1J.T. Stocks, Ph.D.Practice Models and OutcomesPractice Models and OutcomesJ.T. Stocks, Ph.D.Two Models and a FrameworkTwo Models and a FrameworkSystems Framework!Psychoanalytic Model!Behavioral ModelJ.T. Stocks, Ph.D.Effect Sizes for Therapy TypesEffect Sizes for Therapy TypesTherapy Type Mean Effect Size NCognitive 1.31 145Cognitive Behavioral 1.24 157Behavioral 0.91 646Dynamic 0.78 255Humanistic 0.63 218Placebo 0.56 200Developmental 0.42 157from Smith, M.L., Glass, G.V., & Miller, T.I. (1980). The benefits of psychotherapy. Baltimore: The Johns Hopkins University Press.J.T. Stocks, Ph.D.What Are Negative Outcomes?What Are Negative Outcomes?((StruppStrupp& Hadley )& Hadley )!Exacerbation of Presenting Problems!Appearance of New Problems!Misuse/Abuse of Therapy!Undertaking Unrealistic Tasks or Goals!Loss of Trust in Therapy and the TherapistJ.T. Stocks, Ph.D.1. Exacerbation of Existing Problems1. Exacerbation of Existing Problems!Heightened Resistance or Defensiveness Associated with Increase in Problems!Generalization of Problems to New Areas!Loss of Previously Exhibited Equilibrium!Increased Cognitive RigidityJ.T. Stocks, Ph.D.2. Appearance of New Problems2. Appearance of New Problems!Erosion of Solid Interpersonal Relationships!Decreased Ability to Experience Pleasure!Suicidality!Psychotic Breaks!Withdrawal, Rage, Dissociation!Alcohol/Other Drug Abuse!Criminal Behavior2J.T. Stocks, Ph.D.3. Misuse/Abuse of Therapy3. Misuse/Abuse of Therapy!Substituting Intellectualized Insights for Other Obsessional Thoughts!Using Insights to Rationalize Feelings of Smugness over Others!Using Insights to Aggressively Comment on Other’s Behaviors!Preoccupation with Intrapsychic Phenomena over Solving Problems!Being a “Good Patient” is Primary GoalJ.T. Stocks, Ph.D.Factors Associated with Negative Factors Associated with Negative EffectsEffects!Inaccurate/Deficient Assessment!Therapist Variables!Client Variables!Misapplied and Deficient Technique!Problems in the Client-Worker Relationship!Communication ProblemsJ.T. Stocks, Ph.D.1. Inaccurate/Deficient Assessment vs. 1. Inaccurate/Deficient Assessment vs. Appropriate AssessmentAppropriate Assessment!Cognitive Flexibility, Reality Testing, Coping Skills!A General Baseline, including"Age "Capacities"Family History"Life Situation!Natural History of Difficulties!Functional Assessment of Problem Behaviors (How are they adaptive?)J.T. Stocks, Ph.D.2. Therapist Variables2. Therapist Variables!Deficiencies in Training and Skills"loose performance criteria in training"inadequate supervision in training"limited available knowledge for training"limited knowledge of therapist!Therapist’s “Personality”"incompatibility between worker & client"ignorance, incompetence, & the need to exploit the patient"sadomasochism, voyeurism, & faddism"Narcissism, greed, seductivenessJ.T. Stocks, Ph.D.3. Client Variables3. Client Variables(Mays & Franks)(Mays & Franks)!Impaired or Conflicted Social Support!Disturbances in the Ability to Communicate with Others!Disturbances in Mood or Affect!Disturbances in Identity and Sense of Self!Disturbances in Impulse ControlJ.T. Stocks, Ph.D.3.a. Social Support Difficulties3.a. Social Support Difficulties!Social Isolation!Intense, Unstable Interpersonal Relations!Poor Interpersonal Rapport due to Poor Interpersonal Skills!Important Dependence/Autonomy Conflicts !Inability to Accept Social Support due to:"Hopelessness;"Suspiciousness, Ideas of Reference, Paranoia"Conflicts About the Meaning of Accepting Help3J.T. Stocks, Ph.D.3.b. Disturbed Communication3.b. Disturbed Communication!Overuse of Distorted or Indirect Communication!Digressive, Vague, Overelaborate, Circumstantial, or Metaphorical Speech!Undue Social Anxiety or Hypersensitivity to Criticism (real or imagined)J.T. Stocks, Ph.D.3.c. Mood/Affect Disturbances3.c. Mood/Affect Disturbances!Depression!Inappropriately Intense Anger or Lack of Control over Anger!Labile Affect (rapid shifts from normal mood to depression, anger, or anxiety)!Chronic Feelings of Emptiness or BoredomJ.T. Stocks, Ph.D.3.d. Disturbances of Identity & 3.d. Disturbances of Identity & Sense of SelfSense of Self!Disturbed Identity"Self-Image (including body image)"Gender Identity"Long-Term Goals!Recurrent Illusions, Depersonalization, or Derealization (not associated with panic attacks)J.T. Stocks, Ph.D.3.e. Impulse Control3.e. Impulse Control!Impulsive Suicide Attempt!Actually/Potentially Self-Damaging Behavior!Eating Disorders!Impulsive Sexual Patterns!Alcohol/Other Drug Abuse!Stealing!Self-MutilationJ.T. Stocks, Ph.D.4. Misapplied/Deficient Techniques4. Misapplied/Deficient Techniques!False Assumptions About Scope/Potency of Treatment!Problems with Goals of Treatment (lack of goals or unrealistic goals)!Misplaced Focus of Therapy!Mismatch of Technique to Patient!Technical Rigidity in Therapy!Overly Intense Intervention!Misuse of Interpretation/Insight!Dependency-Fostering TechniquesJ.T. Stocks, Ph.D.5. Client5. Client--Worker Relationship Worker Relationship ProblemsProblems!“Too Little” or “Too Much” Rapport!Hostile Countertransference (Goldberg)"blocking working alliance"lack of respect for client’s pain"restricting client choice"aggressive assault on client defenses"disappointed attitude toward client!Failure to Maintain Appropriate Professional Distance (Dual Relationships)4J.T. Stocks, Ph.D.6. Communication Problems6. Communication Problems!Worker’s Inability to Communicate Clearly!Worker’s Failure to Determine Whether Client Understands!Client Distortions, Omissions, Falsifications!Worker’s Failure to Understand Client Communications (especially