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April 04, 2012

Analysis of Treatment Modalities

Cognitive Behavioral Therapy

Of all the different types of therapies, I entered the class with the most previous knowledge about CBT in comparison to the other types. Although I knew about the premise of CBT, I did not actually know the steps and activities associated with the therapy. I really enjoyed the worksheets and the information about how to progress in therapy. Such as, identifying negative thought patterns or then using the 10 most common negative thought patterns to help client’s self-identify. This is followed by analyzing the negative thought and restructuring the cognitive schema. I think this is also an easy therapy to explain to clients because of examples such as the two different reactions to the dog (picture) and the question: can you make yourself feel a certain type of emotion and how (through thinking). I think it’s important for client’s to relate to the therapy this way, and it’s easy to see how CBT will work.
I think CBT also takes away some of the stigma of mental illness because it is less focused on symptoms, and more focused on cognition. Clients can feel empowered as they recognize how they think and how thinking this way affects their mood and behavior. It does require a lot of effort on the part of the client because of the weekly homework assignments, but I think that most clients will find it beneficial and take the time to work on their thought processes. Also, CBT can be tailored for different disorders (depression, specific phobias, Obsessive Compulsive Disorder, etc.). CBT can also work for clients of any cultures because it focuses on client’s maladaptive cognitions, and usually the client has insight about what his/her illogical thoughts are. Because of this, CBT can be utilized to help clients work through feelings of cultural topics such as prejudice and discrimination, but it can help clients work through any other life problems as well.
My only concern, and the reason that I might not be able to use CBT very often, is because of the population I work with. At ACT, most of my clients have severe and persistent mental illness and often have low cognitive functioning. For CBT to work, a client needs to have good insight, and most of my client have very poor insight about their mental illness. For clients who are more stable and insightful, I can try to use CBT. Although, a second concern is the time frame. Many of the activities and conversations about schema require a substantial amount of time (probably at least 30 minutes per session), and at ACT, I only see clients in 15 minute increments.
However, next semester I may be able to do individual therapy in longer sessions, so perhaps I will try CBT with clients who have more insight. This may be especially good for ACT clients who are not always compliant with taking their medications, because it can help them dissect their thoughts about their medications and analyze if these negative thoughts about their medications are true. One of the greatest criticisms of ACT programs is that while they do reduce costs because they deter hospitalizations, they do not help improve symptoms or increase quality of life. Perhaps implementing CBT with medication management would help clients even more.
Another reason that this treatment modality could benefit these clients is that many of my clients have a history of trauma and have experienced abuse. Clients who have been abused view the world through a very skewed lens, and cognitive restructuring would be one of the best ways to aid this population. The set-back of this (although it would likely be a set-back for any modality) is that clients will need to face their trauma head-on. And from the experiences that I have had with clients, many do not want to discuss their trauma, let alone analyze it and spend more time thinking about it. But I think that this could be a key in helping many clients.

Dialectical Behavioral Therapy

Entering class, I had some basic knowledge about DBT, such as that it is used for clients with Borderline Personality disorder and was created by Marsha Linehan, but I did not know much about the specifics. For example, I one of the most beneficial aspects of DBT is that it can also be used for clients who have difficulty with emotional regulation problems and interpersonal problems. Because of this aspect, DBT would be a good technique for some clients with severe and persistent mental illness because they have do not have strong social networks and many would like to make friends and be closer to others. However, like CBT, DBT requires a great deal of insight into the client’s mental illness, behaviors, and thought patterns. Because of this, it may be a challenge to help my clients with emotional regulation problems.
The technique that seems the most powerful of DBT is validation. Clients who struggle with BPD or emotional regulation problems have often been invalidated by parents and those around them from an early age. Clients have created maladaptive ways of coping with stress because they were told that their original ways were inappropriate in some way. In other types of therapy, clinicians may question client’s thought and behavior patterns without recognizing how these actions help clients in some way. That is why DBT is so unique. It is a therapy style in which clinicians truly listen to client’s and help them feel worthy and not put-down. Already, at field, I have tried this and found great success. I work with a client who has paranoid schizophrenia and trouble regulating emotion. His affect at baseline is extremely labile. I have taken the approach to validate his treatment concerns (he is on an ATO), and tell him that it isn’t fair that he must be seen by ACT but that I know he can do a better job taking care of himself to be relieved of his ATO. When I validate his concerns, he often opens up and speaks to me more and calms down. This is a big difference from his usual screaming about “unconstitutional” services.
Although there are many positive aspects of DBT, one of the difficulties is that the clinician must be willing to be available 24/7 per the treatment contract. With agencies, like ACT, this may be difficult, because while there is someone on call at all times, the person is not always the same. Another problem with DBT in an ACT setting is that clinicians must be trained in DBT and also provide weekly individual therapy and group therapy. This all requires a lot of time that ACT staff may not always have from week to week. ACT currently runs a co-occurring substance use group, so creating a DBT group may be possible, but it would be difficult to have enough time for individual therapy sessions for all clients. Next semester, my supervisor told me that I will be able to conduct therapy sessions with 2-3 clients, and perhaps I will be able to try some DBT techniques, but I will not have the resources to conduct therapy according to an actual DBT model.
I do not think that DBT necessarily needs to be modified for different cultures because of the aspect of validation. DBT hopes to consider the client’s perspective and understand where the client is coming from regardless of race, religion, ability, age, etc. The only aspect that may be different from culture to culture might be the way that emotion is expressed and what is acceptable might be different among different groups. Because of this, having an understanding of the population and their views on expressed emotion is necessary when working with clients.

Interpersonal Therapy

This briefer intervention might be more useful in an ACT setting than the other types of therapy simply because clients generally are not looking for long-term, if any, therapy. Clients are used to seeing caseworkers anywhere from 1-6 times each week, so this type of therapy, which has less worksheets and homework might be better implemented. Also, the majority of the concerns that clients with severe and persistent mental illness have are either about psychosocial education relating to medication management or interpersonal problems. Thus, this type of therapy could greatly benefit clients who want to work on their relationships with others.
However, the problem with Interpersonal therapy is that it is structured more for clients struggling with depression. So, while the focus on interpersonal conflict is good for ACT settings, the structure and ideas behind it which are based in depression may not be the best, since most clients have schizophrenia or bipolar disorder. Another similar problem is that Interpersonal Therapy is only beneficial to use with clients with mild to moderate symptoms. So, perhaps this type of therapy could be used for clients who are down to 1-2 days per week and those with good insight into their mental illness. Then again, clients who are seen so infrequently generally do not wish to seek therapy or other services because they do not think they ‘need’ ACT services anymore.
Some of the beneficial aspects of this type of treatment include the implementation of treatment goals, the structure, and the functions of the ‘sick role’. First, it is important for clients to create goals for treatment, so that there is a focus for each session. When spending extra time with clients, I have tried to implement this aspect so that there is a focus for the conversation with a measurable outcome. However, I have found that it is very difficult for clients to set goals for longer sessions because, while they would love to talk to me, they do not want ‘therapy’. They would prefer that the time is unstructured and referred to as “extra time with staff”. Another problem with using this type of therapy with clients with severe and persistent mental illness is that while they would like their quality of life to improve, they often cannot identify what steps need to be taken for improvement. Even when I suggest goals or ways to form goals, they do not see a need to make any lifestyle changes.
With Interpersonal Therapy, I also like that there is emphasis on the sick role because many clients do not want to view themselves as ill or mentally ill. Clients want to feel like they have full control over their lives and do not need to take a step back from responsibilities. Allowing clients to understand that this is an illness similar to a physical illness can be very powerful in removing the shame from obtaining treatment or from not being able to do things as well or as frequently as before. Also, I appreciate the structure of Interpersonal Therapy because it gives an itinerary of sorts for the sessions, which is helpful in maintaining evidence-based practices.
Cultural diversity needs to be taken into account for this type of therapy because clients of different ethnic groups may view interpersonal relations (the roles in different relationships and ways of communicating) differently from cultural to cultural. Confronting someone may be acceptable in some cultures and not in others. When working with an African American client who is having difficulty with a friend of twenty years, she has a mentality that friends are for life and even though this ‘friend’ treats her extremely poorly and takes advantage of her, that it is wrong to cut her out of her life.

Psychodynamic Psychotherapy

The goal of psychodynamic therapy is to make the unconscious conscious by asking questions like, “where did you learn to think that way?”. This can be powerful because it allows clients to release some of the guilt and shame they might feel by identifying the source of this belief or behavior. It may help clients make connections between their present actions and how these are learned from parents, family, or friends. Already I have been able to utilize this powerful question in working with a client who feels a lot of guilt. When I asked him, where do you think you learned to feel that way? He became tearful and quiet and said he did not want to speak anymore. Although the conversation did not continue at that point, it was a breakthrough and has led to many good conversations in the last few weeks because it allowed him to think about where these ideas and personal narrative come from.
Another important aspect of psychodynamic therapy is that it explores how the past shapes people today. Clients are able to discuss the pains and joys of their life and make connection about how their past is affecting their present in order to change the cycle for a better future. This can be somewhat difficult to utilize in a way that leads towards a better future because clients can get caught in problem saturation. If clients have no guidance with discussing the past, they will tell many stories about the pains of their lives. However, making the links from how the past relates to current behavior and how it can alter the future is very powerful. Once again though, clients need insight for this to truly work.
Clients must have insight into their mental illness and be able to self-reflect, and oftentimes this is not the case. But it can be utilized with the clients who are seen 1-2 times a week and have more insight. While a traditional psychodynamic therapy model may benefit some clients, the brief psychodynamic psychotherapy would be better for an ACT setting because clients are generally not interested in long-term therapy, and clients may not be in the program for many years, which is often the length of time required for traditional psychotherapy. Another problem with this type of treatment is that, similar to Interpersonal Therapy, this is utilized more for clients with depression and anxiety.
Some of the aspects that I like include the roles of the id, ego, and superego, and the descriptions of the defense mechanisms. The visual depictions of the trio that make the personality would be beneficial for clients who are more visually oriented. It may also be beneficial for clients to imagine the id, ego, and superego in order to identify what plays a role in their decision making. Teaching clients about the defense mechanisms would benefit clients because it would help them identify how they cope with stress and problems in order to analyze their ways of dealing with the world and see if it is helpful or harmful.

Motivational Interviewing

Of all the types of therapy that were discussed in class, Motivational Interviewing is the most utilized treatment modality at ACT in Ypsilanti. I do not know if this is the case for all teams or simply because we have a large percentage of substance users and run a pre-contemplation co-occurring group that also utilized motivational interviewing. Also, I conducted research on treatment modalities in ACT settings for another course (Mental Health Policy) and found that Motivational Interviewing seems to be the most beneficial type of treatment to use in ACT settings. CBT was a close second but produced similar results to ACT itself as an evidence-based practice and did not show greater results when paired with ACT.
One of the reasons that Motivational Interviewing is so effective is that the client is at the center of recovery. The client has the choice to heal rather than receiving advice from the therapist. The therapist and client have a balanced relationship where the two are equals, rather than the therapist being on a pedestal and telling the client what needs to be accomplished. This type of therapy seem similar to solution-focused therapy and goal-focused therapy based on the therapeutic alliance and the idea that the client is the expert on him/her self and has the answers, and the therapist used OCEAN techniques to help the client attain self-actualization.
The OCEAN techniques are useful and clear techniques for the therapist to use, especially empathy and affirmations (similar to validation in DBT) and reflective listening. While reflective listening is definitely a skill that needs practice, I do not know how effective it is for clients with severe and persistent mental illness. I have attempted these techniques with clients, and reflective listening is quite difficult, because often clients just give a brief response and sit in silence. Even waiting them out does not phase them! They have so much going on in their minds that sitting in silence is not uncomfortable.
Motivational Interviewing is also especially useful in ACT settings because of the high rate of co-occurrence of substance use. Because this treatment modality is structured to be utilized with this population it can serve a double purpose at ACT. Motivational Interviewing is also beneficial because it can be easily modified for group settings and does not require a certain amount of time per visit with a client to be effective. The only problem that is more of a ‘user error’ is keeping the emphasis on positive behaviors and goals. I have been getting tangled in reflections and affirmations and have not made as much ground work with actually moving towards any type of change or resolution when I use this modality with clients. But with more training, this may be the most beneficial treatment for ACT clients.

Posted by desolada at April 4, 2012 10:11 PM


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