The Role of Military and Veterans Affairs Chaplains in the Treatment of Alcohol Problems

Chaplains can play a unique and valuable role in the treatment of alcohol dependence, a condition that has physical, psychological, and spiritual dimensions. To best fulfill this role, chaplains need to have a broad understanding of the nature of alcohol problems and current strategies for effectively interacting with individuals who have these problems, especially those with severe problems, and with their families. This article is designed to expand the chaplain’s knowledge about alcohol use disorders as well as evidence-based treatments and to offer recommendations on how chaplains can promote recovery of individuals with alcohol-related problems.     

Evidence-based treatment and practice: new opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care

The long-standing divide between research and practice in clinical psychology has received increased attention in view of the development of evidence-based interventions and practice and public interest, oversight, and management of psychological services. The gap has been reflected in concerns from those in practice about the applicability of findings from psychotherapy research as a guide to clinical work and concerns from those in research about how clinical work is conducted. Research and practice are united in their commitment to providing the best of psychological knowledge and methods to improve the quality of patient care. This article highlights issues in the research- practice debate as a backdrop for rapprochement. Suggestions are made for changes and shifts in emphases in psychotherapy research and clinical practice. The changes are designed to ensure that both research and practice contribute to our knowledge base and provide information that can be used more readily to improve patient care and, in the process, reduce the perceived and real hiatus between research and practice.     

Analysis of Hispanic representation and conceptualization in psychology and law research

Hispanics are now the largest minority group in the United States, yet research examining the impact this will have on the American legal system is limited. The first purpose of this article was to synthesize the studies that have been conducted, which have found that Hispanics have a perspective toward the police, the courts and the law, and jury decision making that is unique from those of Caucasians and other ethnic groups. The second purpose of this article was to analyze whether psychology and law research has been conducted in a manner conducive to identifying this unique Hispanic perspective. An analysis of 800 articles published in five psychology and law journals revealed that, while Hispanics were typically conceptualized properly, the proportion of articles devoted to the Hispanic perspective is disturbingly low. To increase understanding of the Hispanic perspective, psychology and law researchers must increase the amount of empirical attention given to Hispanics.     

The Persistent Case of Major Depression: An Argument for Long-Term Treatment

According to psychotherapy outcome literature, treatments for major depressive disorder (MDD) yield impressive results. Study after study demonstrates the efficacy of brief, evidence-based interventions for depressed individuals. Nevertheless, MDD continues to exact a devastating toll on modern society. The World Health Organization has identified it as the leading cause of disability worldwide. This reality is surprising given the implications from the academic literature. A historical analysis of MDD treatment suggests that most people with MDD experienced complete remission and enhanced outcomes when long-term, psychodynamically influenced treatments prevailed. An analysis of the system that perpetuates the brief intervention model for MDD, managed care, is discussed. This analysis is followed by a case study that illustrates the harm managed care can do to patients with MDD who are not permitted treatment of longer duration. Implications and recommendations for psychologists to intervene at the micro and macro levels are discussed.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

Evidence-Based Therapist Responsivity to Disruptive Clinical Process

Although a historically prominent model of evidence-based practice (EBP) privileges the faithful delivery of single empirically supported treatment (EST) packages, psychotherapy research demonstrates that therapist adherence to an EST is often unrelated to patient outcome. Additionally, perseverative adherence when facing disruptive clinical process can relate to worse outcomes. In contrast, unmanipulated within-case variability in adherence, or the natural incorporation of theoretically “off-brand” interventions into an EST, can associate with more improvement. Further supporting the value of therapist flexibility, treatments that intentionally integrate theory-informed departures (away from the foundational EST) vis-à-vis specific disruptive clinical processes can outperform the standard EST without such departures. Thus, responsively adjusting treatments, such as cognitive-behavioral therapy (CBT), to patients’ contextualized pathology, characteristics, and momentary interactions with the provider may represent a more empirically well-supported form of EBP. Consistent with these ideas, we present an overview of context-responsive psychotherapy integration (CRPI), an approach to EBP in an if-then key. CRPI frames common factors as typical and potentially disruptive clinical “if” situations that therapists will encounter and to which they “then” need to be responsive beyond strict adherence to any EST. Notably, such departures can be temporary, thereby supporting vs. replacing the primary EST interventions. To illustrate CRPI’s application to practice, we focus on one example of patient resistance to CBT as a contextual process marker and motivational interviewing as a theory- and evidence-informed departure response. We also discuss clinical, cultural, empirical, and training considerations from the CRPI perspective.     

The Treatment Acceptability/Adherence Scale: Moving Beyond the Assessment of Treatment Effectiveness

It is becoming more broadly recognized that beyond effectiveness, the acceptability of interventions for anxiety disorders is an important consideration for evidence-based practice. Although advances in treatments for anxious psychopathologies have demonstrated that cognitive-behavioural interventions are more desirable than other types of psychotherapy or pharmacotherapy, there continue to be problems with adherence and dropout. It has been suggested that low treatment acceptability may be partially responsible for high dropout rates. Although a number of preliminary investigations in this domain have been conducted, further progress is hampered by the absence of a single self-report measure that assesses both acceptability and anticipated adherence. Therefore, the current paper aimed to test the psychometric properties of the newly developed Treatment Acceptability/Adherence Scale (TAAS). In two studies of brief cognitive-behavioural interventions, the TAAS was administered immediately following the therapy session. In Study 1 (N = 120 non-clinical undergraduates), the therapy included two variants of an exposure-based intervention for contamination fear. In Study 2 (N = 27 individuals with obsessive-compulsive disorder), the therapy was a cognitively based intervention evaluating a novel treatment technique for checking compulsions. Measures of convergent and divergent validity were included. Results demonstrated that the TAAS exhibited sound psychometric properties across the two samples. It is hoped that this measure will help clinicians to predict and intervene when a treatment is not acceptable and/or when the client anticipates poor adherence to it. Furthermore, the TAAS may aid researchers in continuing to improve upon effective interventions for anxiety and related disorders.     

The Use of Empirically Supported Strategies for Building a Therapeutic Relationship With an Adolescent With Oppositional-Defiant Disorder

Manualized evidence-based treatments, particularly behavioral and cognitive-behavioral interventions, have been found efficacious for the treatment of adolescents with oppositional-defiant disorder (ODD). However, despite research that underscores the importance of the therapeutic relationship for the success of treatment, manuals do not adequately address how a therapist should engage an adolescent and his/her family in treatment. This paper demonstrates how to utilize findings from the empirical literature on youth and parent engagement when delivering evidence-based treatment to an adolescent diagnosed with ODD. Examples of strategies for engaging adolescents and parents in treatment are provided.     

Psychosocial treatment of depression and suicidality in adolescents

Depression is a common disorder among adolescents and is associated with a high risk of suicide. Suicide is the third leading cause of death among adolescents in the United States. Currently, there are only two evidence-based psychotherapies for adolescence depression: cognitive-behavioral therapy and interpersonal psychotherapy. Furthermore, psychosocial interventions that specifically target suicidal behavior in adolescents are even fewer in number than treatments for depression. This article will review the psychosocial interventions for depression and suicidality in adolescents and will describe a recently developed treatment that is under study for depressed suicidal adolescents.     

Integrated treatment: a conceptual framework for an evidence-based approach to the treatment of personality disorder

Evidence that various therapies are effective in treating personality disorder and that outcome does not differ substantially across treatments suggests that it is time replace concerns about the efficacy of specific therapies and which form of therapy to use with an evidence-based approach that combines methods that work from all therapies. A framework is proposed for selecting and combining eclectic treatment methods and delivering them in a coordinated way. The framework has two components: (1). a system for conceptualizing personality disorder based on empirical knowledge about the structure, etiology, development, and stability of personality pathology to use as a guide to selecting interventions and planning the sequence in which they will be used; and (2), a model of therapeutic change based on the general literature on psychotherapy outcome and specific studies of PD treatments. The framework proposes that integrated treatment be organized around general principles of therapeutic change common to all effective therapies supplemented with more specific treatment methods taken from the different therapies as needed to tailor treatment to individual patients and treat specific problems and psychopathology. The coordinated delivery of such a diverse array of interventions is achieved by using a phases of treatment scheme that proposes that treatment focus on specific symptoms and problems is a systematic and orderly way according to their stability and potential for change.     

Psychological Interpbetation by Leon H. Levy

Hispanics in the United States mainland underutilize mental health services and drop out of treatment sooner than dominant culture groups. One reason for this problem is that the sociocultural value orientation and expectations of the Hispanic patient are discordant with the values and expectations of the professional offering help. This paper focuses on the special problems resulting from the sociocultural differences between therapist and patient, and discusses why group therapy is uniquely suited to address these problems. It argues that group therapy offered by a leader with knowledge of the culture has an advantage over other forms of treatment in engaging Hispanic patients and in helping them to increase the effective use of mental health services. Issues of group formation, pregroup contracting, and the stages in the life of a Hispanic therapy group are also discussed.     

Implications of the Empirically Supported Treatment Movement for Psychoanalysis

In this article, I critique the empirically supported treatment (EST) movement and discuss the limitations of traditional psychotherapy research from a psychoanalytic perspective. The EST movement is based on a medical model that assumes that a psychotherapeutic treatment can be conceptualized independent of the human relationship in which it takes place. Psychotherapy and psychoanalysis are, however, treatments only in a metaphorical sense and are more akin to educational processes than medical treatments. Every therapeutic dyad is unique, and research that treats therapy as a standardized, disembodied entity will not contribute to our understanding. Nevertheless, there is a real need for psychoanalysts to become more actively involved in psychotherapy research both for political and scientific reasons. Although I do not believe that “empirical validation” in the form envisaged by the American Psychological Association task force is a realistic goal, I do believe in the value of microscopic studies of therapeutic process, particularly in the context of research-informed case histories.     

Adapting Cognitive Processing Therapy for PTSD for People With Disabilities: A Case Study With a U.S. Veteran

Many veterans receiving treatment for PTSD in the VA health care system are also living with a disability and utilize assistive technologies for communication and/or mobility. While evidence-based treatments for PTSD have been disseminated in VA hospitals nationwide, clinicians may have concerns about implementing these treatments with people with disabilities or question how to adapt evidence-based protocols to facilitate successful outcomes. This clinical case study details the treatment of a 48-year-old male U.S. veteran with a diagnosis of military-related PTSD and significant functional and communicative complexities characteristic of locked-in syndrome. The study implemented an adapted protocol of Cognitive Processing Therapy (CPT), a first-line evidence-based psychotherapy for PTSD with unknown application to people with disabilities. CPT protocol structure, length, and delivery was adapted to accommodate the veteran’s assistive devices and functional abilities. The veteran experienced a clinically significant reduction in PTSD symptoms over the course of treatment, suggesting successful application of the adapted protocol. In addition to symptom reduction, the veteran reported advances in his ability to tolerate emotional distress while engaged in goal-directed behavior and improved interpersonal functioning. Results suggest that CPT can be adapted and effective in instances where the presence of disability and multiple assistive technologies impact standard treatment implementation. This information is valuable in its potential ability to make evidence-based psychotherapies more accessible and disability-sensitive. Clinical recommendations for using and adapting CPT for people with disabilities are provided.     

Using client feedback in training of future counseling psychologists: An evidence-based and social justice practice

Training in counseling psychology has evolved to emphasize both evidence-based practice (EBP) and social justice, though these two dimensions have often seemed disconnected, or even at odds in the practice of psychotherapy. The Partners for Change Outcome Management System (PCOMS), an EBP that monitors treatment outcomes and the therapeutic alliance across treatment (often called “client feedback”), may offer a means to connect evidence-based and socially just practices. The purpose of this article was to outline how the use of PCOMS in psychotherapy and supervision can serve as a useful training tool that is a form of EBP and also promotes a socially just paradigm in psychotherapy. We also offer an implementation example from a counseling psychology doctoral program to demonstrate how PCOMS can be used with clients in psychotherapy and included within the supervisory process.     

Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.     

Serial Mediators of Memory Support Strategies Used With Cognitive Therapy for Depression: Improving Outcomes Through Patient Adherence and Treatment Skills

Patient memory for treatment is poor. Memory support strategies can be integrated within evidence-based psychological treatments to improve patient memory for treatment, and thereby enhance patient outcomes. The present study evaluated possible mechanisms of these memory support strategies. Specifically, we tested whether therapist use of memory support strategies indirectly predicts improved patient outcomes via serial improvements in (a) patient adherence throughout treatment and (b) patient utilization and competency of treatment skills. Adults with major depressive disorder (N = 178, mean age = 37.93, 63% female, 17% Hispanic or Latino) were randomized to Cognitive Therapy plus a Memory Support Intervention or Cognitive Therapy-as-usual. Because therapists from both treatment groups used memory support strategies, data from conditions were combined. Blind assessments of depression severity and overall impairment were conducted before treatment, immediately posttreatment (POST), at 6-month follow-up (6FU), and at 12-month follow-up (12FU). Patient adherence to treatment was rated by therapists and averaged across treatment sessions. Patients completed measures of treatment mechanisms—namely, utilization and competency in cognitive therapy skills—at POST, 6FU, and 12FU. Results of serial mediation models indicated that more therapist use of memory support predicted lower depression severity at POST, 6FU, and 12FU indirectly and sequentially through (a) increased patient adherence during treatment and (b) more utilization and competency of Cognitive Therapy skills at POST, 6FU, and 12FU. The same patterns were found for serial mediation models predicting lower overall impairment at POST, 6FU, and 12FU. Together, boosting memory for treatment may represent a promising means to enhance pantreatment mechanisms (i.e., adherence and treatment skills) as well as patient outcomes.     

Psychotherapy for Individuals with Autism Spectrum Disorders

Individuals with autism spectrum disorders (ASDs) present unique challenges for psychotherapists. Those with autism, Asperger’s Disorder and pervasive developmental disorder-not otherwise specified (PDD-NOS) show impairments in social communication and social relationships as well as unusual behavioral features that set them apart from peers. Further, individuals affected with autism spectrum disorders may experience anxiety, depression, obsessive–compulsive disorder and other psychiatric symptoms that can be distressing and, at times, disabling. At present, there is limited information regarding evidence-based approaches for addressing either core impairments of ASDs or associated conditions in a psychotherapy setting. Nevertheless, information about how persons with ASD experience their world and learn can provide clues about what interventions might be useful to assist them such that they can reach their fullest potential. From this standpoint, new or modified approaches to therapy can be tested and further refined to provide a more comprehensive understanding of the psychotherapeutic challenges and the most efficacious therapeutic approach to maximize functioning in this population.     

Improving Methodologies for the Treatment of Child and Adolescent Disorders: Introduction

This special issue grew out of a workshop sponsored by the National Institute of Mental Health, the MacArthur Foundation, and the Child and Adolescent Psychosocial Interventions Consortium. The goals of the workshop are outlined. The contents of the special issue are then described: definitions of psychotherapy and its mechanisms of action, developmental issues in psychotherapy research, methodologies for the treatment of anxious youth, measurement of change in interventions, predicting the outcome of treatment, and advancing the efficacy and effectiveness of psychosocial treatments. Finally, some areas that need to be addressed in the future are discussed, such as process research, the effects of comorbidity on outcomes, intensity, and duration, and transferability of treatments.     

Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment

The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.     

The Hispanic Treatment Program: Principles of effective psychotherapy

The Hispanic Treatment Program was an inpatient psychotherapy Unit at the Colorado State Hospital that operated from October 1979 to February 1982. Staffed exclusively with personnel of Hispanic heritage, the Program emphasized the use of linguistic and cultural elements, as well as the customs and beliefs characteristic of Hispanic culture. A specialized inpatient treatment unit for Hispanic patients with psychotic (especially, schizophrenia) disturbances, the Program offered a unique opportunity to these patients by providing a variety of psychotherapies conducted in a culturally-sensitive manner. Spanish and English were used in a manner conducive to enhancing the treatment process, with flexibility in use of language.This project was supported by Grant No. ROlMH29016-01A2, awarded by the National Institute of Mental Health, Center for Minority Group Mental Health.The authors acknowledge Gregorio Kort, M.D. and Wayne Smyer, M.A. and other staff for their contributions to the development and success of the Hispanic Treatment Program.Original version of paper was selected for the First Senior Award given by the Psychological Services Center's (NYSCP) Minority Mental Health Award Competition.