2012 EXECUTIVE SUMMIT » LAS VEGAS
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SUMMER 2012 VOLUME 15, NUMBER 2
NATURAL REMEDIES
BOOSTING BUSINESS THROUGH BLOGGING
Bitter Orange THE COMPREHENSIVE ANALYSIS OF
SCREENING INSTRUMENTS REVISITED
OCD
UNDERSTANDING
AND THE USE OF THE COGNITIVE MODEL
BIPOLAR DISORDER
THE ALLIANCE
ES-21 Features NICHOLAS CUMMINGS
KEYNOTE SPEAKER
VERONICA ANDERSON
KEYNOTE SPEAKER
MEDITATION
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S U M M E R 2 0 1 2 • VO L U M E 1 5 , N U M B E R 2
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41
ON THE COVER BOOSTING BUSINESS 10 THE ALLIANCE 16 BIPOLAR DISORDER 28 OCD 34 2012 EXECUTIVE SUMMIT 41 NATURAL REMEDIES 58 RECIPE 59 MEDITATION 60 SCREENING INSTRUMENTS 64
2012 EXECUTIVE SUMMIT » LAS VEGAS
INSIDE: COMPLETE SCHEDULE | DISCOUNTS TO STAY AT THE RIO | KEYNOTE SPEAKERS W W W. T H E E X E C U T I V E S U M M I T. N E T / A N N A L S
FEATURES 16 THE ALLIANCE:
FROM THEORY TO PRACTICE
BY HEATHER L. LASKEY, BA, LESLEY K. TAYLOR, PhD, AND MARK D. WEIST, PhD
28 UNDERSTANDING BIPOLAR DISORDER PSYCHOSOCIAL TREATMENT METHODS FOR THE PSYCHOTHERAPIST BY KEVIN P. FEISTHAMEL, PhD, AND CARRIE PRICE, MA
08 MIND NEWS
34 THE COMPREHENSIVE ANALYSIS OF OBSESSIVE-COMPULSIVE DISORDER
26 ASSOCIATION NEWS AND ANNOUNCEMENTS
AND THE USE OF THE COGNITIVE MODEL AS AN EFFECTIVE TREATMENT
64 SCREENING INSTRUMENTS REVISITED A DESCRIPTIVE STUDY
BY DONALD HUTCHEON, RPSYCH, CPSYCHOL (UK), FAPA SUMMER 2012
Annals of Psychotherapy & Integrative Health®
45 SHORT STORY
BY JAMES MCADAMS, MA
BY SALOME DUBENETZKY, BA, MA
4
DEPARTMENTS
46 NEW MEMBERS 62 ACCREDITATION ARTICLE 86 BOOK REVIEW
www.americanpsychotherapy.com | www.AAIMedicine.com
INTEGRATIVE HEALTH 47
60
48 GENERALIZED ANXIETY DISORDER INVESTIGATING CAM APPROACHES BY RYAN HARRISON, MA, HHP, BCIH
58 NATURAL REMEDIES
28
BITTER ORANGE
NCCAM CLEARINGHOUSE
59 HEALTHY RECIPES
COCONUT CREAM PIE SHAKE BY PAMELA HERNANDEZ
COLUMNS
60 GUIDED MEDITATION
10 SUCCESS FILES:
BY EVE ELIOT
BY WENDY BRIGGS
BOOSTING BUSINESS THROUGH BLOGGING
12 CHAIR’S CORNER:
SHE’S PERFECT: MY LIGHTBULB MOMENT BY DANIEL J. REIDENBERG, PsyD, FAPA, DAPA, BCPC, CMT, CRS
76 CHAPLAIN’S COLUMN: VENTILATE & VALIDATE
BY CHAPLAIN DAVID J. FAIR, PhD, CHS-V, CMC
77 CULTURE NOTES:
61
MEMO TO THE HEART
61 EDITOR’S PICK
MEDITATION CDS BY EVE ELIOT BY CHERYL BARNETT, EDITOR
48
OUR OVERWORKED SOCIETY
BY IRENE ROSENBERG JAVORS, LMHC, MEd, DAPA
78 PRACTICE MANAGEMENT: FOCUS OF THERAPY
BY RONALD HIXSON, PhD, LPC, LMFT, BCPC
83 CHAPLAIN’S BRIEF:
WORKPLACE PRAYER ROOMS BY KIM NIMON, PhD, AND S. KRISTINE FARMER, MS, RP, PHR (800) 592-1125 | (877) 718-3053
Annals of Psychotherapy & Integrative Health®
SUMMER 2012
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Become a member of the American Psychotherapy Association®. We provide mental health professionals with the tools necessary to be successful and build stronger practices. Annual membership dues are $165. For more information, or to become a member, call us toll-free at (800) 592-1125 or visit www.americanpsychotherapy.com. 2012 EDITORIAL ADVISORY BOARD Debra L. Ainbinder, PhD, NCC, LPC, BCPC Janeil E. Anderson, LCPC, BCPC, DBT Kelley A. Armbruster, MSW, FAPA Diana L. Barnes, PsyD, LMFT Cherie J. Bauer, MPS Phyllis J. Bonds, MS, NCC, LMHC Sabrina Caballero, LCSW, DAPA Stacy L. Carter, PhD, BCPC Susanne Caviness, PhD, LMFT, LPC Peter W. Choate, MSW, DAPA, MTAPA Linda J. Cook, LCSW, CRS, DAPA, BCETS John Cooke, PhD, LCDC, FAPA Caryn Coons, MA, LPC Clifton D. Croan, MA, LPC, DAPA Catherine J. Crumpler, MA, LPC, BCPC Charette Dersch, PhD, LMFT David R. Diaz, MD Carolyn L. Durr, MA, LPC Adnan M. Farah, PhD, BCC, LPC Patricia Frank, PsyD, FAPA Natalie H. Frazier, PhD, LPC Sabrina Friedman, EdD, CNS-BC, FNP-C Robert R. Gerl, PhD Rebecca Godfrey-Burt Sam Goldstein, PhD, DAPA Jacqueline R. Grendel, MA, LPC, BCPC Richard A. Griffin, EdD, PhD, ThD, DAPA Yuh-Jen Guo, PhD, LPC, NCC Lanelle Hanagriff, MA, LPC, FAPA Ray L. Hawkins, PhD, LPC, AAMFT Gregory B. Henderson, MS Douglas Henning, PhD Mark E. Hillman, PhD, DAPA Elizabeth E. Hinkle, LPC, LMFT, NBCC Ronald Hixson, PhD, LPC, DAPA, BCPC Judith Hochman, PhD Antoinette C. Hollis, PhD Irene F. Rosenberg Javors, MEd, DAPA Gregory J. Johanson, PhD
Laura W. Kelley, PhD Gary Kesling, PhD, FAAMA, FAAETS C.G. Kledaras, PhD, ACSW, LCSW Michael W. Krumper, LCSW, DAPA Ryan LaMothe, PhD P. K. Frederick Low, MAppPsy, MSc, BSocSc, DAPA Edward Mackey, PhD, CRNA, MS, CBT Frank Malone, PsyD, LMHC, LPC, FAPA Beth McEvoy-Rumbo, PhD Thomas C. Merriman, EdD, SBEC (Virginia) Ginger Arvan Metcalf, MS, RN William Mosier, EdD, PA-C Natalie H. Newton, PhD, DAPA Kim Nimon, PhD Donald P. Owens, Jr., PhD Thomas J. Pallardy, PsyD, BCPC, LCPC, CADC Larry H. Pastor, MD, FAPA Richard Ponton, PhD Joel G. Prather, PhD, MS, BCPC, Helen D. Pratt, PhD Ahmed Rady, MD, BCPC, FAPA, DABMPP Daniel J. Reidenberg, PsyD, FAPA, CRS Arnold Robbins, MD, FAPA Arlin Roy, MSW, LCSW Maria Saxionis, LICSW, LADC-I, CCBT, CRFT Alan D. Schmetzer, MD, FAPA, MTAPA Paul Schweinler, MDiv, MA, LMHC, DAPA Bridget H. Staten, PhD, CRC, MS, MA Suzann Steadman, PsyD Ralph Steele, BCPC Moonhawk R. Stone, MS, LMHC Mary E.Taggart, LPC Patrick O.Thornton, PhD Mary A.Travis, PhD, EdS, MA, BS Charles Ukaoma, PsyD, PhD, BCPC, DAPA Lawrence M.Ventline, DMin Melinda L. Wood, LCSW, DAPA Cecilia Zuniga, PhD, BCPC
Annals of Psychotherapy & Integrative Health (ISSN 2167-2113 / print • 2167-213X / online) is published quarterly by the American Psychotherapy Association. Annual membership for a year in the American Psychotherapy Association is $165. The views expressed in Annals of Psychotherapy & Integrative Health® are those of the authors and may not reflect the official policies of the American Psychotherapy Association. Abstracts of articles published in Annals of Psychotherapy & Integrative Health® appear in e-psyche, Cambridge Scientific Database, PsycINFO, InfoTrac, Primary Source Microfilm, Gale Group Publishing’s InfoTrac Database, Galenet, and other research products published by the Gale Group. Contact us: Publication, editorial, and advertising offices at 2750 E. Sunshine St., Springfield, MO 65804. Phone: (417) 823-0173, Fax: (417) 823-9959, E-mail: editor@americanpsychotherapy.com. Postmaster: Send address changes to American Psychotherapy Association, 2750 E. Sunshine St., Springfield, MO 65804. © Copyright 2012 by the American Psychotherapy Association. All rights reserved. No part of this work may be distributed or otherwise used without the expressed written consent of the American Psychotherapy Association.
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EXECUTIVE ADVISORY BOARD CHAIR: Daniel J. Reidenberg, PsyD, FAPA, MTAPA, CRS MEMBERS: Peter W. Choate, PhD, MSW, DAPA, MTAPA Frances A. Clark-Patterson, PhD Clifton D. Croan, MA, LPC, FAPA Gerald L. Dahl, MSW, PhD Natalie H. Frazier, PhD, LPC Donald E. Goff, PhD, MTAPA, DAPA Ron Hixson, PhD, LPC, DAPA, BCPC Robert E. McCarthy, PhD, LPC, MTAPA Mary Helen McFerren Morosko Casseday, MA, LMFT, BCPC Kenneth Miller, PhD, BCPC Chrysanthe L. Parker, JD Stan Sharma, PhD, JD Wayne E.Tasker, PsyD, DAPA, BCPC
CONTINUING EDUCATION The American Psychotherapy Association’s sister organization, American College of Forensic Examiners International (ACFEI), provides continuing education credits for accountants, nurses, physicians, dentists, psychologists, psychiatrists, counselors, social workers, and marriage and family therapists. ACFEI is an approved provider of continuing education by the following: Accreditation Council for Continuing Medical Education National Association of State Boards of Accountancy National Board for Certified Counselors California Board of Registered Nursing American Psychological Association California Board of Behavioral Sciences Association of Social Work Boards American Dental Association (ADA CERP) Diplomate status with the American Psychotherapy Association® is recognized by the National Certification Commission. For more information on recognitions and approvals, please visit www.americanpsychotherapy.com
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Become a member of the American Association of Integrative MedicineSM. AAIM promotes the development of integrative medicine, which is the medicine of the 21st century. Annual membership dues are $165. For more information, or to become a member, call us toll-free at (877) 718-3053 or visit www.aaimedicine.com. 2012 EDITORIAL ADVISORY BOARD Martin Alpert, MS, DC Eleanor Barrager, DCCN, FAAIM Maggie Bloom, PhD Brenda Brown, PhD, ND Phillip Carlyle, DC, CCWP Zhaoming Chen, MD, PhD, MS, FAAIM Debra Dallas, PhD, MIFHI, DCNT Lynn Demartini, DSH-P, RN, LMT Kenneth Dennis, PhD David Getoff, CCN, CTN, FAAIM Cindy Griffin, DSH-P, DIHom, FBIH, BCIH, DCNT, FAAIM Christine Gustafson, MD W. Jeffrey Hurst, PhD Steva Komeh-Nkrumah, DrPH, RD, CNS, BCIM Cuneyt Konuralp, MD, LAc Robert Kornfeld, DPM Tim Leasenby, DC
Don Londorf, MD, CM, LAc, FRCPC Cheyenne Luzader, MS, ADS Robert McCarthy, PhD, LPC, BCPC Bill McClure, DC, JD Pamela McKimie, CHom, LAc Celestine McMahan-Woneis, PhD Mark Morningstar, DC Barbara Phibbs, OMD Donna Scattergood, PhD Cheryl Schuh, CBT, CBS Erin Sharaf Marilia Silva-Brand, FAAIM, DCNT, DCCN Martha Stark, MD Gayle Stockwell, DC Rodger Uchizono, DDS Paul Yanick, PhD, ND
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EXECUTIVE ADVISORY BOARD CHAIR: Zhaoming Chen, MD, PhD, MS, CFP, FAAIM MEMBERS: Shashi K. Agarwal, MD, FAAIM Joseph Di Turo, MD, DAAIM, DEM, BCIM Brian L. Karasic, DMD, MBA, CMI-V, FAAIM, BCIM Mary H. McFerren Morosko Casseday, MA, LMFT, DAAIM, BCIM Gregory W. Nevens, EdD, FAAIM, FACFEI, DAAPM, DABDA Richard C. Niemtzow, MD, PhD, MPH, CHS-V, FAAIM Gail C. Provencher, APRN-BC, MSN, CNS, BCIM, DAAIM Col. Richard Petri, Jr., MC, BCIM, DAAIM Robert E. McCarthy, PhD, LPC, FAAIM, BCIM, MTAPA, FACFEI Mark H. Scheutzow, MD, PhD, DHom, FAAIM, DABHM, DAAPM William M. Sloane, JD, LLM, PhD, FACFEI, FAAIM, DABFC George D. Zgourides, MD, PsyD, DCM
AMERICAN BOARD OF INTEGRATIVE HEALTH MEMBERS: David I. Rosenberg, PhD, LCP, BCIM Jayson B. Calton, PhD, FAAIM, CISSN Mira Calton, CN, FAAIM Nora Osborne, RN, BSN, CNOR, BCIM, DAAIM Phylis Canion, CNC, DCCN
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Annals of Psychotherapy & Integrative Health速
SUMMER 2012
7
Mind News
GLUTEN IN
T E E N AG E
THE DIET MAY
NIGHT OWLS
BE THE CAUSE OF RECURRING HEADACHES
In the spring, later sunset and extended
daylight exposure delay bedtimes in teenagers, according to researchers at Rensselaer Polytechnic Institute’s Lighting Research Center (LRC). “Biologically, this increased exposure to early evening light in the spring delays the onset of nocturnal melatonin, a hormone that indicates to the body when it’s nighttime,” explains Mariana Figueiro, PhD. associate professor. “This extended exposure adds to the difficulties teens have falling asleep at a reasonable hour.” Over time when coupled with having to rise early for school, this delay in sleep onset may lead to teen sleep deprivation and mood changes, and increase risk of obesity and perhaps under-performance in school, according to Figueiro.
Rensselaer Polytechnic Institute (2010, July 26). Exposure to early evening sunlight in spring creates teenage night owls. ScienceDaily. Retrieved May 3, 2012, from http://www.sciencedaily.com/ releases/2010/07/100726124420.htm
MUSIC TRAINING HAS BIOLOGICAL IMPACT ON AGING PROCESS Age-related delays in neural timing are not inevitable and can be avoided or offset with musical training, according to a new study from Northwestern University. The study is the first to provide biological evidence that lifelong musical experience has an impact on the aging process. Measuring the automatic brain responses of younger and older musicians and non-musicians to speech sounds, researchers in the Auditory Neuroscience Laboratory discovered that older musicians had a distinct neural timing advantage. Northwestern University (2012, January 30). Music training has biological impact on aging process. ScienceDaily. Retrieved May 3, 2012, from http://www.sciencedaily.com/releases/2012/01/120130172402.htm
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Annals of Psychotherapy & Integrative Health®
It may be worthwhile to consider how much wheat you eat if you suffer from headaches or lack of coordination and have gluten sensitivity. Researchers found that removing or cutting back on gluten – a protein in wheat and other grains – in the diet greatly reduced these symptoms among a middle-aged study group. The study was reported in the latest issue of Neurology, the scientific journal of the American Academy of Neurology. The study reported 10 patients with gluten sensitivity whose MRI (Magnetic Resonance Imaging) tests suggested inflammation of the central nervous system. All had experienced occasional headaches and some suffered from unsteadiness and failure of muscle coordination. After removing gluten from their diets, nine of the 10 patients in the study found full or partial relief. American Academy Of Neurology (2001, February 13). Gluten In The Diet May Be The Cause Of Recurring Headaches. ScienceDaily. Retrieved May 3, 2012, from http://www.sciencedaily.com/ releases/2001/02/010213072604.htm
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M rly Co ay C Inte lle ur rv en ge b D Dan tion rin ki gero ng us
Treadmills Help Babies With Down Syndrome Learn To Walk Faster And Better, According To Kinesiology Researchers
Ea
Babies with Down Syndrome can learn to walk earlier and better through regular exercise on a slow treadmill, according to research headed by Dale Ulrich, director of the Center for Motor Behavior in Down Syndrome at the University of Michigan Division of Kinesiology. The research was published in the November issue of the journal Pediatrics (http://www.pediatrics.org/), the peer-reviewed journal of the American Academy of Pediatrics. Ulrich said practicing with a parent eight minutes a day, five days a week, on a slow treadmill resulted in children beginning to walk three and a half months sooner than those with Down Syndrome who did not receive the treadmill exercise therapy. Typically, babies with Down Syndrome walk about one year later than their normally developing peers. This delay affects not only a child’s independence but also other developmental milestones. University Of Michigan (2001, November 5). Treadmills Help Babies With Down Syndrome Learn To Walk Faster And Better, According To Kinesiology Researchers. ScienceDaily. Retrieved May 3, 2012, from http://www.sciencedaily.com/releases/2001/11/011105072819.htm
DECAFFEINATED COFFEE May Help Improve Memory Function and Reduce Risk of Diabetes
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The first few weeks of college is a critical time in shaping students’ drinking habits. Now Penn State researchers have a tailored approach that may help prevent students from becoming heavy drinkers. “Research shows there is a spike in alcohol-related consequences that occur in the first few weeks of the semester, especially with college freshmen,” said Michael J. Cleveland, research associate at the Prevention Research Center and the Methodology Center. “If you can buffer that and get beyond that point and safely navigate through that passage, you reduce the risk of later problems occurring.” The researchers tested two different methods of intervention on incoming freshmen -- parent-based intervention and peer-based intervention. Cleveland and his colleagues found that students who were non-drinkers before starting college, and who received the parent-based intervention, were unlikely to escalate to heavy drinking when surveyed again during the fall semester of their first year. Penn State (2012, January 30). Early intervention may curb dangerous college drinking. ScienceDaily. Retrieved May 3, 2012, from http://www.sciencedaily. com /releases/2012/01/120130131204.htm
Researchers from Mount Sinai School of Medicine have discovered that decaffeinated coffee may improve brain energy metabolism associated with type 2 diabetes. This brain dysfunction is a known risk factor for dementia and other neurodegenerative disorders like Alzheimer’s disease. A research group led by Giulio Maria Pasinetti, MD, PhD, Professor of Neurology, and Psychiatry, at Mount Sinai School of Medicine, explored whether dietary supplementation with a standardized decaffeinated coffee preparation prior to diabetes onset might improve insulin resistance and glucose utilization in mice with diet-induced type 2 diabetes. The researchers administered the supplement for five months, and evaluated the brain’s genetic response in the mice. They found that the brain was able to more effectively metabolize glucose and use it for cellular energy in the brain. Glucose utilization in the brain is reduced in people with type 2 diabetes, which can often result in neurocognitive problems. Mount Sinai Medical Center (2012, February 1). Decaffeinated coffee may help improve memory function and reduce risk of diabetes. ScienceDaily. Retrieved May 3, 2012, from http://www.sciencedaily.com /releases/2012/02/120201092316.htm
Annals of Psychotherapy & Integrative Health®
SUMMER 2012
9
SUCCESS FILES
Boosting Business Through
Blogging By Wendy Briggs
If you are a professional counselor or therapist, and you don’t produce a blog connected to your business or practice, you may be missing out on an incredible opportunity. In 2011, eMarketer.com estimated that by 2014, the number of blog readers would reach 150.4 million people. That’s about 60% of Inmillion ternet users. Most experts consider this a low estimate. Many blog people viewed blogs as a fad readers when they first started in the mid-1990s, but blogs have evolved by into a growing industry.
150.4 2014
They are here to stay. WHY START A BLOG FOR YOUR BUSINESS OR PRACTICE?
In his book, The Secret Power of Blogging, Bruce Brown claims that the underlying principles of blogging are a perfect fit for a customer-oriented business model in which you want to allow customers, potential customers, and basically anyone on the web 10
SUMMER 2012
Annals of Psychotherapy & Integrative Health®
to engage you in two-way communication. You can promote services, answer questions, give expert advice, and much more. A blog is a low-cost way to establish or increase the web presence of your practice. Having a blog connected to your website can actually increase traffic to your site. According to Andy Wibbels, author of the book Blog Wild!, search engines love blogs. That’s because blogs are frequently updated, link and network with other blogs and websites, contain HTML that makes them easily indexed, and are set up to be easily read by search engines. This can help drive traffic to your website. Blogs are relatively easy to use. Services like Wordpress.com, Typepad.com, and Blogger.com provide blog software that is very easy to set up, use, and link to your current website. Do a little research or ask around to find the service or software that fits your needs. A blog can help establish you as an expert in your field. If you present information in a helpful way online, how much more helpful would you be in person? Also, as an established expert with an informative blog, news agencies and law firms may consult you about issues or cases they encounter. Blogs offer a way to provide information and connect with a lot of people efficiently. You can provide clinical information and opinions about issues, providing clients and colleagues with the answers they are looking for.
WHAT TO CONSIDER BEFORE YOU START BLOGGING
In an article for mashable.com, Scott Gerber made this poignant statement: “Even though you can write a blog, doesn’t mean you should. Not every business needs one, no matter what the ‘one-size-fits-all’ startup books and ‘experts’ say.” Before you dive into the blogging pool, you should ask yourself a few questions to make sure blogging is right for you. What is the purpose of your blog? To generate interest in your practice? To communicate with patients? To create an online www.americanpsychotherapy.com | www.AAIMedicine.com
community for colleagues? To establish yourself as an expert or leader in your field? The answers to these questions will dictate how you go about creating your blog and what you will post on it. Consider your purpose carefully before getting started. Then keep that purpose in mind during each step of building and maintaining your blog. Who is your target audience? A blog created for an audience of professional counselors will be very different from one created to communicate with clients. This will direct the type of content and how it is presented. Who will contribute to your blog? Will you be the only person posting content or will you be part of a team of bloggers? A group of counselors can divide the responsibility of posting information, but it requires setting up some policies and procedures before you get started. How much time can you spend on your blog? Blogging involves not only writing posts, but reading other blogs, managing comments, linking to other websites, researching topics, and much more. Determine whether you have the time needed to blog well. Are you a good communicator? Blogging requires the ability to write engagingly, clearly, and concisely. Make sure you can actually write before committing or contributing to a blog. Have you considered the legal risks associated with business blogs? Anticipate and plan for these risks. The book Blog Rules by Nancy Flynn is a great resource that covers legal liabilities and best practices for businesses that want to establish a blog. She suggests using the Three E’s of blog risk management: Establish policy, Educate employees, and Enforce policies with discipline, content management, and monitoring technology.
HOW TO MAKE YOUR BLOG A SUCCESS
There is no end of advice when it comes to being an effective blogger. Every blogging expert, website, and book provides lengthy lists of tips and tricks to make your blog a success. Here are a few of the tips most often provided by the experts: • Post consistently. Some experts claim that a blog post must be made every day and others claim that once a week is sufficient. Whatever you decide, whether once a week, once a day, or every other day, choose a pattern and stick with it. Your readers will come to expect your regular posts. • Add value. Blog posts should provide information, inspiration, or simply entertain. Your readers should walk away from reading the post feeling that the time was well spent. If your blog is only made up of thinly veiled advertisements for your services, people will soon lose interested. Remember blog posts can be read by anyone. Make sure it is appropriate and sends the correct professional message to readers. • Guard professional secrets and confidential information. Companies in the health care industry are legally required by the Health Insurance Portability and Accountability Act (HIPAA) to protect the privacy of patient information. Make yourself aware of any specific laws that govern the practices of counseling services and therapists. • Keep posts short. Internet readers are impatient. Stay concise and to the point. Your word count can range between 150 and 800+ words. Choose a word count range that works for you (800) 592-1125 | (877) 718-3053
and stick with it. Topics that need longer articles can be broken up into two or three different posts. • Read blogs that cover similar topics. While blogs are very attractive to search engines, it can be difficult to find specific blogs by using the usual means such as Google or Yahoo! It’s faster to use a blog search website such as blogsearch.com, techorati.com, or blog-search.com.
If you’re interested in adding value to your business, boosting customer loyalty, establishing yourself as an expert in your field, and attracting potential clients, set up a business blog. The following resources may help: Blog! by David Kline and Dan Burstein—a collection of essays and interviews about blogging Blog Rules by Nancy Flynn—considered the business community’s best practices reference guide for managing blogs Blog Wild! By Andy Wibbels—a short, simple break down of what blogging is and how to get started The Corporate Blogging Book by Debbie Weil—an overview of business blogging The Everything Blogging Book by Aliza Sherman Risdahl—an easyto-use guide to get you started with your business or personal blog The Secret Power of Blogging by Bruce C. Brown—a great resource that specifically tackles how to promote your business or organization by using blogs • Respond to comments on your blog and post comments on the blogs of others. This makes your blog more appealing to search engines. It’s also a great way to link to other blogs for greater exposure among people who are interested in your blog topics. • Be genuine. Post what you mean and mean what you post. Bloggers are notorious for recognizing a fake or ulterior motive. • Make it easy for people to subscribe to your blog by having an RSS feed or subscription by e-mail. Before you get too overwhelmed with all the do’s and don’ts of blogging, remember that many bloggers go through a trial and error period. No one gets it right from the very start. The best thing to do is jump in and give it a try, learning the ropes as you go.
REFERENCES: Brown, B. C. (2007). The secret power of blogging. Ocala, FL: Atlantic Publishing Group, Inc. Flynn, N. (2006). Blog rules. New York, NY: AMACOM. Gerber, S. (2011, May 24). 11 pro tips for better business blogging. Mashable.com. Retrieved from http://mashable.com/2011/03/24/better-business-blogging/ Wibbels, M. A. (2006). Blog wild! New York, NY: Penguin. Reese, S. (2011, May 26). Quick stat: 53.5% of Internet users will read blogs this year. eMarketer.com. Retrieved from http://www.emarketer.com/ blog/index.php/tag/number-of-people-who-read-blogs/
Annals of Psychotherapy & Integrative Health®
SUMMER 2012
11
CHAIR’S CORNER Normal dog hip x-ray
Reba’s hip x-ray
“She’s Perfect.” My light bulb moment. By Daniel J. Reidenberg, PsyD, FAPA, DAPA, BCPC, CMT, CRS
ometimes you are in the middle of a conversation and it happens. Other times you are watching television and it happens. It also happens when you are listening to music, reading an article, or for some it could be when reading a Facebook post. Light bulb moments happen where people worship, and while riding a bike on a country road in solitude. For all of us these moments of enlightenment stop us right where we are while the world keeps turning, conversations and homilies continue, but for us at that moment, something is different. Maybe you now see something more clearly. It might be that the pieces to a dilemma now fit together, or it could be that you finally understand what your partner has been trying to tell you for the last 5 years. For clients it can be the moment they feel relief from a long-held painful memory that now has a new meaning. These are light bulb moments and we all have them. As therapists, we help our clients move toward these moments. We help interpret them, and probably most importantly, we ourselves recognize them, both for us and for our clients. Recently, I had a light bulb moment that has changed everything for me, for the better and for the future. The world looks very different to me now. A little background on how and why I got to this moment is important. My father has been a trial attorney for nearly 50 years. He has lived his life in a world of the courtroom, or shall we say in a world of “black and white,” which is something I am sure all the readers of this article can relate to. I began working with my father when I was 10 years old, and for almost 20 years I did everything in a law office that can be done. I filed papers, added up columns of numbers on timesheets, ordered supplies, and kept things neat. I also learned how to conduct legal research, write motions and briefs, and I even trained lawyers who, although they had graduated with a law degree, couldn’t write an affidavit, or a motion, or walk correctly into a courtroom if they wanted to. In my time with my father I learned 12
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the difference between right and wrong, what the statutes said and what they did not, as well as how to test every limit of the law that there was without ever violating it. I was also taught that sometimes you have to help people understand that there was a different way to see something, i.e. you had to write a new law through how you presented a case. Outside of my father’s office he was still a lawyer and he, my brother, and I knew that. Intensely. All of this was great training for me if I wanted to become a lawyer and follow in his footsteps. In many ways, that would have been a much easier life for me. I knew how he thought and how he worked. Over the course of his career he developed an impeccable reputation and a large, successful practice. I knew it and I knew it well. I could have taken over his practice whenever he decided to retire and, while I was not my father, I was good enough and his reputation was strong enough for me to have maintained his practice, and a good life would have been at my doorstep. The problem was that I didn’t want it. I had an intellectual interest in the law and a desire to play the game, but I did not have the heart for it, especially not like he did. Instead, following a conversation I had with my mother when I was 5 or 6 years old; I wanted to help people, and this is ultimately what I would pursue. Helping people, especially the way I wanted to work as a therapist, was definitely not the black and white world I had known and lived. As I pursued my education, I volunteered in, and then began working in, the mental health field. Life was full of shades of every color, and in some ex-
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tremes black or white; yet the black and white world I had become accustomed to, always remained somewhere in my mind. Maybe it was a fallback just in case I needed it, or it may have been just so deep-rooted in my brain that no matter what I pursued with my clients, I couldn’t fully let it go. Because I found that somehow comforting, I never really did acknowledge that when things became difficult for me, I would always return to this type of thinking (thankfully this only applied to me interpersonally and not to my therapy). Overall, life went along just fine after graduation and through the years since, as I’ve worked in the psychotherapy field for the last 20 years. Before I share my light bulb moment, I want to give you one more piece of background information. I have had animals in my life since I was an infant. It has almost always been dogs, except for a cat that I had for 15 years just after high school. After my cat died, I vowed never to have another pet. I didn’t see the need for one, and I definitely didn’t want to suffer the pain of losing another one, as inevitably happens to all pet owners; however, for the last 10 years there have been dogs in my life, but I’ve never truly gotten attached to them. I care about them, absolutely I do, but I just never became attached
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to them. I thought this was a good, self-protective measure. Oddly enough, it remains on one end of the black-white spectrum. Now fast forward to last fall when our family grew by one dog in October when we got an English Golden Retriever puppy. At just 8 weeks old, Reba was very cute as puppies go. She was small, fluffy, cute, and filled with an irresistible personality. For example, when she would get a bone, she would pick it up, raise her head as high as she could and then run around the house like she was the Queen and everyone should pay attention, despite living with a Great Dane who looked at her as if she could be a light snack at any moment, if she stepped too far out of line. If you let her outside, she would invariably find a stick much bigger than the length of her entire body and would always try to bring it inside, even though it never fit through the door. Every time I would return home she would run to the door and cry, in a very high pitch puppy way, for minutes upon minutes until I would pet her and let her know that I saw (and heard) her, but I resisted getting attached to her and held onto my black and white line with her. Traveling weekly, and working just as much when I am in town, I’m rarely home and don’t have much time to spend with the dogs. Nonetheless, as the months went by, little Reba grew and kept developing her strong personality and with it, a way to capture people’s hearts when they met her. I have to admit that I did enjoy the little time that I did have with her, and she was becoming more 14
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important to me all the time. Then one Sunday I noticed that she seemed to be having a hard time getting up and walking. While she did not seem to be in any pain, she was not nearly as “happy” and playful as she typically was. One day I found her in a downstairs bedroom even though there was a houseful of people and other dogs to play with. Then I noticed that as she walked, something odd was happening with her back legs. Having had dogs before, my thought immediately went to hip dysplasia and what that might mean for this little 6-month-old puppy that was truly capturing my heart more and more each day. Two days later after a visit to the vet and an X-Ray, the news was worse than I suspected. “She has no hip sockets. None at all.” Huh? How could anyone (dog or person) not have hip sockets? How can she walk and what kind of future can she have? What did this all really mean? Technically speaking, according to Dr. Levine, DVM, MS, ACVS, she has “bilateral rear limb atrophy and bilateral luxoid hip dysplasia. There is virtually no acetabulum on either side of the pelvis and the femoral heads are misshapen.” What was going to happen to her? This little fur ball that was dragging me into a place I didn’t ever want to be in again - can she be fixed? Can we afford to have this repaired and, more importantly, can it even be done? Is it fair for her to suffer with whatever pain she might be in and then what she would have to endure with surgery and recovery? After hearing the news from the vet, hundreds of questions ran through my mind and then as I was sad, scared, worried, and a hundred other things, the matriarch in our house – and true alpha to the dogs – looked at me and said: “She’s perfect.” What? Perfect? Have you lost your mind? How could you say that? How could anyone say that? Did you hear what the doctor said? She’s not perfect. Not at all. The dog has no hips. None at all. It’s the worst case they’ve ever seen. It couldn’t be more black and white than this, not in my mind. “Yes, she is. She is exactly as God made her to be and she is perfect.” In that moment, a light bulb went on that has not since turned off. She really is perfect. She is the way that she is and that is perfect. Yes, she has all the bilateral problems and acetabulums missing, but she is also perfect. In that split second, my lifelong definition of “perfect” changed. As that little puppy looked longingly at me to not let her go and to do whatever I could to help her get better, I realized that not only did she have my heart, but I learned that
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my retreat to black and white, that safe place I could always turn to in difficult moments, was no longer black or white. Instead, it just was what it was. It did not need to fit into a neat little box or definition as I had always lived and believed everything should. It could now and forever be entirely different. Perfect could mean so many things to me and to others, and, to my amazement it could change too. Then what? If my definition of perfect could change, what else could change and what might that mean for me? It would ultimately mean that long-held beliefs and certain ways of thinking no longer had to be viewed that way. It would mean that perceptions and judgments engrained in my mind and relied upon for a variety of situations just to help me get through the day, should maybe be reassessed. It would also mean that I could see through a whole new lens as to how we get stuck in patterns that affect each of us personally, and I surely know these patterns get transferred to our work with clients, whether we want it to or not. I spent the next couple of weeks researching all forms of hip problems in dogs, the science behind repairs, replacements, and even who could make a hip socket where none existed. I investigated all of the universities, veterinary specialists, and diplomats there were in the country. I prayed that we could find someone who could do something for Reba so she could live the life she was meant to live. I resolved to live with whatever expert opinion we could find, and I realized that there might be more than one opinion, which gave me reason to hope. Ultimately, we did find an orthopedic specialist for dogs who not only confirmed this was the worst case he had ever seen in more than 20 years in veterinary medicine, but he also had a plan! I was beyond feeling a sense of relief, and when Reba turns a year old, she will have the first of two surgeries to fix what isn’t there. The doctor says she can lead a full and normal life, and in this I know my life of black and white thinking will never be the same.
Lessons I learned: Definitions are not absolutes. I defined perfection as being perfect, and what I learned is that perfect could be as different for someone else as it could be for me. Thus, remember that when you define something, or your client does, it is important to continually check to make sure that the definition you/they have hasn’t changed. Circumstances make it necessary to see definitions as a place to start, not always to return to. I learned that as circumstances change, so does where you begin to assess each situation. In my case, I thought the circumstances led me to return to what was “natural” for me; however, the reality was that the circumstances actually led me to redefine my starting place. We all make judgments almost immediately and instinctually, especially in times of stress, which relies on our past. Therefore, we must be cognizant of the impact our history has had on our present. I learned that this was not serving me well, even though it was what I had done for years and years. Light bulb moments are ones that can change a lifetime. You will remember them, because they just don’t happen often enough. When you allow yourself to see something that you’ve never seen before, you can do a great deal with it - more than you’ve ever imagined. Just as we want our clients to be open to new possibilities, when we open ourselves up to seeing things differently there is no limit as to what we can do with that. (800) 592-1125 | (877) 718-3053
Lessons for therapists: I think that we often underestimate the impact of the direction we take our clients. Clients are guided in the direction that the therapist sees as “perfect” or the “right direction.” However, is the perfect place for the therapist the same perfect place for the client? Maybe yes but maybe no. We do our best to help clients get to where we think is best and where they want to go, but can we say for sure this is the same place another therapist might direct the same client? Continually check with the client to make sure you are working in the same direction, on the same goal plan, and when necessary, consult with others to ensure you are helping your client(s) move in the direction best for them. Watch for these “light bulb” moments in your clients and interpret these instances with them, not for them. Because they are rare, we can help our clients to see them when they happen, even if they don’t recognize it; however, even more important is that we help them interpret the true meaning and the significance of the experience with them and avoid placing our interpretation on them. Recognize the lifetime value for your clients in having these experiences. As my light bulb moment changed how I forever will define and see perfect, we must remember that as clients have these experiences, it changes them forever and this will have a lasting impact and importance for them. Help your clients as they redefine themselves! Be careful of your immediate judgments made about clients and what they bring to you. It can never be said enough that “we get what we get from our clients.” This comes to us through their lens, their experience, and for them it is real, not just reality. This is important and needs to be validated. At times it also needs to be clarified, modified, and even made entirely different for them. I know too many people who go to therapy and tell their therapist only what they want to tell them and it is usually less than half the story. Our work requires us to question, without judging, what and how we receive the information that we ultimately rely on in helping our clients. Find ways to share examples like this with clients so they know how possible anything is. Interestingly enough, no one can ever truly know my light bulb moment like I did. You can know what it is like to have a moment like this because likely you’ve had one. Thus while you know what they are like, regardless of how I describe it, it can’t be fully felt by anyone other than the person who experienced it; however, at the same time, because light bulb moments happen to most of us, sharing examples of how connected we all are can help relieve some clients’ anxieties and offer them hope.
ABOUT THE AUTHOR DANIEL J. REIDENBERG, PsyD, FAPA, DAPA, BCPC, CMT, CRS, is the chair of the American Psychotherapy Association’s Executive Advisory Board and has been a member since 1997. He is a Fellow and Master Therapist of the American Psychotherapy Association and executive director of Suicide Awareness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your thoughts at dreidenberg@save.org. Annals of Psychotherapy & Integrative Health®
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treatment.
stakeholders throughout
maintained with key
to be formed and
alliances need
The Alliance
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From Theory to Practice by Heather L. Lasky, BA Leslie K. Taylor, PhD, & Mark D. Weist, PhD Interest in the therapeutic alliance traces back to early developments in psychotherapy, and alliance continues to be a critically important topic of discussion and study. A meta-analysis conducted by Martin, Garske, and Davis (2000) of 79 studies pertaining to therapeutic alliance in adult therapy found it to be moderately related to treatment outcome. Other studies have confirmed that the greater the strength of the alliance, the greater the therapeutic change (Horvath & Bedi, 2002), emphasizing the importance of alliance within the treatment process.
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THE GREATER THE STRENGTH OF THE ALLIANCE, THE GREATER THE THERAPEUTIC CHANGE. he alliance has been widely researched in adults, and although critical to outcomes, has been less studied with youth. When asked to rate what variables they believed to most influence the effectiveness of treatment, around 90% of psychologists and psychiatrists responded that the therapist’s relationship with the child was “very much” or “extremely related” to therapeutic change (Kazdin, Siegel, & Bass, 1990). More notably, a meta-analysis of constructs related to the therapeutic alliance in child and adolescent therapy pointed to the therapeutic alliance as a predictor of treatment outcomes (Shirk & Karver, 2003). Alliance formation with children and youth can be complicated for clinicians by the inclusion of multiple “alliances” of importance with key players, such as parents, other family members, and teachers. Further, clinicians must then balance their attention to these multiple alliances over time (Zack, Castonguay, & Boswell, 2007). Working effectively with families and teachers can be a particularly challenging process that is often foundational to achieving positive outcomes (Yeh & Weisz, 2001; Hawley & Weisz, 2003; Youngstrom, Loeber, & Stouthamer-Loeber, 2000; Garland, Lewczyk-Boxmeyer, Gabayan & Hawley, 2004; Hoagwood, 2005). Not only are additional stakeholders involved in the youth therapeutic process, often therapy occurs in differential locations, such as schools, which contributes new dynamics to mental health services (Stephan, Weist, Kataoka, Adelsheim & Mills, 2007). As policy changes call for families to become active consumers of mental health services and for children to receive more comprehensive services (New Freedom Commission, 2003), a review of the differences in alliance 18
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pathways for youth, caregivers, and others is in order to assist in clinical skill development and to advance ideas regarding training and research.
Definitions of Alliance
The concept of the alliance has a fairly long history. The terms therapeutic alliance, therapeutic relationship, alliance, helping alliance, working alliance, as well as others are often used interchangeably and are used to refer to several related constructs. Although there is not a universally accepted definition of the alliance, there are important shared aspects among the definitions (Horvath & Bedi, 2002). Most commonly in the youth psychotherapy literature, alliance has been conceptualized broadly as some form of a relational connection with the clinician (Karver, Handelsman, Fields & Bickman, 2005). This relational connection has then been further broken down as an emotional connection, a cognitive connection, or some combination of the two. An emotional connection has been variously conceptualized as a bond, trust, acceptance, warmth, mutual positive regard, feeling allied, supportiveness, and/ or helpfulness. Alternatively, the cognitive connection has been conceptualized as an agreement on goals or tasks, and/or a positive working relationship. These broad and varying definitions suggest that the alliance is conceptualized in a number of ways (Karver et al., 2005).
Adult and Child Therapy: The Impact on Alliance
In 2003, Shirk and Karver conducted a meta-analysis identifying only 23 studies that focused on constructs related to the therapeutic alliance in child and adolescent therapy. By contrast, in 2000, Martin, Garske,
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and Davis conducted an exhaustive literature review of published and unpublished adult studies and found 79 (58 published, 21 unpublished) that pertained specifically to therapeutic alliance. Due to evidence that indicates therapeutic alliance is related to therapeutic outcome (Hawley & Weisz, 2005; Garcia & Weisz, 2002; Shirk & Karver, 2003), it will be important to better understand the alliance in youth psychotherapy; however, in order to do this, it is important to recognize key differences in youth, as compared to adults, that may hinder the formation of alliances. Here, developmental considerations are of high importance. For example, children are not often self-referred to treatment (Kazdin, 1989), relying on caregivers who mediate the treatment experience (Kazdin, 1989; Stanger & Lewis, 1993). Other potential referral agents are teachers. This may be because outside of the family, teachers are often the first to recognize mental health problems, and caregivers often depend upon teachers for guidance about seeking mental health services (Allison, Roeger & Abbot, 2008). With others referring the child to treatment, there is the potential for the youth to disagree on the purpose of therapy and/or to resist therapeutic change. Youth who do not refer themselves for therapeutic services may not have reached the conclusion that they have a problem and are in need of help. As such, it may be difficult for the therapist and the young person to set mutual goals, and this may inhibit collaboration on tasks in therapy. Another unique variation in youth mental health is the provision of services in schools. The development of school mental health programs allows for more coordinated efforts amongst key stakeholders in child treatment such as educators, clinicians,
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THE ALLIANCE: FROM THEORY TO PR AC TICE youth, and caregivers. These programs may help to overcome youth resistance to treatment and facilitate alliance formation. Schools are uniquely positioned to provide mental health services to youth and their families (Stephan et al., 2007; Weist, Evans & Lever, 2003), and school mental health programs have grown exponentially over the past two decades (Rones & Hoagwood, 2000; Weist et al., 2003). This is most likely due to factors such as significantly enhanced accessibility (Weist, Myers, Hastings, Ghuman, & Han, 1999) and reduced stigma associated with receiving services in schools (Owens et al., 2002). Moreover, federal agencies have emphasized the importance and enhancement of school climates in fostering positive social and emotional outcomes in youth (Office of Safe and Drug Free Schools, 2007). With this in mind, it is important to examine alliance formation specifically in the schools. Compared to practice in other settings, there are variations in the school setting, such as the involvement of additional stakeholders (i.e., teachers, school administrators, etc.) in the treatment process and striving for school relevant outcomes (i.e., disciplinary referrals, suspensions, and retention, etc.), which could affect alliance formation. It is plausible that alliance formation occurs more rapidly in schools, given that they are considered to be less stigmatizing than community mental health centers and private offices (Weist et al., 2003). For example, caregivers and youth may be familiar with school counselors prior to receiving mental health services. Thus, when they begin treatment, they may feel more comfortable with a school counselor than a counselor in a community mental health center with whom there is no previous history. Regardless of the setting, a critical characteristic of youth therapy is the involvement of the caregiver in the treatment process. In much of adult therapy, the emphasis is on the individual client, whereas in child and adolescent therapy, therapists need to incorporate the concerns of both the youth and the caregiver (Hawley & Weisz, 2003). The incorporation of multiple parties into the therapeutic process adds complexity to determining presenting problems and the focus of therapeutic intervention, as well as balancing and integrating the formation of multiple alliances. For instance, if the caregiver, youth, and educator come to treat(800) 592-1125 | (877) 718-3053
ment with different presenting concerns, then it complicates determining what the focus of treatment will be. Much of youth therapy focuses on parent-identified problems, as the caregiver often initiates treatment (Kazdin, 1989; Stanger & Lewis, 1993). Focusing on caregiver-identified problems may work well in therapeutic situations in which the child, caregiver, and other stakeholders agree on the presenting problems and therapy goals. Unfortunately, when the child and others disagree, the ability for the child and other key players in therapy to strive towards common therapeutic goals may be undermined (Yeh & Weisz, 2001). Yeh and Weisz (2001) conducted a study of 381 parent-child pairs examining parent and child disagreements on referral problems. When examining specific problems, almost two thirds (63%) did not agree about even one problem. Specific categories of problems that showed modest parent-child agreement were attention problems, delinquent behaviors, and social problems. Alternatively, when examining broader problem categories, two-thirds of the parent-child pairs agreed on at least one problem. Externalizing problem matches were significantly higher than internalizing problem matches. Further, problems that bothered children were more likely to show parent-child agreement than problems that bothered parents. Overall, this study points to a lack of agreement in parent-child dyads about the primary problems for which they were seeking help. In 2003, Hawley and Weisz conducted a study of 315 parent, child (aged: 7-17), and therapist triads. Caregiver and child target problems were assessed separately by interviews. Similar to parent-child dyads in the
To get credit and complete the article, please go to http://www.annalsofpsychotherapy.com/ ANSU0112 and look for course code ANSU0112 to take the exam and complete the evaluation. If you have special needs that prevent you from taking the exam online, please contact the registrar at 800.205.9165. This article is approved by the following for continuing education credit: Abstract Interest in the therapeutic alliance can be traced back to the founding fathers of psychotherapy, Alliance continues to be a critical variable in both adult and youth therapy, given its impact on treatment outcomes. In youth therapy research has pointed to significant relationships between alliance and family and youth participation in treatment, session cancellation rates, early case closure, caregiver and youth satisfaction, and symptom severity improvement; however, the role of alliance in therapy with youth is not as straightforward as its role in therapy with adults. The purpose of this paper is to review critical issues related to therapeutic alliance in working with youth, and to suggest new directions for practice and research. Learning Objectives: 1. Define alliance and related constructs. 2. Discuss aspects of youth therapy that may make alliance formation difficult. 3. Describe the relationship between alliance and therapeutic outcome in youth therapy. 4. Discuss alliance building behaviors. KEYWORDS: alliance, youth psychotherapy, psychotherapeutic processes, treatment outcome TARGET AUDIENCE: Mental Health Professionals PROGRAM LEVEL: Intermediate DISCLOSURES: The authors have nothing to disclose. PREREQUISITES: None
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PARENT ALLIANCE
CAREGIVER ALLIANCE was found to be related to
was positively related to the
measures of therapy
level of family participation
retention and engagement
in treatment and negatively related to cancellation rate.
YOUTH ALLIANCE was found to be related to measures of therapy retention and engagement
Yeh and Weisz (2001) study, there were low levels of agreement among child-parenttherapist triads. Only 22% of the triads agreed on even one problem and 1% of triads agreed on two problems; however, agreement on externalizing problems, specifically aggressive behavior, was significantly greater than other problems. “Such low agreement among the key therapy participants raises concern about whether there is sufficient concordance to foster optimum treatment planning and to maximize treatment benefit” (Hawley & Weisz, 2003, p. 68). It is significant to note that the study utilized a sample consisting of both children and adolescents, but it was found that age did not correlate significantly with child–therapist agreement (Hawley & Weisz, 2003). In a comparable study of 170 adolescents (aged: 11-18) undergoing outpatient mental health therapy, it was discovered that only 20
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38% of adolescent-caregiver-therapist triads agreed on even one desired outcome, and none of the triads agreed on all three of the desired therapeutic outcomes; however, the desired outcome that did have rather high agreement was to reduce the adolescent’s anxiety. All in all, there was low agreement among the multiple raters on the desired outcome of therapy (Garland, LewczykBoxmeyer, Gabayan, & Hawley, 2004). Another pertinent study by Youngstrom, Loeber, and Stouthamer-Loeber (2000), examined patterns of caregiver-teacheryouth triad agreement on the Child Behavior Checklist (CBCL; Achenbach, 1991a). Dyads (youth-caregiver, youth-teacher, and teacher-caregiver) showed low agreement on symptoms. Interestingly, both youth and caregivers reported more externalizing problems than teachers, while all three informants reported different levels of inter-
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nalizing problems; with youths reporting the most and teachers reporting the least. Problem identification may be one of the most critical tasks facing clinicians (Nezu & Nezu, 1993), but if the child and other key players in therapy are not in agreement, then the therapist has a dilemma in deciding with whom to agree or not to agree. Hawley and Weisz (2003) found that 76% of caregiver-therapist pairs agreed on at least one target problem and 53% of adolescenttherapist pairs agreed on at least one target problem. Similarly, Garland and colleagues (2004) found that 70% of caregiver-therapist dyads agreed on at least one desired outcome and 62% of adolescent-therapist dyads agreed on at least one desired outcome. Therefore, in general, therapists may align more strongly with the caregiver than with the adolescent; however, for some specific types of problems, the therapist tends
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THE ALLIANCE: FROM THEORY TO PR AC TICE to align more with the adolescent. For example, in regards to daily living skills and family/life stress problems, the therapist’s determination of the target treatment was significantly related to child report but not caregiver report. This suggests that therapists may be approaching adolescentcaregiver disagreement in a conscientious manner; taking different perspectives into account for different types of problems (Hawley & Weisz, 2003).
Relation to Outcomes
As previously mentioned, alliance has been shown to be a predictor of outcomes (Shirk & Karver, 2003). It should be noted that different alliances (i.e., youth-therapist alliance, caregiver-therapist alliance, teacher-therapist alliance) are predictive of different outcomes. Caregiver alliance was found to be related to measures of therapy retention and engagement. Hawley and Weisz (2005) found that parent alliance was positively related to the level of family participation in treatment and negatively related to cancellation rate. On a related note, when asked to complete a measure on reasons for ending treatment, parents of children that did not complete treatment indicated higher levels of therapeutic relationship problems than parents of children that completed treatment (Garcia & Weisz, 2002). Further, it is interesting that parent alliance was significantly associated with therapist agreement about ending treatment (Hawley & Weisz, 2005). That is, caregivers that had higher ratings of the caregiver-therapist alliance agreed more with their therapist about when to end services. These findings are important because they may indicate that in order for the child to get to treatment and to engage the family, the clinician should invest in an alliance with the child’s caregiver. Findings are, most likely, a direct result of the fact that caregivers are most often the source of transportation to therapeutic services. Perhaps if youth had more control over attendance, then youth alliance would be more significantly related to retention measures (Hawley & Weisz, 2005). Youth alliance is predictive of symptom severity improvement. Stronger youth alliance is significantly associated with a decrease in youth reported symptom severity (Hawley & Wesiz, 2005) and significantly (800) 592-1125 | (877) 718-3053
associated with a decrease in caregiver reported symptom severity (Hawley & Weisz, 2005). It has also been suggested that youth alliance is predictive of engagement in therapeutic tasks (Karver, Handelsman, Fields, & Bickman, 2006). All of these findings suggest that both caregiver-therapist and youth-therapist alliances are significant, yet different, in their relation to outcome. Therefore it is important for the therapist to develop and maintain alliances with each key player in therapy.
Alliance Predictors
There are several predictors of alliance in youth therapy. Creed and Kendall (2005) examined therapist alliance building behaviors within cognitive behavioral therapy for youth with anxiety disorders and found several behaviors that were predictive of alliance. “Collaboration” between the therapist and the child was predictive of higher child ratings of alliance at Session 3. The authors defined collaboration as the therapist characterizing therapy as a team effort. This included mutual goal setting as well as the therapist encouraging the child to be involved and to give feedback about treatment. To the contrary, “finding common ground” and “pushing the child to talk” were predictive of lower child ratings of alliance at Session 3. The therapist emphasizing commonalities with the child characterized “Finding common ground”. “Pushing the child to talk” was defined as pressuring the child to talk about their anxiety beyond the point that the child was interested or comfortable. This behavior remained predictive of alliance at Session 7 as well. Creed and Kendall (2005) also found behavior that was predictive of therapist ratings of therapeutic alliance. Although there were no therapist alliance building behaviors that predicted therapist ratings of alliance at Session 3, at Session 7 “being overly formal” was negatively predictive of therapist rated alliance while “collaboration” positively predicted alliance. “Being overly formal” was described as the therapist
creating a relationship with the child that was not relaxed or comfortable. These findings are interesting and noteworthy as they may inform clinicians of important alliance building behaviors to engage youth. Moderators were extensively examined in Shirk and Karver’s (2003) meta-analysis of relationship variables in child and adolescent therapy. While investigating patient characteristics, neither patient characteristics (i.e., patient age), treatment characteristics (i.e., behavioral or non-behavioral), mode of treatment (i.e., individual, parent, or family treatment), manualized versus non-manualized treatments, or community service agency therapy versus research therapy significantly moderated the relationship between therapy relationship and outcome. While Shirk and Karver’s (2003) findings suggest that youth presenting externalizing behaviors, in contrast with internalizing behaviors, had a significantly stronger relationship between therapeutic relationship and outcome, strong conclusions regarding the alliance cannot be drawn based on presenting problem. The authors note multiple methodological confounds accounting for this effect given difficulties in developing relationships with externalizing youth (Eltz, Shirk, & Sarlin, 1995; Henggeler,
CAREGIVER ALLIANCE WAS FOUND TO BE RELATED TO MEASURES OF THERAPY RETENTION AND ENGAGEMENT.
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Schoenwald, Borduin, Rowland & Cunningham, 1998) including small sample size across studies, and results indicating stronger, though not reliable, associations between therapy relationship and outcome with respect to treatment mode in this population. That is, meta-analysis data from samples of externalizing youth typically included an individual and parent component and this was not the case for internalizing youth (Shirk & Karver, 2003). Moreover, this pattern of results is consistent with a more recent meta-analysis regarding youth alliance conducted by Karver et al. (2006) highlighting the best predictors of youth outcomes, including counselor interpersonal skills, therapist direct influence skills, youth and parent willingness to participate in treatment, and youth and parent participation in treatment.
Measurement
Alliance is commonly measured in child samples by modified adult alliance scales, such as the Vanderbilt Therapeutic Alliance Scale (VTAS; Hartley & Strupp, 1983), Helping Alliance Questionnaire (Haq; Luborsky, 1976), and Working Alliance Inventory (WAI; developed by Horvath [1986, 1989] and revised by Tracey and Koktovic [1989; 83]). There are a few measures that have been created specifically for younger populations. These include the Family Engagement Questionnaire (FEQ; Kroll & Green, 1997) and the Therapeutic Alliance Scales for Children (TASC; Shirk & Saiz, 1992). It is crucial to note that there is no “go to” alliance measure. In fact, in the meta-analytic review conducted by Shirk and Karver (2003) there was no most commonly used measure. Measures ranged from modified adult alliance measures to measures that researchers had newly developed for a particular study. Moreover, various individuals completed the measures (i.e., patients, therapists, parents, family members, and observers). This lack of standard measurement tools and methodologies poses problems. The term “alliance” is used on measures assessing different, yet related, constructs (Zack et al., 2007). Karver et al., (2005) found that measures of therapeutic alliance appear to con22
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sist of several overlapping domains, yet not enough is known about the domains that are measured. The authors proposed that the therapeutic alliance construct should be broken down into separate constructs that are measured independently. They suggest creating measures of cognitive connection, emotional connection, and behavioral participation to examine if these three aspects of the alliance differentially develop over time. This could create a clearer picture of alliance over time as well as helping to standardize definitions of constructs that may be the core dimensions of the alliance.
is not a significant methodological issue. This mixed pattern of findings suggests the need for enhanced research on the timing of alliance measurement. Another methodological issue that is important to note with alliance measures are ceiling effects. There is often little variability in youth ratings of alliance due to the fact that youth tend to report highly on alliance measures (Shirk & Karver, 2003; Kendall, 1994). This is an important topic as it may cloud statistical analyses. For example, the association between clinician rated therapeutic relationship and outcome
WHILE MUCH HAS BEEN ACCOMPLISHED IN TERMS OF UNTANGLING THE ROLE OF ALLIANCE IN THERAPEUTIC CHANGE, On a related note, timing of alliance measurement is also an area of concern. Later measurement of therapeutic relationship has a significantly greater association with outcome than does earlier measurement of the therapeutic relationship (Shirk & Karver, 2003). Within the adult literature, this has been known to be confounded by treatment gains (Zack et al., 2007), suggesting that alliance ratings at the end of treatment may be biased by treatment gains. Based on this finding, earlier measurement of alliance may provide a more accurate alliance score (Zack et al., 2007), or perhaps in youth therapy the relationship between alliance and outcome actually develops over time. It is interesting to note that in another study the timing of therapeutic relationship measurement did not serve as a significant moderator of the therapeutic relationship to outcome association (Karver et al., 2006). This finding could suggest that the timing of alliance measures
Annals of Psychotherapy & Integrative Health®
is significantly greater than the association between youth rated therapeutic relationship and outcome (Shirk & Karver, 2003). This finding is possibly confused by the restricted range of youth responses to therapeutic relationship measures (Zack et al., 2007; Kendall, 1994).
Future Research and Current Research Endeavors
While much has been accomplished in terms of untangling the role of alliance in therapeutic change, unanswered questions regarding the alliance are significant, and further investigations are needed to inform clinical practice. For example, there is a need for a standard definition of alliance and related constructs. Future research might include the development of standardized measurement tools and procedures, and further the development of better measures of the alliance. There are also specific areas of youth psychotherapy in which more information
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THE ALLIANCE: FROM THEORY TO PR AC TICE
about the alliance are needed. Notably, alliance has not been studied in school mental health (SMH) and since schools are the leading provider of mental health services to youth (Leaf et al., 1996; Rones & Hoagwood, 2000; Farmer, Burns, Phillips, Angold & Costello, 2003; Weist, 1999), investigation into the patterns of alliance in SMH and its contribution to outcome would be invaluable. It may be that certain variables in school, such as additional stakeholders or school-centered outcomes, could affect the formation of alliance or the relationship between alliance and certain outcomes. For
ployed full-time by a community mental health center and based in approximately 30 elementary, middle, and high schools in the county, as well as the students and families that the clinicians serve. For the Alliance Sub-Study, clinicians will be offered participation in a project designed to explore the significance of alliance and alliance feedback in SMH services. Research suggests that providing feedback to clinicians through client rated outcome and alliance measures results in significant improvements in outcome and retention in treatment (Miller, Duncan, Brown, Sor-
completed at the beginning of the session by the youth and will measure aspects of functioning. Specifically, these measures assess the domains of symptomatic functioning, interpersonal relationships, and social role performance (Miller, Duncan, Sorrell, & Brown, 2005). The ORS will be used to assess outcome with youth aged 12 and up while the CORS will be used with children aged 6 to 11. Both measures consist of 4-items rated on a 10-point scale. The SRS or the CSRS will be completed at the end of each session by the youth and placed into a folder for the clinician to review after the session. This step is designed to measure the therapeutic alliance. This measure utilizes Bordin’s (1969) theory of alliance that incorporates three components: agreement on goals, agreement on tasks, and the formation of a bond (Miller, Duncan, Sorrell, & Brown, 2005). The measure also incorporates an additional construct deemed the “client’s theory of change” (Duncan et al., 2003). Like with the ORS and CORS, the SRS is utilized with youth aged 12 and up while the CSRS is used with youth aged 6 to 11. Additionally, both scales have 4 items rated on a 10-point scale. After a session, the clinician will plot the ORS/CORS and SRS/CSRS scores to examine patterns of youth outcomes and alliance formation. In a methods presentation, clinicians were instructed to look for general patterns of improvement in outcomes. If improvement is not seen through trends in graphic data, clinicians are encouraged to seek additional clinical consultation. Alternatively, youth tend to report highly on alliance measures (Shirk & Karver, 2003; Kendall, 1994). If youth consistently report low levels of alliance on these scales, clinicians are encouraged to have a discussion with the youth about the therapeutic relationship (e.g., agreement on goals, agreement on tasks in therapy, and the bond). In the presentation of these study procedures, participating clinicians reacted positively and voiced feeling that the sub-study would be a helpful informant to their clinical process
UNANSWERED QUESTIONS REGARDING THE ALLIANCE ARE SIGNIFICANT, AND FURTHER INVESTIGATIONS ARE NEEDED TO INFORM CLINICAL PRACTICE. example, as suggested by Hawley and Weisz (2005), it may be that caregiver rated alliance is no longer significantly related to therapy attendance and retention if the youth does not rely on the caregiver for transportation, pointing to perhaps a greater role of youth rated alliance in SMH. The authors of this paper are investigating the role of alliance in school mental health as part of a larger study funded by the National Institute of Mental Health. This study, entitled “Strengthening Quality in School Mental Health” (R01MH0819141; 2010-2014; M.Weist, principal investigator), focuses on a school mental health quality assessment and improvement intervention and its impact on service quality, family engagement/ empowerment, and clinician knowledge and use of evidence based practices. Secondary aims will be to examine the impact of the quality assessment and improvement intervention on family and student outcomes. Participants in the study are clinicians em(800) 592-1125 | (877) 718-3053
rell & Chalk, 2006; Whipple et al., 2003). The methodology of this sub-study is very similar to that used by Miller and colleagues (2004; 2005) in developing the Partners for Change Outcome Management System (PCOMS) which was utilized to monitor and improve the effectiveness of treatment (Duncan, Miller & Sparks, 2004). At each individual and family session in which the youth is present, the school clinician will administer the Outcome Rating Scale (ORS; Miller & Duncan, 2000), the Child Outcome Rating Scale (CORS; Duncan, Miller, & Sparks, 2003) and the Session Rating Scale (SRS; Miller, Duncan, & Johnson, 2002), or the Child Session Rating Scale (CSRS; Duncan, Miller, & Sparks, 2003). In order to ensure that the tracking system is feasible for participating clinicians, all measures utilized in the substudy can be completed in approximately one minute (Miller, Duncan, Sorrell, & Brown, 2005). The ORS or CORS will be
Annals of Psychotherapy & Integrative Health®
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23
CE ARTICLE: 1 CE Credit
and feasible in their daily practice. Continued data from clinicians will be collected regarding the feasibility of incorporating this system into their existing practices (e.g., brief feasibility measure, progress notes). Overall, this study will help to clarify the formation of alliance in school mental health and the relationship between alliance and outcomes for this service delivery approach. This repeated measure design would provide session-by-session ratings and track patterns of alliance as they develop over time. It is anticipated that sub-study findings will be associated with positive outcomes. Examining the interplay among additional alliance feedback tasks and the perceived utility of feedback might indicate the relevance and widespread adoption of alliance assessment within school mental health.
Conclusion
In summation, alliance appears to be a critical construct in youth therapy, as it is in adult therapy, despite significant disparities between adult and youth mental health services (Kazdin, 1989; Stanger & Lewis, 1993; Stephan et al., 2007; Weist et al., 2003; Hawley & Weisz, 2003; DiGiuseppe, Linscott & Jilton, 1996). Research has pointed toward strong relationships among alliance, family, and youth participation in therapy, session cancellation rates, early termination of treatment, caregiver and youth satisfaction, and symptom severity improvement. This highlights the need for alliances to be formed and maintained with key stakeholders throughout treatment. Creed and Kendall’s (2005) study of alliance building behaviors may be a good reference for practices that foster the formation of alliances in therapy. That is, promoting collaboration in therapy while avoiding “pushing the child to talk”, finding commonalities with the youth, and being overly formal. Measurement of the alliance and utility of the alliance in predicting treatment outcomes continues to be widely researched, and is now being examined more extensively in SMH. This is an important avenue of research, as integrating evidence-based practices (EBPs) into school as well as child and adolescent mental health programs and services is a prominent and critically important avenue of research (see Evans & 24
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IT IS ANTICIPATED THAT SUB-STUDY FINDINGS WILL BE ASSOCIATED WITH POSITIVE OUTCOMES. Weist, 2004). If straightforward and brief alliance building strategies prove to be, in fact, associated with improvements in valued outcomes for children and adolescents receiving mental health intervention, this would have significant implications for future research, practice, and training efforts; for example, as a complementary strategy or alternative to costly, as well as time and resource intensive evidence-based practices that are manualized.
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19, 419–431. Evans, S.W., & Weist, M.D. (2004). Implementing empirically supported treatments in schools: What are we asking? Child and Family Psychology Review, 7, 263-267. Farmer, E.M., Burns, B.J., Phillips, S.D., Angold A. & Costello, E.J., (2003). Pathways into and through mental health services for children and adolescents. Psychiatric Services, 54, 60-66. Freud, S. (1940a). The dynamics of transference. In J. Starchey (Ed.), The Standard Edition of the complete psychological works of Sigmund Freud (Vol. 12, pp 99-108) London: Hogarth. Garcia, J., & Weisz, J. (2002). When youth mental health care stops: Therapeutic relationship problems and other reasons for ending youth outpatient treatment. Journal of Consulting and Clinical Psychology, 70(2), 439-443. Garland, A. F., Lewczyk-Boxmeyer, C. M., Gabayan, E. N., & Hawley, K. M. (2004). Multiple stakeholder agreement on desired outcomes for adolescents’ mental health services. Psychiatric Services , 55, 671-676. Hartley, D. E., & Strupp H. H. (1983). The therapeutic alliance: Its relationship to outcome in brief psychotherapy. In M. Masling (Ed.), Empirical Studies of Psychoanalytical Theories (pp. 1-27), Hillsdale, NJ: Analytical Press. Hawley, K. M., & Weisz, J. R. (2003). Child, parent, and therapist (dis)agreement on target problems in outpatient therapy: The therapist’s dilemma and its implications. Journal of Consulting and Clinical Psychology , 71, 62-70.
Duncan, B.L., Miller, S.D., & Sparks, J. (2003). Child session rating scale.
Hawley, K. M., & Weisz, J. R. (2005). Youth versus parent working alliance in usual clinical care: Distinctive associations with retention, satisfaction, and treatment outcome. Journal of Clinical Child and Adolescent Psychology , 34, 117-128.
Duncan, B.L., Miller, S.D., & Sparks, J. (2004). The heroic client: Principles of client-directed, outcome-informed therapy (Rev. ed.). San Francisco: Jossey-Bass.
Henggeler, S., Schoenwald, S., Borduin, C., Rowland, M., & Cunningham, P. (1998). Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford Press.
Duncan, B.L., Miller, S.D., Sparks, J., Claud, D.A., Reynolds, L.R., Brown, J., & Johnson, L.D. (2003). The session rating scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3, 3-12.
Hoagwood, K. E. (2005). Family-based services in children’s mental health: A research review and synthesis. Journal of Child Psychology and Psychiatry, 46 (7), 690-713.
Duncan, B.L., Miller, S.D., & Sparks, J. (2003). Child outcome rating scale.
Eltz, M. J., Shirk, S. R., & Sarlin, N. (1995). Alliance formation and treatment outcome among maltreated adolescents. Child Abuse and Neglect,
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Horvath, A. O. & Greenberg, L. S. (1986). The development of the Working Alliance Inventory. In L. S. Greenberg & W. M. Pinsoff (Eds.) The psychotherapeutic process: A research handbook (pp. 529-
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THE ALLIANCE: FROM THEORY TO PR AC TICE
556). United States: The Guildford Press. Horvath, A. O., & Greenberg, L. S. (1989). The development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223-233. Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 37-69). New York: Oxford University Press. Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2005). A theoretical model of common process factors in youth and family therapy. Mental Health Services Research, 7, 35-51. Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: The evidence for different relationship variables in the child and adolescent treatment outcome literature. Clinical Psychology Review, 26, 50-6 Kazdin, A. E. (1989). Developmental psychopathology: Current research, issues, and directions. American Psychologist , 44, 180-187. Kazdin, A. E., Siegel, T. C., & Bass, D. (1990). Drawing on clinical practice to inform research on child and adolescent psychotherapy: Survey of practitioners. Professional Psychology: Research and Practice , 21, 189-198. Kendall, P.C. (1994) Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62(1), 100-110. Kroll, L., & Green, J., (1997). The therapeutic alliance in child inpatient treatment: Development and initial validation of a family engagement questionnaire. Clinical Child Psychology and Psychiatry,2(3), 431-447. Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., et al. (1996) Mental health service use in the community and schools: Results from the fourcommunity MECA stud Journal of the American Academy of Child & Adolescent Psychiatry, 35(7), 889-897. Luborsky, L. (1976). Helping alliances in psychotherapy. In J. Claghorn (Ed.), Successful Psychotherapy (pp. 92-111). New York: Brunner, Mazel. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology , 68, 438-450. Miller S. D & Duncan, B. L. (2000). Outcome rating scale. Miller, S. D., Duncan, B. L., Brown, J., Sorrell, R., & Chalk, M.B. (2006). Using outcome to inform and improve treatment outcomes. Journal of Brief Therapy. Miller, S. D., Duncan, B. L., & Johnson L. (2002). Session rating scale. Miller, S. D., Duncan, B. L., Sorrell, R. & Brown J. (2004). The partners for change outcome management system. Miller, S. D., Duncan, B. L., Sorrell, R. & Brown J. (2005). The partners for change outcome man(800) 592-1125 | (877) 718-3053
agement system. Journal of Clinical Psychology, 61(2), 199-208. Nezu, A. M., & Nezu, C. M. (1993). Identifying and selecting target problems for clinical interventions: A problem solving model. Psychological Assessment , 5, 254-263. Office of Safe and Drug-Free Schools (2010). Safe schools healthy-students initiative. US Department of Education. Retrieved from http:// www2.ed.gov/programs/dvpsafeschools/index. html. Owens, P., Hoagwood, K., Horwitz, S., Leaf, P., Poduska, J., Kellam, S., et al. (2002). Barriers to children’s mental health services. Journal of the American Academy of Child & Adolescent Psychiatry, 41(6), 731-738. President’s New Freedom Commission on Mental Health. (2003). Achieving the Promise: Transforming Mental Health Care in America. Final Report for the President’s New Freedom Commission on Mental Health (SMA Publication No. 033832). Rockville, MD: Author.
Yeh, M., & Weisz, J. R. (2001). Why are we here at the clinic? Parent-child (dis)agreement on referral problems at outpatient treatment entry. Journal of Consulting and Clinical Psychology , 69, 1018-1025. Youngstrom, E., Loeber, R., & Stouthamer-Loeber, M. (2000). Patterns and correlates of agreement between parent, teacher, and male adolescent ratings of externalizing and internalizing problems. Journal of Consulting and Clinical Psychology, 68(6), 1038-1050. Zack, S. E., Castonguay, L. G., & Boswell, J. F. (2007). Youth working alliance: A core clinical construct in need of empirical maturity. Harvard Review of Psychiatry , 278-288.
ABOUT THE AUTHORS
HEATHER L. LASKY
received a BA with honors in psychology from Ohio University with the topic of her Honors Thesis focused around the therapeutic alliance. She is currently a Research Specialist at the Univer-
Rones, M., & Hoagwood, K. (2000). School-based mental health services: A research review. Clinical Child and Family Psychology Review, 3 (4), 223-241. Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 452–464. Shirk, S. R., & Saiz, C. S. (1992). Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy. Development and Psychopathology, 4, 713–728.
sity of South Carolina.
Stanger, C., & Lewis, M. (1993). Agreement among parents, teachers, and children on internalizing and externalizing behavior problems. Journal of Clinical Child Psychology, 22(1), 107-115.
earned her PhD in Applied Developmental Psychology from the University of New Orleans with a minor in Clinical Interventions. She is a postdoctoral fellow in school mental health at the University of South Carolina.
Stephan, S. H., Weist, M., Kataoka, S., Adelsheim, S., Mills, C. (2007). Transformation of children’s mental health services: The role of school mental health. Psychiatric Services, 58, 1330-1338. Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the Working Alliance Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1(3), 207-210. Weist, M. D. (1999). Challenges and opportunities in expanded school mental health. Clinical Psychology Review, 19, 131–135. Weist, M. D., Myers, C. P., Hastings, E., Ghuman, H., & Han, Y. (1999). Psychosocial functioning of youth receiving mental health services in the schools vs. community mental health centers. Community Mental Health Journal, 35, 69-81. Weist, M. D., Evans, S. W., & Lever, N. (2003), paperback reprint, 2007). Handbook of school mental health: Advancing practice and research. New York, NY: Springer. Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., & Hawkins, E. J. (2003). Improving the effects of psychotherapy: The use of early identification of treatment and problem-solving strategies in routine practice. Journal of Counseling Psychology, 50, 59– 68.
LESLIE K. TAYLOR
MARK D. WEIST received a PhD in clinical psychology from Virginia Tech and is currently a Professor in the Department of Psychology at the University of South Carolina. He was on the faculty of the University of Maryland for 19 years where he helped to found and direct the Center for School Mental Health, one of two national centers providing leadership to the advancement of school mental health (SMH) policies and programs in the United States.
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Bipolar disorder currently affects
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significant role in the development. The specific causes of the disorder vary from individual to individual (Miklowitz, 2011), but some researchers have suggested that recent life events (e.g.,
death of a loved one) or interpersonal struggles (e.g., divorce, stress) may contribute to the
onset, or recurrences, of the mood episodes associated with the diagnosis (Alloy et Al., 2005). In addition, clients diagnosed with bipolar disorder have a high suicide risk, with 25 percent of clients attempting suicide at some point in their lives, and 11 percent completing the act (Post & Leverich, 2006; Hilty, Brady & Hales, 1999). Learning self-management strategies to help reduce occurrences gives way to optimism for healthy living.
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The diagnosis of bipolar disorder includes periods of mood swings that fall on a continuum from extremely high manic states to extremely low depressive states, or may present a mixture of the two (4th ed.; text rev.; DSM-IV-TR, American Psychological Association, 2000). Clients with a true manic episode may experience highly euphoric feelings, elevated moods, and incredibly high levels of irritability. Changes in normal behavior may include: increases in goal directed activities, an increase in high risk activities, a decreased need to sleep, and even possibly rushed or pressured speech, and excessive talkativeness. Manic clients typically experience a shift in cognitive functioning in which they experience grandiose delusions or an inflated sense of self-worth. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV-TR, American Psychological Association, 2000), to qualify as having a manic episode, the client needs to experience the previously mentioned symptomology for approximately 1 week, show an impairment in psychosocial functioning (e.g., occupational, social), have been hospitalized, or present with psychotic features. Individuals in a less intense hypomanic state show evidence of many of the same symptoms, but experience it for approximately 4 days (Miklowitz, 2008). On the opposite side of the continuum, are clients presenting with depression. For a two-week period, these clients experience depressive moods nearly every day, lose pleasure in most regular activities, gain and lose weight, and suffer from insomnia. Some of these clients experience higher levels of agitation, fatigue or a general lack of energy, and have feelings of worthlessness and guilt. These clients may have an inability to concentrate, experience indecisiveness, and can have thoughts of suicide (4th ed.; text rev.; DSM-IV-TR, American Psychological Association, 2000). One way to identify depression in clients is to use the mnemonic connotation SIGECAPS (Remick, 2002). This acronym identifies 30
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Clients
diagnosed with
bipolar disorder have a high
suicide risk,
eight of the primary characteristics associated with depression: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, and Suicidal. Utilizing this basic screening tool can assist psychotherapists in identifying depressive symptoms quickly and efficiently. For example, when a client presents with depression, this mnemonic strategy may help assist psychotherapists in identifying the presenting depressive symptoms most relevant to the client. Once the symptoms of depression are recognized, the client and psychotherapist may work in collaboration on helpful therapeutic interventions such as cognitive-behavioral techniques (e.g. thought-stopping techniques). Bipolar disorder is becoming increasingly prevalent within the therapeutic arena, and given that there is some thought that an-
Annals of Psychotherapy & Integrative HealthÂŽ
tidepressant medications may increase the risk of mood destabilization and acute manic or mixed episodes (Zaretsky et al., 2007) , it is important for psychotherapists to consider different psychotherapeutic constructs as addendums to medication. For example, it is essential to have a strong therapeutic alliance between the therapist and client to help manage the client’s symptoms and detect any recurrence of the illness. It helps enhance compliance and also aids in addressing psychosocial stressors. Clients require continual education about their illness, their treatment options, the impact of their illness on social and family relationships, and its effect on vocational and financial matters (Hilty et al., 1999). According to Culver, Arnow, and Ketter (2007), there are specific therapeutic interventions
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