Substance Abuse Treatment Outcomes: Treatment Practice and Policy Implications

Treatment professionals, whether clinicians, scientists, or policy makers, are interested in developing methods to improve behavioral health treatment outcomes. Clinicians are interested in knowing what treatment practices to incorporate into the services they offer clients. Policymakers request guidance regarding which decisions are most likely to lead to effective treatment approaches and structures. Scientists are eager to contribute knowledge pertinent to building and evaluating effective treatment practices and policies. The papers in this special series provide information on substance abuse treatment practices andpresent findings relevant to clinical practice, policy decisions, and scientific inquiry. This paper provides a brief overview of the National Treatment Improvement Evaluation Study (NTIES) and briefly summarizes the other research papers included in this issue, all of which exemplify practice and policy issues in the substance abuse treatment field and bolster approaches applied to address these issues.     

ETHICAL ISSUES IN FEMINIST THERAPY

This article describes ethical issues that have emerged from the past decade of feminist therapy practice in response to context-specific ethical dilemmas. The model of feminist therapy practice within small communities is used to illustrate the types of problems encountered and strategies for ethical practice used by feminist therapists. Two topics are examined in detail: boundary overlap between therapist and client, and role-related strains inherent in feminist therapy practice. The Feminist Therapy Institute (FTI) Ethical Code is drawn upon as a source of norms for ethical feminist practice, and specific examples are related to statements from the FTI Code regarding self-care and management of over-lapping relationships.     

Remarital Issues in Couple Therapy

Abstract

Remarriage and cohabitation after divorce are becoming societal norms. Given the increasing numbers of these couples, mental health professionals will encounter them in their clinical practice. There are unique issues associated with remarriage (e.g., role and boundary ambiguity, unrealistic expectations) that can hinder the family reorganization process and exacerbate typical communication problems experienced by couples. Therefore, therapists must have knowledge of these challenges to provide the most effective treatment. A brief overview of the remarriage and stepfamily literature, and recommendations for clinicians are presented.     

Does participation in research lead to changes in attitudes among clinicians? Report on a survey of those involved in a French practice research network

Background/Objective: With increasing awareness of some of the limitations of randomised controlled trials as the ‘gold standard’ of psychotherapy evaluation, researchers at the start of the twenty‐first century have focused on a number of new priorities: developing studies in natural conditions; investigating the psychotherapeutic process to better understand the conditions, causes and mechanisms of change; and reducing the gap between clinicians and researchers. Can these three interrelated objectives be combined? Method: A French psychotherapy practice‐based research network (PRN) is used as a field of research for these issues. A survey was used to investigate the conditions that encouraged the clinicians to participate in the PRN study within the context of clinicians’ general opposition to research. Results: Several elements emerged as the key to clinicians’ positive involvement in research: the methodology implemented (intensive case studies during one year); the choice of measures; the constant attention to the practicalities and the potential contribution of studies to clinical practice; the organisation of work in peer groups; the training methods; the use of new information technologies and the sense of participation in a project that would support the profession. Implications: These elements are briefly discussed in relation to the question of how best to encourage clinicians to engage with research.     

The concept of the mission of the Church in the Anglican tradition

This article examines the inherent social imagery in Martin Luther’s liturgical writings An Order of Mass and The German Mass from a practice theoretical and liturgical theological approach. How can the liturgical writings be apprehended as images both of and for social life in the specific communities where they are enacted as concrete liturgical practice? The article aims at presenting a thorough reading of the actual texts with emphasis on the social implications of the liturgical reflections and recommendations, and of material and performative specifications. The underlying thesis of the article is that the liturgical writings both embed, develop and sustain significant social images and comprise multiple reflections regarding the societal dimensions of partaking in liturgy.     

Mental Health Counseling in the Islamic Republic of Iran: A Marriage of Religion,Science, and Practice

This article explores the state of mental health counseling in the Islamic Republic of Iran. Topics that are addressed include training of clinicians, theoretical developments in Islamic‐based theories of psychology, and issues related to the practice of counseling. Counseling issues in the Islamic Republic of Iran are influenced by its unique culture and history. A discussion of issues related to the prevalence and treatment of addiction is included.     

Religious issues in diagnosis: The V-Code and beyond

This paper addresses the issues around considering clients' religious and spiritual functioning as a matter of client diversity. Such issues may be under appreciated by many clinicians. The introduction of a religious and spiritual problem V-Code (V62.89) into the DSM-IV provided a significant accommodation of client religious and spiritual functioning in contemporary psychodiagnostics. The V-Code allows for explicit identification of a non-pathological religious or spiritual focus in treatment. The nature of and history of the V-Code's inclusion in DSM-IV is briefly reviewed. The strengths and limitations of the V-Code for raising clinician awareness of the religious and spiritual domain of client functioning is discussed and illustrated by a number of case examples. The V-Code approach is contrasted with Hathaway's (2003) clinically significant religious impairment concept. Both are viewed as making complementary contributions to a religiously and spiritually sensitive clinical practice.     

Practice‐based evidence in school‐based counselling

Aims: Counsellors are becoming commonplace within the support structures of secondary schools. To date, research findings from practice‐based outcome studies suggest this is a positive move. There are, however, numerous limitations to this work, and this project aims to develop this existing body of literature. Method: Nine 13–15 year olds attending counselling in six school‐based services participated in the project – one individual withdrew. A standardised self‐report questionnaire (YP‐CORE) was collected at four intervals: (1) the point of referral; (2) the onset of counselling; (3) the completion of counselling; and, (4) a two‐month follow‐up. The change indicated in each of these phases is examined and reported here. Additionally, YP‐CORE was completed during each session. Findings: The YP‐CORE indicates an improvement in the well‐being of this small sample, while waiting for and attending therapy. Further examination of session‐by‐session data also highlights how pre‐ and post‐outcome data should not necessarily be viewed as linear in nature. Discussion: This is a small‐scale investigation and further work is needed in this area. It does, however, raise a number of issues regarding the complexity inherent in conducting outcome research that warrant further investigation.     

Ethics and Culture in Mental Health Care

This article examines the complex relationship between culture, values, and ethics in mental health care. Cultural competence is a practical, concrete demonstration of the ethical principles of respect for persons, beneficence (doing good), nonmaleficence (not doing harm), and justice (treating people fairly)—the cornerstones of modern ethical codes for the health professions. Five clinical cases are presented to illustrate the range of ethical issues faced by mental health clinicians working in a multicultural environment, including issues of therapeutic boundaries, diagnosis, treatment choice, confidentiality and informed consent, and the just distribution of limited health care resources.     

Reducing the serious behavior problems of people with developmental disabilities living in the community

Trends and issues regarding the community-based support of people with developmental disabilities who exhibit severe behavior problems are discussed. Living in the community provides a unique framework within which behavior change programs are developed, implemented, and monitored. Support models for people with challenging behavior need to: (a) program for diversity across people, settings, and activities; (b) plan for high levels of integration in community settings among typical community members; and (c) meet guidelines regarding restrictions in intervention typologies. Increasingly, behavior analysts are conducting analog and in vivo assessments prior to intervening in order to develop an understanding of why behavior problems are occurring. Along with the increase in assessing the functions of behavior, is a greater attention to the contexts in which interventions are applied. The rearranging of contexts, communication training, choice-making, matching people's competence to their settings, the use of novelty, and proactive programing reflect these concerns.     

The Importance of Therapist/Client Ethnic/Racial Matching in Couples Treatment for Domestic Violence

Outcome research indicates a relative degree of variability regarding the effectiveness of client and therapist ethnic/racial matching (see Cabral and Smith 2011; Shin et al. in J Couns Psychol 52(1):45–56, 2005). Considering these findings, our study hopes to further understand the complexity behind ethnic/racial matching in treatment. In this study, we examined interviews with clients and therapists regarding ethnic/racial matching in couples treatment for domestic violence (e.g., McCollum and Stith in Violence Vict 23(2):187–201, 2008). Our findings indicated that ethnic/racial matching is a complex multi-faceted issue and connected ethnic/racial matching with issues of culture, human experience, and others. We recommend clinicians consider the complexity of ethnic/racial matching in practice.     

Can Population-Based Carrier Screening Be Left to the Community?

As more genes and mutations are identified in diseases for which particular populations are at increased risk, it is becoming more important to address the social interface between communities and carrier screening. While disproportionately targeted in genetic research, the Orthodox Jewish community often shies away, due to social and religious constraints, from genetic testing and counseling offered by the public health system. The solution is provided by Dor Yeshorim—a program which has become for many a prototype for the successful merging of modern reprogenetic screening and traditional communities. My commentary focuses on the gaps between the rationale and practice of Dor Yeshorim, and the implications of these gaps regarding the trade-off involved in leaving carrier screening to the community. I conclude with a set of questions raised by the implications of the unintended consequences of community genetics.     

Suicide survivors' perceptions of the treating clinician

Seventy-one suicide survivors were surveyed about their perceptions of the clinicians who were treating their loved one at the time of death. Survivors provided information regarding their perceptions and attitudes toward clinician behaviors before and after the suicide and their perceptions of helpful and troubling aspects of clinician behaviors. Results indicated that survivors share a number of common opinions regarding the mental health care providers treating their loved ones. Several differences existed between survivors who consider lawsuits against mental health care providers versus those who do not. The implications of these findings for clinical practice, legal issues, surviving suicide, and future research are discussed.     

Family therapists, community, and civic renewal

In this article, we review family therapy's history regarding community concerns and broader societal issues; offer a model of levels of therapists' involvement with communities and community systems; and propose that family therapists join the citizen activation movement by becoming catalytic partners with families in communities. We call for a new kind of community practice that is driven less by therapist-defined problems and professional expertise, and more by community-defined problems and families' own expertise.     

Religious Knowledge and Its Use in Psychiatry

Clinicians' knowledge of and sensitivity to religious issues have been questioned. The present study measures religious knowledge and willingness to utilize such knowledge in clinical practice. We administered a 41-item questionnaire testing religious knowledge and willingness to utilize such knowledge to 28 psychiatric clinicians. The mean religious knowledge score was 61% of the total possible score. In spite of low scores, only 33% of clinicians consistently refrained from initiating discussions of religious issues. Results support a low level of religious knowledge but do not support a contention that clinicians are insensitive to religious issues.     

The Observant Jewish Victim of Spouse Abuse: Dynamics and Countertransference Issues

This article provides an overview of the dynamics of wife abuse, including its definition, the victim's tendency towards self blame, and the forces keeping her in the relationship. Socio-cultural and practical concerns relevant to the Orthodox victim are specifically examined. These include stigma of divorce, Rabbinic involvement, difficulties with obtaining the Get, and reluctance to seek shelter away from the community. Common countertransference issues that clinicians may struggle with when working with women who are abused are discussed, for example feeling pressured to save the marriage, frustration with resistance, and/or rescue fantasies. The article also offers implications for practice with this very complex population.     

The practice of psychology in rural communities: potential ethical dilemmas

The practice of psychology in rural areas offers unique challenges for psychologists as they try to provide optimal care, often with a minimum of resources. Psychologists are frequently required to be creative and flexible in order to provide effective services to a wide range of clients. However, these unique challenges often confront psychologists with ethical dilemmas and problems for which their urban-based training has not prepared them. The author examines how certain characteristics of rural communities may lead to specific ethical dilemmas. By being a part of a small community, psychologists will inevitably face multiple relationship dilemmas. Confidentiality is harder to maintain in a small town, particularly with its informal information-sharing network. To provide services to meet community needs, with a limited number of referral options, psychologists typically need to be generalists. This may lead to concerns about scope of practice, training, and experience with diverse populations. Psychologists also face other competency issues, such as a lack of supervision and consultation resources. Other concerns addressed include the psychologist's personal life, and the blurring of professional and personal roles. Suggestions are made for coping with each of these ethical issues, although more quantitative research and discussion are needed on the practice of psychology in rural areas.     

Being Mindful About the Use of Mindfulness in Clinical Contexts

Over the last 10 years, interest in the use and investigation of mindfulness-based interventions in clinical settings has expanded greatly. This commentary addresses key questions facing clinicians and researchers in order to undertake future work with rigor and care. We consider, in particular, questions regarding the definition of mindfulness, the context within which mindfulness has evolved over time, including its origins as a spiritual practice, and requirements for clinicians and researchers to deliver and study mindfulness-based interventions competently. We offer suggestions for clinical practice and research, including the expansion of mindfulness-based interventions to increasingly diverse populations.     

A descriptive study of e-counsellor attitudes,ethics, and practice

Introduction: The purpose of this study was to examine questions related to the process, perceived outcomes, and ethics of therapists who provide counselling and therapy online. Method: An online survey was conducted (N=93) with identified e-counsellors with at least a Master's Degree. Questions included demographic information and Likert-type scales related to extent of practice, theoretical orientation, training and supervision, attitudes about appropriate practice, referral, legal and ethical issues, practice difficulties, and therapist satisfaction. Results: Overall, e-counsellors are satisfied with their practice and believe it is effective. They generally do not have formal training or supervision in online practice. Current e-counselling appears to be a part-time, supplemental practice with little overlap to FTF practice. There was little agreement among respondents on attitudes, practice, ethical issues, and knowledge of regulations related to e-counselling. Discussion: Lack of consensus about ethical obligations and practice suggest the need for formal training in e-counselling by professional programmes and international cooperation in formulating practice ethics. Areas for further research are discussed.     

Addressing Consent Issues in Donation After Circulatory Determination of Death

Given the widening gap between the number of individuals on transplant waiting lists and the availability of donated organs, as well as the recent plateau in donations based on neurological criteria (i.e., brain death), there has been a growing interest in expanding donation after circulatory determination of death. While the prevalence of this form of organ donation continues to increase, many thorny ethical issues remain, often creating moral distress in both clinicians and families. In this article, we address one of these issues, namely, the challenges surrounding patient and surrogate informed consent for donation after circulatory determination of death. First we discuss several general concerns regarding consent related to this form of organ donation, and then we address additional issues that are unique to three different patient categories: adult patients with medical decision-making capacity or potential capacity, adult patients who lack capacity, and pediatric patients.