SOCW 6200 Week 10 Project: Bio-Psycho-Social Assessment
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DOI: 10.1037/14441-011 Biopsychosocial Practice: A Science-Based Framework for Behavioral Health Care, by T. P. Melchert Copyright © 2015 by the American Psychological Association. All rights reserved.
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The behavioral health care field as a whole has relied on a remarkably eclectic set of diverse theoretical orientations for conceptualizing the treatment process. Although allegiance to these orientations appears to have declined in recent years, they still play a major role in case conceptualization and treat- ment. Students learning the profession are expected to adopt a theoretical orientation to guide their clinical practice, and the Association of Psychology Postdoctoral and Internship Centers’s (APPIC) uniform application for applying to an American Psychological Association (APA)-accredited or APPIC-listed psychology internship includes the following required essay item: “Please describe your theoretical orientation and how this influences your approach to case conceptualization and practice” (APPIC, 2009).
The science-based biopsychosocial perspective takes a very different approach to understanding behavioral health care treatment. It is essentially oriented around being a clinical science. It begins with a systematic approach
TREATMENT
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to learning and applying the scientific and ethical foundations of the field, and its primary focus is on meeting the behavioral health and biopsychosocial needs of patients. Chapters 8 and 9 outlined how patients’ behavioral health needs and functioning can be assessed and a treatment plan can be developed that addresses their needs in the context of their biopsychosocial circum- stances. Those chapters were relatively technical, emphasizing the informa- tion needed and the decisions that have to be made as part of the assessment and treatment planning processes. This chapter discusses treatment from a more conceptual perspective, emphasizing the implications of a science- based, health care–oriented approach to behavioral health treatment. It begins by discussing the overarching framework for approaching behavioral health treatment from the biopsychosocial approach and then outlines a thorough approach to evaluating the safety and effectiveness of treatment.
COMPREHENSIVE SCIENCE-BASED APPROACH TO BEHAVIORAL HEALTH CARE TREATMENT
The science-based biopsychosocial approach takes a very different per- spective on behavioral health care than most traditional approaches to learn- ing and practicing the profession. Traditional approaches typically involve learning one or more of the traditional schools of psychotherapy (e.g., psy- chodynamic, behavioral, humanistic, cognitive, systemic). The theoretical model and its associated techniques, methods, and processes are then learned and applied in supervised clinical practice. The science-based biopsycho- social approach, on the other hand, has a very different starting point. After reviewing current scientific knowledge regarding human psychology along with the ethical foundations of the field, attention shifts to research on the behavioral health and biopsychosocial functioning of the population so that therapists understand the nature of health, dysfunction, and biopsycho- social well-being in general. This background allows therapists to then put the biopsychosocial needs of individual patients in proper context. Building on this foundational knowledge, the treatment process for addressing behavioral health needs is then learned. So rather than start by learning a theoretical orientation that can be applied and adapted to work with some range of individuals, therapists begin by focusing on scientific knowledge of human psychology and biopsychosocial functioning, and then they learn about the treatment process and interventions that can be used to address behavioral health problems and improve biopsychosocial functioning.
Understanding individuals as whole persons in the context of their bio- psychosocial life circumstances presents a very broad perspective for under- standing human psychology and behavioral health treatment. Chapters 4
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through 7 noted the wide range of biopsychosocial issues that are common in the general population. For example, the most common psychiatric disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (fifth ed.; American Psychiatric Association, 2013) are sexuality concerns, addictions, panic attacks, and sleep problems (see Table 4.1). A substantial proportion of the population (approximately 15%–20%) meets the criteria for a person- ality disorder as well. In the sociocultural domain, large proportions of the population deal with relationship problems, parenting problems among those with children, financial stress and vocational instability, criminal involve- ment and victimization, single parenthood, and divorce and reconfigured families. All aspects of biopsychosocial functioning occur within the context of cultural, ethnic, and socioeconomic diversity that greatly affect develop- ment and functioning as well. In the medical domain, common conditions among American adults include weight gain and obesity, lower back pain and chronic joint symptoms, high blood pressure, arthritis and other pain conditions, and restlessness and nervousness (see Table 6.1). These medical conditions frequently cause substantial distress and impairment, and psycho- logical factors are involved in their etiology, consequences, and treatment. The co-occurrence of problems within and across these domains is common.
Conceptualizing behavioral health care in this manner is ambitious, as it must be to capture the complexity of individuals’ lives. The starting point is the recognition that psychological outcomes are multifactorially determined based on interacting biological, psychological, and sociocultural processes. This type of perspective is necessary for understanding personality function- ing, psychopathology, intellectual and social functioning, physical health, the nature and etiology of acute and chronic problems, risk factors, strengths and resources, and virtually all the common issues that one encounters in behavioral health care. From career decision-making to serious mental ill- ness, this type of comprehensive, integrative perspective is necessary for understanding problems in context and planning and implementing inter- ventions that maximize the likelihood of treatment effectiveness over the short and long term.
To make matters more complicated still, the biopsychosocial approach also incorporates a health and wellness perspective that includes the goal of optimizing functioning across the biopsychosocial domains. Even when patients have no significant problems that warrant clinical attention in par- ticular areas, converting these to areas of strength helps develop resilience and promotes optimal functioning. This perspective is critical for individuals at all levels of functioning. Even highly vulnerable individuals, such as chil- dren or seniors dealing with serious biopsychosocial problems or individuals with serious mental illness, can benefit greatly from stronger internal and external resources and supports. Minimizing vulnerabilities and risk factors
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while strengthening resources is frequently critical for maximizing treatment effectiveness and optimal functioning over the long term for these popula- tions. This perspective is increasingly being advocated. The New Freedom Commission on Mental Health (2003) concluded that the U.S. mental health care system should be fundamentally transformed around the goals of build- ing resilience and facilitating recovery, and SAMHSA (2011a) initiated a national effort to focus attention on developing strengths and resources among individuals recovering from mental illness and substance use disorders. They advocated that health care providers promote recovery by emphasizing wellness across eight areas of well-being: emotional, physical, social, occupa- tional, intellectual, financial, environmental, and spiritual.
Broad Perspective on Treatment
Traditional approaches to behavioral health care have often used par- ticular theoretical orientations to treat mental disorders. These orientations are certainly still important for informing the methods and processes of empiri- cally supported psychotherapies, but the understanding of human psychology and behavioral health care has now broadened significantly beyond the con- ceptualizations offered by the traditional theoretical orientations.
The research clearly indicates that a variety of therapeutic interven- tions can effectively address behavioral health needs and promote biopsycho- social functioning. It is not possible to develop expertise with a large number of these interventions, and current practice guidelines offer no advice on the range of treatments that therapists in different types of general and specialized practice should be able to provide. One’s approach to treatment varies greatly depending on one’s specialization and practice setting. General practitioners are able to address a broad range of common behavioral health issues, whereas specialists possess extensive knowledge regarding a narrower range of issues. The number of treatments one offers across these practice settings can vary significantly, but in all cases one must be able to conceptualize cases from a holistic biopsychosocial approach. Whether one is a general practitioner treating patients for depression, anxiety, and relationship issues or a specialist in sex therapy or neuropsychological rehabilitation, the general expectation of health care systems is now that one is able to conceptualize care from a biopsychosocial perspective.
Several trends currently underway are likely to continue shaping behav- ioral health care treatment for psychologists. For one thing, psychologists are increasing the number of treatments they can provide. Psychologists’ endorse- ment of eclectic and integrative approaches to practice has grown steadily in recent decades (Norcross, 2005), and small numbers have even completed psy- chopharmacology training so that they can provide pharmacological treatment
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in addition to psychotherapeutic intervention (in Louisiana, New Mexico, Guam, and the U.S. Department of Defense; Fox et al., 2009). Another related trend involves the increasing diversity of settings where psycholo- gists practice. Psychologists now work in a wide variety of medical, edu- cational, industrial and organizational, military, rehabilitation, sport, and correctional settings (APA Center for Workforce Studies, 2011). Providing traditional psychotherapy is often not the first priority in many of these settings, whereas assisting individuals’ to function effectively and meet the goals and needs of the institution or organization they are a part of is usually a top priority. Being able to offer a range of interventions beyond traditional psychotherapy is necessary in these settings.
If the Patient Protection and Affordable Care Act of 2010 is imple- mented as it was originally intended, it is likely to have a significant impact on the future employment of psychologists as well. This law is the largest driver of change in the health care delivery system in the United States for the foresee- able future, and it strongly encourages the development of new delivery sys- tems such as Accountable Care Organizations and Patient-Centered Medical Homes (Nordal, 2012). Integrating behavioral and physical health care in a single setting through interprofessional team-based care has the potential to lead to improved quality of care and reduced costs (see Chapter 13). If psy- chologists work in these new settings, these new health care delivery models require that they efficiently assess and treat a wide range of behavioral health issues in a collaborative manner with other health care professionals. This requires familiarity with a range of treatment options. Many would also argue that a biopsychosocial approach is necessary to work effectively in these set- tings (e.g., APA Presidential Task Force on the Future of Psychology Practice, 2009). It may not be possible to apply approaches revolving around one of the traditional theoretical orientations in primary health care settings.
Another trend that is likely to continue, especially among those work- ing in primary health care, is the use of stepped treatment approaches. As noted in Chapter 9, these often include brief screens and a range of minimal to intensive intervention options that match the severity of patients’ needs (e.g., Screen, Brief Intervention, Brief Treatment, and Referral to Treatment [SBIRT] and permission, limited information, specific suggestions, and inten- sive treatment [PLISSIT]). Increasing numbers of psychologists are likely to adopt more of these stepped approaches, deliver the less intensive interven- tions themselves, and then refer individuals with more severe needs to specialty health care providers (Nordal, 2012).
Another growing trend is the emphasis on health and wellness. The posi- tive psychology movement is now well established within psychology, and the recovery and wellness movements are getting established within the broader behavioral health care delivery systems. The medical community is also
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increasingly recognizing the importance of behavior and lifestyle in the devel- opment and treatment of disease (Institute of Medicine, 2004). These move- ments continue to focus attention on promoting health and wellness across the biopsychosocial domains in addition to treating disorders and pathology.
Priority on the Safety and Effectiveness of Treatment
The biopsychosocial approach advocated in this volume is grounded in science and ethics. As discussed in Chapter 3, health care ethics is very clear with regard to the obligations to provide safe and effective treatment. The implications of the ethical obligation of nonmaleficence (“do no harm”) are obvious when a health care professional intentionally harms others, whereas the implications of unintentional harms are typically more complex and sub- tle. Harm can be caused by omission as well as commission, by imposing risks through either ignorance or carelessness such as when a therapist has insuf- ficient training and supervised experience to accurately diagnose common disorders, complete an adequate suicide risk assessment and treatment plan, or does not appropriately manage countertransference. If patients are harmed as a result, the therapist can be judged negligent and potentially guilty of malpractice. In addition, the ethical principle of beneficence obligates health care professionals to provide benefits and promote patients’ welfare, attempt to prevent harms from occurring, remove them once they do occur, and bal- ance benefits and harms in an optimal manner.
The principles of evidence-based practice also strongly emphasize the safety and effectiveness of treatment. In its landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (2001) identified safety and effectiveness as core needs in health care. Its authors further concluded that clinical decision making should be based on empirical evidence regarding the safety and effectiveness of interven- tions as well as one’s clinical experience and expertise, in addition to accom- modating patient values and preferences. The APA (2006) also adopted a policy of evidence-based practice for psychology that endorsed the same principles.
Although therapists have always been concerned about the safety and effectiveness of their interventions, the safety of psychotherapy received relatively little empirical research attention until recently. Bergin (1966) investigated patient deterioration that appeared to be caused by psycho- therapy, but little further attention was given to the issue until the 1990s when repressed memories of child abuse became highly controversial. Other therapies for which there is evidence of potential or actual harm include rebirthing attachment therapy, group interventions for antisocial youth, con- version therapy for gay and lesbian patients, critical incident stress debriefing,
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and grief therapy (see Chapter 3). Research also indicates that individual therapists vary in their effectiveness, a finding that obligates therapists and their supervisors to monitor the progress of treatment.
Systematic Monitoring of the Progress and Effectiveness of Treatment
Emphasizing the safety and effectiveness of treatment also focuses atten- tion on the systematic monitoring of treatment outcomes. The importance of outcomes measurement is highlighted by both the ethical emphasis on pro- viding care that is safe and effective and the scientific emphasis on measuring outcomes in a reliable and valid manner in order to determine the effects of treatment. The effectiveness and efficiency of health care spending are also rising priorities as recognition grows that current levels of health care spend- ing in the United States are not sustainable.
The biopsychosocial approach to behavioral health care emphasizes outcomes assessment. Monitoring the progress of treatment is important for detecting patients who have not improved or who have deteriorated so that appropriate adjustments can be made. Outcomes assessment at termination and at follow-up is necessary to properly evaluate the effectiveness of treat- ment. Given their importance, these topics are discussed in more detail below in the section “The Safety and Effectiveness of Individual Psychotherapy” and in Chapter 11.
Communication and Collaboration With Other Professionals and Third Parties
Health care professionals address a wide range of biopsychosocial issues and consequently need to be able to communicate and work collabora- tively with health care and human service professionals from all professions. Concern about inadequate communication and collaboration among health care professionals grew quickly as part of the patient safety movement. The 2000 report by the Institute of Medicine, To Err Is Human, alarmed policy- makers and the public because it reported on widespread safety problems in American health care (see Chapter 3). Problems with communication and collaboration were cited as the root of these problems. In their call for a fundamental redesign of the American health care system to improve qual- ity, the 2001 Institute of Medicine report, Crossing the Quality Chasm, found that active collaboration and communication among clinicians and insti- tutions was imperative for improving safety and effectiveness. Their 2003 report, Health Professions Education: A Bridge to Quality, further concluded that interdisciplinary teamwork was one of five core competencies for all health professionals. The Interprofessional Education Collaborative Expert
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Panel (2011) also included interprofessional communication and teamwork in its Core Competencies for Interprofessional Collaborative Practice.
Therapists frequently communicate and collaborate with family members of patients, other health care professionals, educators, employers, criminal justice and social service professionals, and others who can assist with assess- ment or treatment. Chapter 8 emphasized the importance of collateral con- tacts for obtaining reliable and valid assessment information in many cases, and collaborating with these individuals can also be critical for treatment effective- ness. For example, collaborative approaches are seen as necessary for effectively treating the many behavioral health problems found among infants, children, and adolescents in the United States (Egger & Emde, 2011; Kazak et al., 2010). Collaborative approaches are typically also necessary when problem severity and complexity are high (e.g., serious substance abuse, psychiatric disorders, medical conditions, relationship and family dysfunction) and when patients are more vulnerable and dependent (e.g., children, many individuals with cog- nitive or physical disability, many seniors).
The need for psychologists to collaborate with other professionals is also growing as they increasingly work in more diverse settings. Interprofessional collaborative primary care teamwork is necessary for integrating behavioral health, disease management, and preventive interventions in primary care settings (see Chapter 13). Psychologists working in hospital, educational, military, industrial and organizational, rehabilitation, sport, and correc- tional settings also need to communicate and collaborate effectively with other professionals in order to meet institutional and agency goals as well as patients’ individual needs and goals.
THE SAFETY AND EFFECTIVENESS OF INDIVIDUAL PSYCHOTHERAPY
This section examines in detail the safety and effectiveness of treatment, which are clearly of central concern in behavioral health care. A science-based and health care–oriented approach to behavioral health care tends to increase the specificity of the questions asked because practitioners need to know much more than just whether a treatment has been found to be effective.
The discussion of treatment effectiveness focuses on individual adult psychotherapy. Several of the findings discussed also apply with regard to family, child and adolescent, and group therapy, but readers should consult other resources for discussions of those treatment formats. As illustrated in Chapter 9, a variety of additional interventions are useful in behavioral health care such as computer-assisted and online interventions, bibliotherapy, self- help groups, supportive counseling, combined medication and psychotherapy,
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mindfulness, biofeedback, and diet and physical exercise. Readers also should consult other resources for evaluations of those interventions. The following questions are addressed in this section:
77 Is psychotherapy effective? 77 Is the effectiveness of psychotherapy clinically significant?
How often do patients return to normal functioning following treatment?
77 Do the benefits of psychotherapy last? 77 How does the effectiveness of psychotherapy compare with the
effectiveness of psychotropic medications? 77 Does psychotherapy work better for some patients than others?
Do some patients get worse following therapy? 77 What factors account for the effectiveness of psychotherapy? 77 How important are the skills of the individual therapist in
explaining therapy effectiveness? 77 Given that not all patients in therapy improve, can the number
of treatment failures be reduced?
Is Psychotherapy Effective?
In 1952, Hans Eysenck presented a fundamental challenge to the psycho- therapy field when he concluded that research data did not provide support for the effectiveness of psychotherapy and specifically that psychotherapy did not result in more improvement beyond what occurred with natural spon- taneous remission. It took a quarter century of therapy outcome research before his conclusion was reversed. This question was considered settled by the 1980s as the accumulated data showed that psychotherapy is generally effective for a broad range of mental health disorders and across a wide range of therapy approaches. M. L. Smith and Glass (1977) conducted the first meta- analysis of the therapy outcomes research and found an overall effect size of .85 (M. L. Smith, Glass, & Miller, 1980). Many meta-analyses followed, and eventually it was possible to conduct meta-analyses of meta-analyses. Lipsey and Wilson (1993) reviewed all the meta-analyses they could locate and determined that the mean effect size was .81. Lambert and Bergin (1994) conducted a similar analysis and found an average effect size of .82; Grissom (1996) found an aggregate effect size of .75. Wampold (2001) evaluated the results from these and other meta-analyses and concluded:
A reasonable and defensible point estimate for the efficacy of psycho- therapy would be .80. . . . This effect would be classified as a large effect in the social sciences, which means that the average patient receiving therapy would be better off than 79% of untreated patients, that psychotherapy
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accounts for about 14% of the variance in outcomes, and the success rate would change from 31% for the control group to 69% for the treatment group. Simply stated, psychotherapy is remarkably efficacious. (italics in the original; pp. 70–71)
The effectiveness of psychotherapy is substantial when compared with that of medical, psychopharmacological, educational, correctional, and other human service interventions (Barlow, 2004; G. J. Meyer et al., 2001; Reed & Eisman, 2006). In fact, the effect size for psychotherapy (d = .80, which translates to r = .37) far exceeds that of many common medical treatments. For example, G. J. Meyer et al. (2001) found that the correlation between coronary artery bypass surgery for stable heart disease and survival at 5 years is .08; between antibiotic treatment for acute middle ear pain in children and improvement at 2 to 7 days, .07; and between taking aspirin and reduced risk of death by heart attack, .02. These would be categorized as small or exceed- ingly small effect sizes; (r = ± .10 is considered a small effect following Cohen’s (1988) guidelines).
An easily interpreted and increasingly popular metric for measuring the effectiveness of treatment is the number needed to treat (NNT). NNT refers to the number of patients who need to be treated (often with a medicine) for one patient to benefit compared with the patients in a control group not receiving the treatment (e.g., receiving a placebo instead of a medicine; Laupacis, Sackett, & Roberts, 1988). A perfect medicine would have an NNT of 1.0, meaning that only one patient needs to receive the drug in order for one patient to benefit. Very few treatments are 100% effective, and placebo controls often have some positive effects as well. Therefore, very effective treatments are usually in the range of 2 to 4, and researchers are often pleased with NNT values of less than 10 for brief treatments of active disease (Kramer, 2008; A. Moore, 2009). Antibiotics sometimes represent an exception because they can be highly effective in some cases. One of the most effective treatments of all are antibiotics to treat h pylori bacteria that cause peptic stomach ulcers, which has an NNT of 1.1—if 11 people receive the medicine, the bacteria will be eradicated in 10 of them (although the NNT to keep the ulcers away for 1 year is 1.8; McQuay & Moore, 1997).
Many medicines are actually found to have very large NNT values. For example, the very small correlation between taking aspirin and preventing death by heart attack (r = .02) translates into an NNT of 127 (Wampold, 2007). The statin medicine atorvastatin (Lipitor) for lowering cholesterol, the best selling drug in pharmaceutical history, was found to have an NNT of 99.7 after 3.3 years—that is, 100 patients would need to take the medicine for 3.3 years to prevent one heart attack (Carey, 2008; Sever et al., 2003). This does not mean that treatments with very high NNT values are not indi- cated in many cases. As long as the risks of taking a medicine are minimal
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(e.g., the incidence of internal bleeding is low for those taking aspirin) and the costs are reasonable, the benefit of preventing even a very small number of individuals from realizing a devastating event (e.g., death by heart attack) may result in a positive balancing of risks, costs, and benefits. The same ratio- nale applies to suicide intervention. The sometimes limited benefit of many highly marketed medications in comparison to their risks and costs, however, has become a very controversial topic recently (e.g., Goldacre, 2013; Healy, 2012; Whitaker, 2002, 2010).
In contrast to the very large NNT values of many medicines, the NNT for psychotherapy based on an effect size of .80 is 2.7, meaning that 2.7 psycho- therapy patients would need to be treated before one of them can be expected to benefit from the treatment. (An effect size of .60 translates into an NNT of 3.5, and an effect size of 1.0 translates to an NNT of 2.2; Norcross & Lambert, 2011.) Although not all patients improve, this is in the range of treatments considered very effective. Therapists, patients, insurance companies, and the general public can all be assured that psychotherapy has been found to be a very effective treatment that compares favorably to many other health care interventions.
Is the Effectiveness of Psychotherapy Clinically Significant? How Often do Patients Return to Normal Functioning?
Psychotherapy is a very effective treatment that has been found to fre- quently result in a clinically meaningful improvement in patients’ functioning and not just a statistically significant improvement. In fact, large numbers of patients return to normal functioning following treatment. Research that examines this question typically uses standardized measures of therapy out- come, and posttreatment scores falling to within one standard deviation of the normative mean suggest a return to normal functioning. In three meta- analyses, patients’ average posttreatment scores on outcome measures moved into the range reflecting normal functioning (Abramowitz, 1996; Nietzel, Russell, Hemmings, & Gretter, 1987; Trull, Nietzel, & Main, 1988). After reviewing these and other studies, Lambert and Archer (2006) concluded that approximately three quarters of patients who undergo treatment show positive benefits, and 40% to 60% return to a state of normal functioning.
Do the Benefits of Psychotherapy Last?
The effectiveness of a treatment over the long term is critical to judging how successful it is. Treatments that alleviate symptoms in the short term but do not address the underlying causes and improve functioning over the long term are generally much less valuable. Relapse is a huge problem in the treatment of
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physical problems (e.g., heart disease, cancer, obesity) as well as psychological ones (e.g., depression, anxiety, substance abuse). Maintaining treatment gains and preventing relapse are consequently high priorities in health care.
In the case of therapy, research finds that treatment gains are frequently maintained over the long term. This question is difficult to research because many patients drop out of follow-up studies or obtain other forms of therapeutic intervention during the follow-up period. Nonetheless, numerous studies have tracked patients up to 5 or more years following the end of treatment and con- sistently found that therapy improvements tend to endure (Lambert & Archer, 2006). There tends to be some decay in improvements over time for most psychotherapies, though the decay is far less than for psychotropic medications. There is also some intriguing evidence that therapy benefits sometimes increase over time. In five independent meta-analyses, effect sizes for psychodynamic therapy at long-term follow-up (ranging from .75 to 3.2 years) were actually higher than they were at posttreatment—the effect sizes at follow-up ranged from .94 to 1.57, which are very large effect sizes (Shedler, 2010).
Long-term positive treatment effects have been found even with disorders considered among the most difficult to treat. For example, Bateman and Fonagy (2008) were able to follow up 100% of the patients who completed treatment for borderline personality disorder 5 years after they finished a randomized, controlled trial comparing the effectiveness of psychodynamic therapy and treatment-as-usual. The psychodynamic group was found to have much lower rates of suicidality, further outpatient treatment, and use of medication. They also had much improved vocational functioning and higher Global Assessment of Functioning scores (Diagnostic and Statistical Manual of Mental Disorders, fourth ed., Text Revision; American Psychiatric Association, 2000a). Only 13% of patients in the psychodynamic group still met the diagnostic criteria for borderline personality disorder at the 5-year follow-up compared with 87% in the treatment-as-usual group. In another study with an even longer follow- up period, Resick, Williams, Suvak, Monson, and Gradus (2012) were able to follow-up three quarters of a sample of female patients 5 to 10 years after they completed cognitive–behavioral and exposure treatment for posttraumatic stress disorder that resulted from rape. They found that only 18% to 22% still met the criteria for posttraumatic stress disorder.
How Does the Effectiveness of Psychotherapy Compare With the Effectiveness of Psychotropic Medications?
The use of psychotropic medications to address behavioral health symp- toms has grown dramatically in the United States in recent years. Antidepressants have become the most frequently used medication by Americans ages 18 to 44 years, an increase of nearly 400% since 1988–1994. In 2005–2008, about
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11% of Americans ages 12 and older took antidepressant medication, and 23% of women ages 40 to 59 took antidepressants (Pratt, Brody, & Gu, 2011). The use of any psychotropic medication by adolescents 12 to 17 years of age in the United States has increased to 6.6% of the population, an increase of approxi- mately 500% from a decade and a half earlier (Jonas, Albertorio-Diaz, & Gu, 2012). The use of psychotherapy, on the other hand, appears to have decreased during the same time (Wang et al., 2006).
Despite the rapid growth in the use of medications over psychotherapy for many behavioral health concerns, psychotherapy has been shown to be effective when compared to pharmacological intervention. Although medications have often been considered the first line of treatment for mental disorders in the med- ical community (e.g., Muñoz, Hollon, McGrath, Rehm, & VandenBos, 1994), psychological interventions have generally been shown to be equal or greater in effectiveness than medicines for a range of psychological disorders except for severe conditions such as severe schizophrenia and bipolar affective disorder (Barlow, 2004; Elkin, 1994; G. J. Meyer et al., 2001; Thase & Jindal, 2004).
Recent meta-analytic results are particularly informative for evaluating the effectiveness of antidepressant medication. An analysis of U.S. Food and Drug Administration (FDA) databases found that the overall mean effect size for antidepressants approved by the FDA between 1987 and 2004 was .31 (E. H. Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008). The effect sizes ranged from .26 for Prozac to .31 for Lexapro. Methodological differences between medication and psychotherapy trials may be significant enough to prevent direct comparisons of effect sizes found for these two types of treat- ment, but the effect sizes for the antidepressants were not large. When the effects of antidepressants are compared with those of a placebo pill, anti- depressants have also been found to be no more effective than placebo for mild, moderate, and severe depression (Fournier et al., 2010). Both placebo and antidepressant medication were associated with clinically significant improve- ments in depressive symptomatology, and the effect of the antidepressant was found to be superior to placebo only for those with very severe depression, which is a relatively small proportion of the total population with depression.
Individuals often prefer psychological interventions over pharmaco- logical approaches. Surveys consistently find that the public prefers psycho- logical to pharmacological interventions when they are given a choice (e.g., Hazlett-Stevens et al., 2002; Hofmann et al., 1998; Zoellner, Feeny, Cochran, & Pruitt, 2003). This is in part due to the unwelcome side effects commonly associated with psychotropic medications (e.g., for antidepressants, seda- tion, insomnia, headache, fatigue, dry mouth, constipation, gastrointestinal distress, and sexual disturbance; metabolic side effects alone for second- generation antipsychotics include significant weight gain, high cholesterol, and onset of diabetes; Virani, Bezchlibnyk-Butler, & Jeffries, 2009).
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Concern regarding the safety and effectiveness of psychotropic medi- cation has grown significantly in recent years. Very few psychologists pre- scribe psychotropic medications, but large numbers of patients take them. Many psychologists also actively collaborate with psychiatrists and other physicians, physician assistants, and nurse practitioners who prescribe these medications. Therefore, the safety of these medicines is of significant concern to psychologists. Indeed, psychologists are sometimes vocal with their con- cerns about overprescribing and adverse effects (e.g., Society for Humanistic Psychology, 2011). This is a complicated topic with very important implica- tions (e.g., Goldacre, 2012; Healy, 2012; Whitaker, 2010), and so all health care providers should keep current with the literature in this area.
A critical advantage of psychotherapy over pharmacological interven- tions is the superior durability of its benefits (Barlow, 2004). In the case of major depression, for example, medicines, placebo, and psychotherapy are all typically helpful in reducing symptoms. Depressive episodes also tend to eventually remit on their own without treatment. The critical problem is that depressive episodes usually recur (Judd, 1997). Consequently, treatments need to prevent recurrence in order to be truly effective. Studies consistently find that psychological treatments often provide durable benefits that last long after therapy is discontinued, whereas depressive symptoms are more likely to return when antidepressants are no longer taken (e.g., Hollon & Beck, 2004; Paykel et al., 1999; Teasdale et al., 2000). A meta-analysis of treatment for depression found a relapse rate of 27% for psychotherapy but a 57% relapse rate for pharmacotherapy (De Maat, Dekker, Schoevers, & De Jonghe, 2006). Similar results have been found for anxiety disorders (Gould, Otto, & Pollack, 1995; Gould, Otto, Pollack, & Yap, 1997; Otto, Smits, & Reese, 2005). An important exception to this trend involves more biologically based disorders such as bipolar and schizophrenia where psychotherapeutic interventions are generally second in effectiveness to pharmacologic ones (Lambert & Archer, 2006; Lambert & Ogles, 2004; however, see Seikkula et al., 2006, for data showing the opposite). Aside from the more biologically based disorders, how- ever, psychotherapy is often considered the treatment of choice for many of the most common forms of psychological distress and disorder.
Does Psychotherapy Work Better for Some Patients Than for Others? Do Some Patients Get Worse Following Therapy?
Although psychotherapy is remarkably effective overall, there is sub- stantial variability in the rate of improvement across patients. On one end of the continuum, a significant proportion of patients improve dramatically in short periods of time. Several studies have found that a significant minority of patients make dramatic improvements after the first few sessions of treatment
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and that this improvement is maintained at follow-up contacts up to 2 years posttreatment (Agras et al., 2000; Fennell & Teasdale, 1987; Haas, Hill, Lambert, & Morrell, 2002; Ilardi & Craighead, 1994; Renaud et al., 1998). Lambert (2007) estimated that perhaps 25% of patients are early responders who may not need treatment that extends beyond a few sessions. Not surpris- ingly, low severity of psychopathology is an important predictor of patients who respond quickly to treatment (Haas et al., 2002; Taylor & McLean, 1993).
There also are a significant number of patients who do not appear to benefit from psychotherapy. This is not unexpected given the severity and complexity of many patients’ problems. Some individuals are on a steadily declining trajectory of functioning that even the most effective therapies and therapists cannot reverse (this is true in medicine as well). Some patients with serious persistent mental illness, chronic substance dependence, or serious personality disorder have a poor prognosis and suffer a deteriorating course to their conditions. In such cases, slowing the rate of deterioration can be an important beneficial outcome of treatment. As emphasized in Chapter 9, managing chronic mental and physical health conditions is a responsibility of health care providers that is very important in terms of maximizing quality of life and treatment outcomes and minimizing harms and costs.
Beyond the issue of patients with severe psychopathology and a poor prognosis not benefitting from psychotherapy, the possibility of deterioration as a result of being in psychotherapy grew into a significant concern during the controversy in the 1990s regarding potentially harmful consequences from therapy involving repressed memories of child abuse (Barlow, 2010; Lilienfeld, 2007). Treatments such as rebirthing attachment therapy, conversion therapy for gay and lesbian individuals, critical incident stress debriefing, and grief therapy have also been found to be potentially harmful. In addition, there is evidence that differences in therapist skill level affect therapy outcome.
More research is needed regarding the causes of deterioration while in behavioral health care treatment, but clearly a substantial number of patients do not benefit. Lambert and Archer (2006) estimated that the conditions of about 5% to 10% of patients actually deteriorate during treatment and that an additional 15% to 25% do not measurably improve. Though there are several reasons for the deterioration and lack of improvement, it is impor- tant that treatment progress is monitored so that patient deterioration and nonimprovement are identified, appropriate adjustments are made, and treat- ment failures are prevented as much as possible.
What Factors Account for the Effectiveness of Psychotherapy?
The factors that account for the effectiveness of psychotherapy have been debated throughout the entire history of the field. In fact, this issue
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became very controversial in Freud’s inner circle and resulted in the removal of Alfred Adler, who disagreed about the role of sexual instincts in personality functioning and the best approach to treat neuroses (Gay, 1988). Heated dis- agreements regarding the effective elements and processes of psychotherapy continued and are still being debated. Gradually, however, better controlled research has been providing useful data for addressing some of these issues.
Psychotherapy clinicians and researchers have long hypothesized that several specific factors contribute to the effectiveness of psychotherapy. It appeared obvious that the competence of the individual therapist was a significant factor. It has also long been believed that specific methods and techniques are more effective for certain disorders or personality character- istics than for others. Many researchers also believed that some factors are common across therapies, such as therapist empathy, warmth, acceptance, and encouragement, and that they account for the effectiveness of therapy. To a large extent, that some patients improved while others did not was not because of the quality of the therapist or the treatment being offered, but rather because of characteristics of the patient (especially the severity of the psychopathology) or the patient’s environment (e.g., positive and negative aspects of the patient’s family, support system, and community; Garfield, 1994).
After reviewing the available research, Lambert (1992) identified four general factors that he believed accounted for the effectiveness of treatment and estimated the contribution of each to therapy outcome (see Figure 10.1).
77 Specific techniques (15%) refers to the effectiveness of particular treatments or techniques for treating particular disorders.
77 Expectancy (15%) refers to expectations that one will improve as the result of being in treatment (placebo effect).
Figure 10.1. Lambert’s (1992) estimates regarding the factors that explain the effectiveness of psychotherapy. Data are from Lambert (1992).
30
40 15 Specific techniques
Expectancy
Common factors
Extratherapeu�c change
15
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77 Common factors (30%) refers to factors found across therapies, such as empathy, warmth, acceptance, and encouragement to take risks.
77 Extratherapeutic change (40%) refers to factors associated with the patient (e.g., severity of psychopathology and level of ego strength) or the patient’s environment (e.g., availability of social support)
It is very difficult to empirically measure and determine the contribu- tion of these kinds of factors to the total variance in therapy outcome, and only a few studies have attempted to do so. Wampold (2001) analyzed the findings from several therapy outcome studies and obtained estimates that varied significantly from Lambert’s approximations. He concluded that very little of the variance in outcome was attributable to the specific ingredients associated with particular types of therapy but that the competence of the individual therapist had a substantial effect on therapy outcome. Wampold estimated that no more than 8% of the total variance in therapy outcome is accounted for by the specific type of treatment provided, whereas the competence of the therapist accounted for up to 70% of therapy outcomes. The remainder of the outcome variance was not explained by either of these two factors; much of it likely consisted of patient factors such as severity of psychopathology.
A recent meta-analysis of therapy outcomes for depression obtained results between those of Lambert and Wampold. Cuijpers et al. (2012) found that com- mon factors (which in large part might be attributable to the quality of the therapist) accounted for 49% of the variance in depressive symptom improve- ment, 33% was accounted for by patient characteristics, and 17% was attribut- able to specific therapy factors. When the original researchers’ allegiances to the therapy under investigation were controlled, however, the portion of variance associated with the specific therapy factors fell by nearly one half.
Precise consensus estimates of the proportions of therapy outcome that are attributable to particular factors require further research. The severity of patient psychopathology, the quality of their social support, and other patient variables certainly account for a substantial portion of that variance. The portion attributable to the type of therapy provided, on the other hand, appears to be small. The portion attributable to various aspects of the therapy relationship, or what have often been referred to as common factors, however, is substantial. Experts are virtually unanimous in their conclusion that the quality of the therapist–patient relationship is critical to positive therapy outcomes (Lambert, 2013).
A recent project sponsored by the APA Divisions of Clinical Psychology and Psychotherapy involved numerous meta-analyses of therapy outcome to
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identify factors that are attributable to different components of the therapy relationship. The importance of the therapy relationship and alliance is reflected in the conclusions reached by the panel of experts who reviewed the findings of the project. They concluded that “the therapy relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment” and that “efforts to promul- gate best practices or evidenced-based practices without including the rela- tionship are seriously incomplete and potentially misleading” (Norcross & Wampold, 2011, p. 423).
How Important Are the Skills of the Individual Therapist in Explaining Therapy Effectiveness?
It is widely believed across professions that there is substantial variabil- ity in the quality of services provided by different service providers. This is true not just in health care and human services but in most if not all areas of life. Indeed, research consistently finds that therapist qualities are important determinants of therapy outcome (for reviews, see Baldwin & Imel, 2013; Horvath & Bedi, 2002; Lambert, 2013; Norcross, 2011; Wampold, 2001). The variance accounted for by therapist effects is consistently found to be similar in size to the best predictors of therapy outcome.
The importance of therapist effects on treatment outcome is illus- trated in two large overlapping studies that compared patient outcomes for 71 therapists who each treated a minimum of 30 patients (Okiishi et al., 2006; Okiishi, Lambert, Nielsen, & Ogles, 2003). The therapists were categorized according to the improvement seen in their patients’ treatment outcomes. Therapists who were in the middle 50% of the distribution tended to be largely indistinguishable from one another. At the extremes, however, there were distinct differences. The top 10% of the therapists who were associated with the best outcomes had an improved or recovered rate of 44% and a deterioration rate of 5%. The bottom 10% of therapists, on the other hand, had an improved or recovered rate of 28% and a deterioration rate of 11%. One particularly effective therapist who saw more than 300 patients had a deterioration rate of less than 1%; a less effective therapist who saw more than 160 patients had a deterioration rate of 19%.
The evidence clearly indicates that one of the critical elements accounting for therapy outcome is the therapist’s ability to create therapeutic alliances and relationships. Even in pharmacotherapy, therapeutic alliance has an important effect on patient outcome. In an analysis of the National Institute of Mental Health Collaborative Depression Study, Krupnick et al. (1996) found that the quality of the therapeutic alliance was the most important factor explaining improvement in patients’ depression in both the
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psychotherapy and pharmacotherapy conditions. The expert panel in the project examining the importance of the therapy relationship to outcomes sponsored by the APA Divisions of Clinical Psychology and Psychotherapy also concluded that “adapting or tailoring the therapy relationship to specific patient characteristics (in addition to diagnosis) enhances the effectiveness of treatment” (Norcross & Wampold, 2011, p. 423). Therapists’ sensitivity, flexibility, nondefensiveness, and ability to adapt treatment to the person- ality and background of the patient are critical to establishing therapeutic relationships, and these clearly make important contributions to therapy outcomes.
Can the Number of Treatment Failures be Reduced?
The evidence suggests that large numbers of psychotherapy cases involv- ing deterioration are due to patient variables such as severe psychopathology or a failure of social support, whereas others are due to therapist characteristics or a failure to tailor the therapy relationship to the personality and needs of the patient. Regardless of the cause, there appear to be practices that can identify patients who are not improving or are deteriorating so that adjustments in treatment can be made and outcomes improved.
An uncomplicated and inexpensive approach to accomplishing this goal is becoming widely recommended. Lambert and his colleagues have investigated the effect of providing therapists, and sometimes their patients, with patient outcome feedback regarding the ongoing progress of treatment. Using a standardized outcome measure to track patient symptomatology and level of functioning, patients were assigned (in four out of the five studies, at random) to either the treatment-as-usual control condition or to the condi- tion where their therapists received feedback regarding the patients’ level of functioning scores (Lambert, 2007). In the group of patients who began deteriorating during the course of treatment, the patients of therapists who did not receive feedback had posttest scores that were slightly worse, on aver- age, than when they entered treatment. All of the groups where feedback was provided to the therapists, however, improved significantly by posttest. The effect size between those who received feedback and the treatment-as-usual groups was substantial, approximately .40, and the deterioration rate fell substantially in the groups that received the feedback (Lambert, 2010).
There has been reluctance among therapists to systematically moni- tor patients’ progress during the ongoing course of treatment or at termi- nation. A reluctance to being evaluated is natural, but it should be noted that therapists have always monitored patient progress in nonstandardized ways. Therapy progress is routinely monitored by simply asking patients about how they are doing, and the overall effectiveness of treatment is a normal
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topic of discussion at termination. Behavioral interventions typically incor- porated systematic measurement of treatment progress and sometimes in a detailed manner. Wolpe’s (1958) systematic desensitization, for example, monitors the progress of treatment by having patients indicate the success of the counter conditioning on a moment-by-moment basis by raising their finger or verbally indicating their level of distress during the reciprocal inhi- bition sessions. Sobell and Sobell (2000) noted that an inherent feature of the graduated nature of most substance abuse treatment, where more inten- sive treatment is provided as the severity of problems increase, is that it is self-correcting. Patients’ progress is monitored in an ongoing manner (and urinalyses are frequently used to supplement the unreliability of patient self-report), and treatment strategies are adjusted to match deterioration or improvement in patients’ progress.
The safety, effectiveness, and efficiency of treatment will undoubtedly become high priorities in health care. Consequently, techniques that can reliably identify treatment nonimprovement or deterioration will likewise become more widely adopted in behavioral health care. Therapists and their supervisors normally focus special attention on cases where they know that patients are not improving or are worsening (Lambert, 2010). This practice has such great promise that the recent therapy relationship project sponsored by the APA Divisions of Clinical Psychology and Psychotherapy concluded that “practitioners should routinely monitor patients’ responses to the ther- apy relationship and ongoing treatment. Such monitoring leads to increased opportunities to reestablish collaboration, improve the relationship, modify technical strategies, and avoid premature termination” (Norcross & Wampold, 2011, p. 424). The APA Presidential Task Force on Evidence-Based Practice (2006) also noted: “Clinical expertise also entails the monitoring of patient progress . . . that may suggest the need to adjust the treatment” (pp. 276–277; this topic is addressed more extensively in Chapter 11).
DISCUSSION: THE CONTINUING EVOLUTION OF TREATMENT
Behavioral health care treatment has evolved significantly in recent years. The role of the traditional theoretical orientations has declined sub- stantially as the biopsychosocial approach increasingly takes their place. The traditional theoretical orientations are certainly still critical for inform- ing psychotherapy methods, but their role in conceptualizing cases is being replaced by the comprehensive, science-based biopsychosocial perspective. This perspective also focuses attention on strengths, resilience, and well- being in addition to the traditional emphasis on problems, vulnerabilities, and disorders. This is true across all areas and levels of functioning. The
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focus on health and well-being places more attention on long-term treatment effectiveness. Symptom relief and improved functioning in the short term are certainly important, but these improvements need to be maintained over the long term for treatments to be considered maximally useful and effective.
Several trends in behavioral health care reflect the move toward a uni- fied biopsychosocial approach to practice. Therapists are providing a greater range of treatments as they increasingly endorse integrative and eclectic approaches to practice. Psychologists are also working in more varied set- tings where they provide a variety of interventions to address a wide range of biopsychosocial issues. In addition to traditional independent psycho- therapy practice, many psychologists are working in medical, educational, industrial and organizational, military, rehabilitation, sport, and correctional settings. Psychotherapy is often used infrequently or not at all in these set- tings, whereas assisting individuals to function effectively and help meet the goals of the institution or agency are often a top priority. The future of profes- sional psychology may also be significantly affected by initiatives to integrate behavioral and physical health care into primary health care settings. That topic is discussed in Chapter 13.
The effectiveness of behavioral health care has become a very impor- tant issue in the past three decades. The general effectiveness of psycho- therapy for treating behavioral health issues is now well established. The effect size of psychotherapy indicates that it is a very effective treatment that compares favorably with many medical interventions. The effectiveness of psychotherapy is also very meaningful clinically, enabling large numbers of individuals to return to normal functioning. The effects often endure well beyond the end of treatment, unlike the benefits of many psycho tropic medications. There is also evidence that even complex, serious disorders can be treated effectively with psychotherapy.
Research examining the factors accounting for the effectiveness of psycho- therapy finds that the type of psychotherapy provided appears to account for a small amount of the total variance in outcome. On the other hand, the portion of outcome variance attributable to the quality of the therapy relationship and alliance is large. Research clearly points to the importance of therapist skill in creating therapeutic relationships and alliances as being critical to the overall effectiveness of psychotherapy. This includes the ability to adapt the treatment approach to the personal characteristics and background of the patient. The severity of patients’ psychopathology, the quality of their social support, and other patient variables also account for a substantial portion of the variance in outcome. Some individuals have serious psycho pathology and a poor prognosis. Although psychotherapy may not resolve their issues, even slowing the rate of deterioration in health and functioning can be a very valuable outcome of treatment in these cases.
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Issues related to the safety and effectiveness of health care continue to grow in importance. The research and technology for improving psycho- therapy effectiveness are advancing, and procedures for identifying patients who do not improve or who deteriorate are likely to become more common- place. (Chapter 11 examines these important issues in more detail.)
CASE EXAMPLE: A BIOPSYCHOSOCIAL APPROACH TO TREATMENT WITH A MILDLY DEPRESSED PATIENT
The case example that was discussed in Chapters 8 and 9 is presented again to illustrate the biopsychosocial approach to behavioral health care treatment. The treatment plan discussed in the previous chapter was imple- mented with Maria, the 44-year-old married Latina woman with mild depression. That plan included six components: (a) monitor the depressed mood; (b) stop drinking altogether during weekdays for the next 2 months; (c) schedule dates out with her husband a minimum of once per week; (d) begin a regular exercise routine; (e) go to parent–teacher organization meetings at the children’s school to see if there are good ways to get more involved in her daughter’s education and supporting the school; and (f) explore the possibility of improving the relationship with her mother and the rest of her family of origin.
Maria had been completing the clinic’s standard outcomes question- naire every week before she and her psychologist started their sessions. The psychologist noted that her scores indicated steady improvement with her depressed feelings and in other areas as well. At the fifth session, the psy- chologist asked if Maria would ask her husband to join her once again the following week to reassess how things were going. The couple had a very productive conversation when he came to her second session, though they did not appear to have a close relationship—they interacted respectfully and comfortably but with little affection and limited awareness of each other’s feelings or thoughts. Many times they expressed surprise at the other’s reac- tions about things. It was clear that they cared about one another, however, and they enjoyed recalling some very happy times together, mostly times preceding the birth of their children.
The wife and husband interacted much more warmly when they came in for her sixth session. They sat closer and their words and gestures suggested more comfort and warmth between them. He was clearly impressed with how she had started exercising again, and Maria was proud to have dropped two pant sizes. They also reported going out on dates once per week as Maria had agreed to and that their sex life had returned in a way they hadn’t experi- enced in years. They said their younger child even asked, “Mommy, daddy,
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why are you so happy?” Maria noted, “This actually made me really sad. I told Mike that they probably couldn’t remember me being happy like this because I sort of clammed up, retreated into my shell after they were born. I didn’t think anybody realized that. I didn’t really realize that.” Maria said she still wanted to get more involved with the parent–teacher organization at her children’s school. She also said that she wanted to improve her relation- ship with her own mother. Maria and her husband decided to attend Maria’s parents’ church the following Sunday.
After church the next Sunday, the extended family gathered at Maria’s parents’ home for a large meal and socializing. People were very happy to see Maria and her family, and they received many compliments about their chil- dren. At the next session, Maria and her psychologist discussed how Maria could broach questions she had for her mother. The next Saturday, Maria visited her mother so they could talk. Her mother said she didn’t like it that Maria worked outside the home and they weren’t attending church regularly, but she also noted that Maria had the best kids and husband among their relatives and maybe she was wrong to judge her as much as she did. They also talked about how Maria’s mother was very good at school when she was young and could have done what Maria had in terms of education and career, but instead she did what her parents and culture expected of her. She said that she was beginning to realize that seeing her daughter become so successful actually made her jealous and that was the reason she sometimes criticized Maria. She said she still wanted them to raise their children in the church, but she was trying to accept that that wasn’t her decision to make.
At the ninth session, Maria said that she was very happy with how things were going. There was a large drop in her scores on the clinic’s outcome assess- ment questionnaire into the nonclinical range. She said she felt like a huge weight was lifted from her shoulders in terms of the conversation she had with her mother, though she said she couldn’t help being skeptical about whether her mother really meant everything she said. After attending just two parent–teacher organization meetings at school, she said she was happy and felt respected to be invited to join the parent advisory committee for her children’s school. She noted that she had gotten many compliments about losing weight and that she was committed to staying active and fit. She also noted that she only occasionally felt a desire to drink more than a couple of glasses of wine at special dinners or parties and that she felt better physically as a result. Maria and her psychologist talked about how her mother’s criticism and mixed messages to her were understandable given her mother’s psycho- dynamics. After acknowledging major progress with her issues, she agreed to come back for one more session to discuss the nagging feelings she occasion- ally had about whether she had made the right decisions with her life.
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