxiety, or (e.g., alcohol/drug use, depression, anxiety, or some other problem that effects the relationship). some other problem that effects the relationship).

When both partners go through counseling at the same time, this is called When both partners go through counseling at the same time, this is called conjoint conjoint therapytherapy. However, a couple may go through couples counseling with the same . However, a couple may go through couples counseling with the same therapist, therapist, but at different timesbut at different times. .

***Goals of therapy depend on the problem the couple is dealing with and the ***Goals of therapy depend on the problem the couple is dealing with and the orientation of the therapistorientation of the therapist.***.***

Couples Therapy & therapist’s orientation:Couples Therapy & therapist’s orientation:

• 1. 1. Behaviorist approachBehaviorist approach: : here therapists focus on changing here therapists focus on changing couples’ communication style so that the couple can couples’ communication style so that the couple can address their problems with reduced hostilityaddress their problems with reduced hostility. .

To do this, the therapist may require that couples learn how to To do this, the therapist may require that couples learn how to replace hostile comments with benign ones that convey replace hostile comments with benign ones that convey information (e.g., information (e.g., no name callingno name calling). ).

Therapists may even give out a list of words/phrases that are Therapists may even give out a list of words/phrases that are acceptable to use in discussions.acceptable to use in discussions.

Couples may also be required to create and Couples may also be required to create and sign a contractsign a contract (called a (called a Behavioral ExchangeBehavioral Exchange) that spells out what each ) that spells out what each partner wants and what each partner should do once an action partner wants and what each partner should do once an action of his/her “wish list” has been produced by the other partner.of his/her “wish list” has been produced by the other partner.

2. 2. Cognitive-Behavioral approachCognitive-Behavioral approach::

• Therapists urge couples to change the way they think Therapists urge couples to change the way they think about their relationships. about their relationships. That is, change the maladaptive That is, change the maladaptive beliefs (attributions) they have about their partnerbeliefs (attributions) they have about their partner..

• For instance, if one or both members of a couple are invested For instance, if one or both members of a couple are invested in in “blaming”“blaming” the other partner for the problems in the the other partner for the problems in the relationship, its very unlikely they could work on resolving relationship, its very unlikely they could work on resolving real conflicts fairly (real conflicts fairly (a zero-sum game, everybody losesa zero-sum game, everybody loses).).

• Therapists with this orientation, aim to teach each partner how Therapists with this orientation, aim to teach each partner how to focus on to focus on improving communicationimproving communication with their partners to with their partners to reduce distortion of the other partners’ motives, changing reduce distortion of the other partners’ motives, changing problem behaviors in the relationship, and improving how problem behaviors in the relationship, and improving how they view the other partnerthey view the other partner..

3. 3. Humanistic ApproachHumanistic Approach::

• Therapists with this orientation try to promote the overall Therapists with this orientation try to promote the overall feelings of well-being in the couple’s relationship.feelings of well-being in the couple’s relationship.

• Here, therapists will try to get couples to focus on the Here, therapists will try to get couples to focus on the positive positive emotional bonds that once brought them together as well emotional bonds that once brought them together as well as what’s good in their relationship.as what’s good in their relationship.

• Strengthening positive feelings for each other may “Strengthening positive feelings for each other may “bufferbuffer” ” the couple from the painful aspects of therapy where they have the couple from the painful aspects of therapy where they have to resolve the problem that brought them to therapy. to resolve the problem that brought them to therapy.

• If a partner is disarmed and their hostility level reduced, they If a partner is disarmed and their hostility level reduced, they may be more open to the honest comments made by the other may be more open to the honest comments made by the other partner.partner.

4. 4. Eclectic Approach:Eclectic Approach:

• Therapists today often use a variety of methods from different Therapists today often use a variety of methods from different orientations to treat couples and families.orientations to treat couples and families.

• Regardless of the therapist’s orientation, Regardless of the therapist’s orientation, the goal of most couples the goal of most couples counseling is on problem solvingcounseling is on problem solving..

• This usually entails training couples on how to effectively This usually entails training couples on how to effectively communicatecommunicate their feelings, thoughts, and wishes to their partner. their feelings, thoughts, and wishes to their partner.

• Factors that are also examined are:Factors that are also examined are:****Couples accepting mutual responsibility for issues in relationship. Couples accepting mutual responsibility for issues in relationship. **Releasing grudges/focusing on the present**Releasing grudges/focusing on the present**Express preferences, not demands or ultimatums**Express preferences, not demands or ultimatums**Agreeing to a compromise on issues where both parties disagree**Agreeing to a compromise on issues where both parties disagree..

Family Therapy-GoalsFamily Therapy-GoalsFamily Therapy-GoalsFamily Therapy-Goals

• The goal of family therapy is to modify maladaptive The goal of family therapy is to modify maladaptive family interactions to correct family dysfunctionsfamily interactions to correct family dysfunctions ..

• This form of therapy became popular when it was This form of therapy became popular when it was observed that clients treated in individual therapy observed that clients treated in individual therapy sessions in hospital settings relapsed when they returned sessions in hospital settings relapsed when they returned to their families. to their families.

• Therapists made the Therapists made the connection between individual connection between individual psychopathology & its relationship to dysfunctional psychopathology & its relationship to dysfunctional family systemsfamily systems (e.g., link between dysfunctional families (e.g., link between dysfunctional families & substance use disorders). & substance use disorders).

Differences between family & individual therapyDifferences between family & individual therapy• Family therapy is based on “systems theory” which Family therapy is based on “systems theory” which

emphasizes three major points:emphasizes three major points:

1.1. Circular causalityCircular causality: events are interrelated & mutually : events are interrelated & mutually dependent (not a simple cause-effect relationship). Each dependent (not a simple cause-effect relationship). Each family member’s behavior has an impact on another member family member’s behavior has an impact on another member in the family.in the family.

2.2. EcologyEcology: Systems are integrated patterns. Thus, a change in : Systems are integrated patterns. Thus, a change in one family member’s behavior has an effect on all the other one family member’s behavior has an effect on all the other members. members.

3.3. SubjectivitySubjectivity: Family members each have their own : Family members each have their own perception of family events (i.e., subjective). perception of family events (i.e., subjective).

Family Therapy (Systems approach model)Family Therapy (Systems approach model)Family Therapy (Systems approach model)Family Therapy (Systems approach model)

Child (Diana) Child (Sarah)

Child (Christopher)

Mom and Dad

How Family Therapy WorksHow Family Therapy Works• Family therapy is usually initiated because one family member Family therapy is usually initiated because one family member

has a problem that effects the family as a wholehas a problem that effects the family as a whole..

• Frequently, the family member with the problem is an Frequently, the family member with the problem is an adolescent male childadolescent male child with behavior problems that the parents with behavior problems that the parents identify as a “problem,” or a identify as a “problem,” or a teenage girlteenage girl with an eating with an eating disorder (Nietzel, et al., 2003).disorder (Nietzel, et al., 2003).

• Family therapists need to identify what family communication Family therapists need to identify what family communication issues may be causing/exacerbating the problem (e.g., the issues may be causing/exacerbating the problem (e.g., the “identified” child is often the “identified” child is often the scapegoat scapegoat for the families for the families difficulties). difficulties).

• Therapists adopt a variety of methods to treat family problems, Therapists adopt a variety of methods to treat family problems, starting with improving and clarifying communication among starting with improving and clarifying communication among the family members as well as reducing blaming behavior that is the family members as well as reducing blaming behavior that is so pervasive in these types of situations so pervasive in these types of situations (strategic family (strategic family therapy).therapy).

Family Therapy TechniquesFamily Therapy TechniquesFamily Therapy TechniquesFamily Therapy Techniques

• 1. 1. BehavioralBehavioral: Teach family members appropriate ways to communicate. Parents : Teach family members appropriate ways to communicate. Parents are instructed to be consistent in their discipline methods as well as interactions with are instructed to be consistent in their discipline methods as well as interactions with their children. their children.

• 2. 2. StrategicStrategic: Train family members to focus on family problem instead of the : Train family members to focus on family problem instead of the individual family member with a problem. The goal here is to reduce scapegoating, individual family member with a problem. The goal here is to reduce scapegoating, and promote problem solving.and promote problem solving.

• 3. 3. Intergenerational Family therapyIntergenerational Family therapy: here the therapist intentionally limits direct : here the therapist intentionally limits direct family interaction during sessions. This is done to reduce overall anxiety while family interaction during sessions. This is done to reduce overall anxiety while forcing the focus on the problems and not on any one person in the family.forcing the focus on the problems and not on any one person in the family.

• 4. Narrative or Constructionist4. Narrative or Constructionist: Therapist has each family member describe what : Therapist has each family member describe what their individual role is within the family system. Theoretically, making family their individual role is within the family system. Theoretically, making family members explicitly describe their roles forces them to take responsibility for their members explicitly describe their roles forces them to take responsibility for their actions within the family system. actions within the family system.

Diagnosing Marital & Family problemsDiagnosing Marital & Family problems

• Unlike individual counseling, where clinicians assess Unlike individual counseling, where clinicians assess and diagnose their client’s problems using the DSM, and diagnose their client’s problems using the DSM, there is no gold standard for diagnosing relationship there is no gold standard for diagnosing relationship problemsproblems..

• There is one source for making diagnoses on There is one source for making diagnoses on interpersonal problems, but its fairly recent and not interpersonal problems, but its fairly recent and not widely accepted yet.widely accepted yet.

• This source is: This source is: Handbook of Relational Diagnosis Handbook of Relational Diagnosis and Dysfunctional Family Patternsand Dysfunctional Family Patterns by Koslow, by Koslow, (1996), where 30 diagnostic categories for (1996), where 30 diagnostic categories for relationship problems are presented.relationship problems are presented.

Psychosocial RehabilitationPsychosocial RehabilitationPsychosocial RehabilitationPsychosocial Rehabilitation

• The high efficacy of medications used to treat severe The high efficacy of medications used to treat severe psychopathology (schizophrenia, bipolar disorder, etc.) has psychopathology (schizophrenia, bipolar disorder, etc.) has resulted in reduced abnormal symptomatology & greater level resulted in reduced abnormal symptomatology & greater level of functioning.of functioning.

• In fact, antipsychotics & other meds have resulted in the In fact, antipsychotics & other meds have resulted in the release of thousands of patients from mental institutions across release of thousands of patients from mental institutions across the country.the country.

• Problematically, once these “treated” patients are released they Problematically, once these “treated” patients are released they are unprepared for the demands of functioning in normal life are unprepared for the demands of functioning in normal life & many stop using their medications resulting in a relapse of & many stop using their medications resulting in a relapse of their symptoms.their symptoms.

Psychosocial Rehabilitation (contd.)Psychosocial Rehabilitation (contd.)

• The intervention field of psychosocial rehabilitation The intervention field of psychosocial rehabilitation was developed to teach patients with was developed to teach patients with psychopathology (e.g., schizophrenia) how to cope in psychopathology (e.g., schizophrenia) how to cope in society.society.

• To do this, patients are taught a variety of skills To do this, patients are taught a variety of skills needed for daily life as well as the need to stay on needed for daily life as well as the need to stay on their medication.their medication.

Four components of Psychosocial Four components of Psychosocial RehabilitationRehabilitation

Four components of Psychosocial Four components of Psychosocial RehabilitationRehabilitation

• 1. 1. Teach individuals about the nature of their psychopathology and Teach individuals about the nature of their psychopathology and how to deal with it.how to deal with it.

**teach patients how to recognize onset of maladaptive symptoms **teach patients how to recognize onset of maladaptive symptoms **educate patient’s how to self-monitor their moods.**educate patient’s how to self-monitor their moods. **avoid situations that might put patient at risk (drug use)**avoid situations that might put patient at risk (drug use) **educate patients about taking their medications regularly.**educate patients about taking their medications regularly.

2.2. Educate patients how to live in the communityEducate patients how to live in the community .. **obtaining medical care**obtaining medical care **using public transportation**using public transportation **obtaining a job**obtaining a job **Assist patients in acquiring housing**Assist patients in acquiring housing **teach patients how to buy groceries & cook for themselves**teach patients how to buy groceries & cook for themselves **educate patients on social skills needed for interacting with others**educate patients on social skills needed for interacting with others

3. 3. Case managementCase management: a staff member helps patients : a staff member helps patients obtain services related to employment, housing, medical obtain services related to employment, housing, medical care, finances, etc. care, finances, etc.

• 4. 4. Treatment is promoted by these types of Treatment is promoted by these types of clinicians by maintaining an alliance with mental clinicians by maintaining an alliance with mental health professionals, family, and patients (health professionals, family, and patients (Nietzel et Nietzel et al., 2003).al., 2003).

• **Self-help groups may be formed to promote and **Self-help groups may be formed to promote and offer treatment. offer treatment.

Levels of Preventive InterventionsLevels of Preventive InterventionsLevels of Preventive InterventionsLevels of Preventive Interventions

• 1. 1. Tiertiary Prevention:Tiertiary Prevention: clinicians aim to clinicians aim to lessen frequency lessen frequency & severity of disorder in patients& severity of disorder in patients. This is mainly dealt with . This is mainly dealt with via via psychosocial rehabilitationpsychosocial rehabilitation..

• 2. 2. Secondary PreventionSecondary Prevention: : interventions for individuals at interventions for individuals at risk for developing a disorder.risk for developing a disorder. Assessment & detection of Assessment & detection of early onset of symptoms is crucial here.early onset of symptoms is crucial here.

• 3. 3. Primary PreventionPrimary Prevention: : eliminating/reducing disorders’ eliminating/reducing disorders’ occurrence by changing environmental contingencies or occurrence by changing environmental contingencies or strengthening patients to reduce vulnerabilities to strengthening patients to reduce vulnerabilities to disorderdisorder. These programs aim to counteract factors . These programs aim to counteract factors promoting risk for individuals with a diathesis for a given promoting risk for individuals with a diathesis for a given disorder. disorder.

Primary Prevention programsPrimary Prevention programsPrimary Prevention programsPrimary Prevention programs

• 1. Encouraging Secure Attachments & reducing 1. Encouraging Secure Attachments & reducing family violence.family violence.

• 2. Teaching cognitive & social skills2. Teaching cognitive & social skills

• 3. Modifying environments3. Modifying environments

• 4. Enhancing stress & coping skills4. Enhancing stress & coping skills

• 5. Promoting empowerment5. Promoting empowerment