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reflects a deterministic and pessimistic view of human nature that views current psychological problems as being due to unconscious unresolved conflicts that arose during childhood

assumes that these conflicts cause anxiety and are the result of the divergent demands of the 3 aspects of personality:
a. id: present at birth and its life (sexual) and death (aggression) instincts are the primary source of psychic energy
--operates according to the pleasure principle and seeks immediate gratification of its instinctual needs using unconscious irrational means
b. ego: develops about 6mo and operates according to the reality principle
--it also seeks to at least partially gratify the id's instincts it attempts to do so in realistic rational ways
c. superego: last aspect of personality to develop
--represents the internalization of society's values and standards and acts as the conscience
--attempts to permanently block (rather than gratify) the id's instincts

proposes that when the ego is unable to resolve a conflict between the id and superego using rational means, it resorts to a defense mechanism
-defense mechanisms deny or distort reality and operate on an unconscious level
--includes repression, denial, reaction formation, projection, and sublimation
---repression is the basis of all other defense mechanisms, is involuntary, and involves keeping undesirable thoughts and urges out of conscious awareness
---denial is an immature defense mechanism that involves refusing to acknowledge distressing aspects of reality, includes: ignoring, distorting, and rejecting reality
---reaction formation involves defending against an unacceptable impulse by expressing its opposite
---projection involves attributing an unacceptable impulse to another person
---sublimation involves channeling an unacceptable impulse into a socially desirable (and often admirable) behavior
-occasional use of defense mechanisms is adaptive but repeated reliance on them keeps a person from resolving the conflicts that are causing anxiety

main psychoanalysis goals are to make the unconscious conscious and to strengthen the ego so that the behavior is based more on reality and less on instinctual cravings and irrational guilt
-primary technique is analysis of client's free associations, dreams, resistance, and transference, and the process of analysis consists of 4 steps
1. Confrontation: helping clients recognize behaviors they've been unaware of and their possible cause
2. Clarification: brings cause of behaviors into sharper focus by separating important details from extraneous material
3. Interpretation: involves explicitly linking conscious behaviors to unconscious processes
4. Repeated Interpretation: leads to catharsis (experience of repressed emotions) and insight into the connection between unconscious material and current behavior and then to working through (gradual process where client accepts and integrates new insights into their life)
view behavior as being primarily motivated by a desire for human relationships and they focus on the impact of early relationships between a child and primary caregivers (objects) on the child's future relationships

object constancy: development of mental representations (introjects) of the self and objects that allow the person to value an object for reasons other than its ability to satisfy the individual's needs

Development of object constancy takes place during three stages:
-normal autistic stage: happens during the first few weeks of life, infants are totally self-absorbed and unaware of external environment
-normal symbiotic stage: infants become aware of external environment but are unable to differentiate themselves from their caregivers
-separation-individuation stage: begins at about 5mo and continues until the child is about 3, consists of 4 substages where object constancy gradually develops: differentiation, practicing, rapprochement, and beginning object constancy

Narcissism, BPD, personality disorder, and other psychiatric disorders are often due to problems during the separation-individuation process that cause a pervasive failure of object constancy

Primary goal is to provide clients with a corrective reparenting experience in order to replace the client's maladaptive introjects with more adaptive ones and therby improve their current relationships
-therapists provide clients with empathic acceptance and use a number of psychoanalytic strategies in therapy including the analysis of resistance and transference
based on the assumptions that:
a. people are motivated to maintain a state of homeostasis, which is repeatedly disrupted by unfulfilled physical and psychological needs
b. people seek to get something from the environment to satisfy their unfulfilled needs in order to restore homeostasis

Neurosis (maladjustment) happens when there's a persistent disturbance in the boundary between the person and the environment that interferes with the person's ability to fulfill needs

Boundary disturbances:
-Introjection: when people adopt believes, standards, and values of others without evaluation or awareness
-Projection: when people attribute undesirable aspects of themselves to other people
-Retroflection: when people do to themselves what they'd like to do to others
-Deflection: when people avoid contact with the environment
-Confluence: when people blur the distinction between themselves and others

consider gaining awareness of one's current thoughts, feelings, and actions to be the curative factor in therapy

Strategies used to increase awareness:
-Dream work: client role-play parts of their dream that represent disowned parts of the client's personality
-Empty-chair technique: client interacts with opposing aspects of their personality (ex. top dog and underdog) or to resolve "unfinished business" with a significant person in the client's past or present

in contrast to psychodynamic therapists, Gestalt therapists don't foster or interpret a client's transference but, instead, help the client distinguish between their "transference fantasy" and reality
integrates concepts and strategies from multiple therapeutic approaches and is based on the assumption that strategies are most effective when they match the person's stage of change

Six stages of change, and primary goal of the first 5 stages is to help the client advance to the next stage:

a. Precontemplation: clients have no intention of taking action to change their behaviors in the next 6 months
-may be in denial about their problems or may have made multiple unsuccessful attempts to change and believe that change is impossible
-likely to resist advice of change interventions but may benefit from consciousness raising, dramatic relief (experiencing and expressing emotions), and environmental reevaluation (examining how the environment affects their behavior)

b. Contemplation: clients plan to change in the next 6mo but they're ambivalent about changing, which may make it difficult for them to transition to the next stage
-benefit from self-reevaluation in addition to the strategies that are useful for individuals in the precontemplation stage

c. Preparation: clients plan to take action within the next month
-useful strategies for these people support their decision to change and include self-reevaluation and self-liberation (believing that change is possible and making a commitment to change)

d. Action: clients in this stage are taking action to change their behaviors
-effective strategies for these clients include contingency management, stimulus control, and counterconditioning

e. Maintenance: client's transition to this phase when they have maintained the desired behavior change for 6 months
-primary focus of treatment is relapse prevention which involves the same strategies useful for people in the action stage

f. Termination: clients in this stage are confident that their risk of relapse is low

Motivation to change is affected by 3 factors:
-decisional balance: strength of the person's beliefs about the pros and cons of changing
--is most important as a determinant of motivation during the contemplation stage
-self-efficacy: refers to the confidence the person has about their ability to change and avoid relapse
--important determinant of whether a person transitions from the contemplation to the preparation stage and then from the preparation and the action stage
-temptation: intensity of the urge to engage in the undesirable behavior and is usually the strongest during the first few stages of change
the best couple and family treatments are those that are "based on both science and the accumulated clinical knowledge of experienced practitioners in order to most accurately identify both the efficacy (reliability) and utility (contextual efficacy) of clinical procedure"

Three levels of evidence:
Level 1: evidence-informed interventions that are supported by pre-existing research (ex. common factors research) or are linked to evidence-based treatment models
--have not been evaluated themselves and/or haven't been evaluated for specific populations or problems
--ex. Gottman's marital therapy and structural family therapy at at this level

Level II: consists of promising interventions that have preliminary evidence of their effectiveness but have not been replicated for specific populations or problems
--ex. insight-oriented marital therapy and attachment-based family therapy are in this category

Level III: consists of evidence-based interventions that are supported by systematic high-quality research that shows they are effective for the clinical problems they are designed to treat
--divided into 4 categories:
---category 1: evidence of an interventions efficacy and effectiveness when compared to no treatment (absolute efficacy) - all interventions included included must, at a minimum, meet the criteria for this category
----ex. brief structural family therapy and integrative behavioral couple therapy
---category 2: evidence of an intervention's efficacy and effectiveness compared to alt treatments (relative efficacy)
----ex. behavioral marital therapy and parent management training are examples of interventions in this category
---category 3: evidence of the efficacy and effectiveness of an intervention's model-specific change mechanisms (verified mechanisms of action)
----ex. behavioral couples therapy and family psychoeducation interventions for schizophrenia
---category 4: evidence that the intervention has beneficial outcomes for specific client populations, for specific clinical problems, and for different service delivery systems (contextual efficacy)
----ex. multisystemic therapy for adolescent problem behaviors and behavioral couples therapy for alcohol and substance abuse disorders
Bowen derived this approach from work with children with schizophrenia and their families, which led his conclusion that the transmission of certain emotional processes from one generation to the next is responsible for the development of schizophrenia in a family member

Differentiation: both intra- and interpersonal
-intrapersonal aspect: person's ability to distinguish between their own feelings and thoughts
--ability makes it possible for the person to separate their own emotional and intellectual functioning from the functioning of others
-interpersonal aspect: person with low level of differentiation becomes "emotionally fused" with other family members

Emotional Triangles: when a family dyad experiences tension, it may recruit a third family member to form an emotional triangle which helps alleviate tension and increase stability
-ex. a husband and wife may reduce conflict between them by becoming overinvolved with one of their children - likelihood that an emotional triangle will develop increases as the levels of differentiation of family members decrease

Family Projection Process: refers to the parents' projection of their emotional immaturity onto their children, which causes the children to have lower levels of differentiation

Multigenerational Transmission Process: an extension of the family projection process and refers to the transmission of emotional immaturity from one generation to the next
-happens when the child most involved in the family's emotional system becomes the least differentiated family member, and as an adult, chooses a spouse or partner who has a similar level of differentiation
--the couple then transmits an even lower level of differentiation to one of its children
---process continues in subsequent generations and eventually results in the development of severe symptoms in a child

Bowen believed that increasing differentiation in one family member facilitates greater differentiation in other family members

Therapists often see only 2 family members in therapy - usually the parents - or the individual family member who is most capable of increasing their level of differentiation

Primary goal of therapy is to increase each family member's differentiation, and several strategies are used to achieve this goal:
-begins with an assessment that includes constructing a genogram that depicts family relationships and important life events for at least 3 generations and is used to help family members understand intergenerational patterns of functioning
-during therapy, therapists ask questions that are designed to defuse emotions and help family members identify how they contribute to family problems
-also teach family members how to interact with their families-of-origin in ways that alter triangulated relationships
-therapists assume the role of coach and stay connected with family members but remain neutral and avoid becoming involved in the family's emotional processes
-to reduce emotional reactivity, they have family members talk directly to them rather than to each other
based on assumption that a family member's symptoms are related to problems in the family's structure and identifies subsystems and boundaries as important aspects of a family structure:
-subsystems: smaller units of the entire family system and are responsible for carrying out specific tasks (ex. parental subsystem is family members who care for the children)
-boundaries: implicit and explicit rules that determine the amount of contact that family members have with each other - differ in terms of degree permeability and exist on a continuum
--at one end, boundaries are overly diffuse and lead to enmeshed relationships, at the other end, boundaries are overly rigid and lead to disengaged relationships - midway between the.2 are clear boundaries that let family members have close relationships while allowing each member to maintain a sense of personal identify

Identified 4 rigid family triads - boundary problems that help parents obscure or deny their conflicts:
a. stable coalition: happens when one parent and a child form an inflexible alliance against the other parent
b. unstable coalition: known as triangulation and occurs when each parent demands that the child side with them
c. detouring-attack coalition: happens when parents avoid the conflict between them and blame the child for their problems
d. detouring-support coalition: happens when parents avoid their own conflict by overprotecting the child

maladaptive behaviors are due to a dysfunctional family structure that causes the family to repeatedly respond inappropriately to developmental and situational stress

primary goals of therapy are used to alleviate current symptoms and change the family structure by altering coalitions and creating clear boundaries

Therapy focuses on promoting behavior change rather than insight and consists of three overlapping phases:
a. joining: used by a therapist to establish a therapeutic alliance with the family and relies on 3 techniques:
-mimesis involved adopting the family's affective, behavioral, and communication style
-tracking involves adopting the content of the family's communications
-maintenance entails providing family members with support

b. therapist's next task is to evaluate the family's structure to make a structural diagnosis and identify appropriate interventions
-includes constructing a family map that depicts the family's subsystems, boundaries, and other aspects of the family's structure

c. therapist then uses reframing, unbalancing, boundary making, enactment, and other interventions to achieve therapy goals
-reframing: relabeling a problematic behavior so it can be viewed in a more constructive way
-unbalancing: used to alter hierarchical relationships and happens when a therapist aligns with a family member whose level of power needs to be increased
-boundary making: used to alter the degree of proximity between family members
-enactment: involves asking family members to role-play a problematic interaction so the therapist can get information about the interaction and then encourage family members to interact in an alternative way
based on assumptions that struggles for power and control in relationships are core features of family functioning and that a symptom is a strategy that is adaptive to a current social situation for controlling a relationship when all other strategies have failed
-also assumes that power and control are determined primarily by hierarchies within a family and that maladaptive family function is often related to unclear or inappropriate hierarchies

primary goal of therapy is to alter family interactions that are maintaining its symptoms
-to achieve this, strategic family therapists assume an active role and use a variety of strategies that are aimed at changing behavior rather than instilling insight
-initial session is highly structured and consists of four stages:
--(brief) social stage: therapist welcomes the family and observes the family's interactions
--problem stage: therapist elicits each family member's view is the family problem and its causes
--interactional stage: family members discuss their different views of the family's problem, and the therapist observes how family members interact when addressing the problem
--goal-setting stage: therapist helps family members agree on a definition of the family's problem and concrete therapy goals that target the problem

during subsequent sessions, therapist uses a combo of straightforward and paradoxical directives
-straightforward directives: instructions to engage in specific behaviors that will change how family members interact
-paradoxical directives: help family members realize that they have control over problematic behavior or use the resistance of family members to help them change in the desired way
--prescribing the symptom: involves instructing family members to engage in the problematic behavior, often in an exaggerated way
--restraining: involves encouraging family members not to change or warning them not to change too quickly
--ordeal: unpleasant task that a family member is asked to perform whenever they engage in the undesirable behavior
based on assumption that the family as a whole protects itself from change through homeostatic rules and patterns of communication

patterns of communication are referred to as family games, and family games associated with problematic behaviors are rigid, involve power struggles between family members, and are known as "dirty games:

primary goal is to alter the family rules and communication patterns that are maintaining problematic behavior
-involves providing the family with info that challenges family games and helps family members develop communication patterns that increase the family's ability to adapt to change

distinguished from other family therapies by its use of a therapeutic team and five-part therapy sessions (pre-session, session, intersession, intervention, and post-session) and gaps between therapy sessions of 4-6wks

strategies include hypothesizing, neutrality, circular questioning, positive connotation, and family rituals
-hypothesizing: continual interactive process of speculating and making assumptions about the family situation
--first hypotheses are based on info obtained in the initial telephone interview, and hypotheses are modified during therapy as new info about the family's functioning is acquired
-neutrality: therapist's interest in the family's situation and acceptance of each family member's perception of the problem
circular questioning: involves asking each family member the same question to identify differences in perceptions about events and relationships and uncover family communication patterns
--ex. might ask each member, when mom is depressed, what does dad do?
-positive connotation: type of reframing that helps family members view a symptom as beneficial because it maintains the family's cohesion and well-being
--purpose is to change the family's perception of a symptom from an individual family member's illness to, instead, a behavior that's voluntarily controlled and well-intentioned and involves the entire family system
-family rituals: activities that are carried out by family members between sessions and are designed to alter problematic family games
--ex. when parents are competitive in their control of children's behaviors or family events, the therapist might instruct the mother to make all family decisions on odd-numbered days and the father to make family decisions on even-numbered days
influenced by humanistic psychology and communication and experiential approaches to family therapy

family systems seek a state of balance, with family problems arising when balance is maintained by unrealistic expectations, inappropriate rules and roles, and dysfunctional communication

Four dysfunctional communication styles:
-placating: involves agreeing with or capitulating to others due to fear, dependency, and a desire to be loved and accepted
-blaming: involves accusing, judging, and bullying others to avoid taking responsibility and to hide feelings of vulnerability and worthlessness
-computing: taking an overly intellectual and rational approach to avoid becoming emotionally engaged with others
-distracting: involves changing the subject and making inappropriate jokes to distract attention and avoid conflict

Congruent (or leveling) style: functional style that's characterized by congruence between verbal and nonverbal messages, directness and authenticity, and emotional engagement with others

Primary goal is to enhance the growth potential of family members by increasing their self-esteem, strengthening their problem-solving skills, and helping them communicate congruently

Satir viewed the therapist's "use of self" as the most important therapeutic tool and proposed that therapists have mx roles when working with clients including facilitator, mediator, advocate, educator, and role model
-also used several techniques to achieve therapy goals including family sculpting (involves having each family member to take a turn positioning other family members in ways that depict their view of family relationships) and family reconstruction (type of psychodrama that involves role-playing 3 generations of the family to explore unresolved family issues and events)
consider a person's problems as arising from and being maintained by, oppressive stories which dominate the person's life - view these stories as being socially constructed
-also assume that the problem - not the person - is the problem
--problem is not internal to the person but is something that exists outside the person
---ex. instead of saying that a family member is depressed, a narrative family therapist would say that depression sometimes causes problems for the person

Primary goal is to replace problem-saturated stories with alt stories that support more satisfying and preferred outcomes
-process varies somewhat among practitioners but generally involves the following stages:
--a. meeting family members involves getting to know them separate from their problems by asking them about their interests and everyday activities
--b. listening involves paying attention to what family members say to identify dominant discourses and unique outcomes, which are also known as sparkling moments and are experiences that are not consistent with problem-saturated stories
--c. separating family members from their problems involves externalizing the problems
--d. enacting preferred narratives involves identifying alt stories that lead to more satisfying realities and identities
--e. solidifying involves strengthening alt stories by, ex. writing letters of support to family members and expanding the family's network of social relationships to include people who will support its new stories

therapist assumes the role of collaborator and uses questions and other techniques to help family members identify current stories and construct alt, healthier ones
-ex. externalizing questions: used to help clients view their problems as being outside themselves (ex. asking a family member what his anger tells him to do)
--opening space questions: help family members identify unique outcomes (ex. asking family. members if there have ever been times when conflicts didn't control their lives)
-other interventions include therapeutic letters, therapeutic certificates, and definitional ceremonies
--therapist writes therapeutic letters to family members to reinforce their emerging alt stories
--therapeutic certificates are given to family members toward the end of therapy to acknowledge their accomplishments
--definitional ceremonies provide family members with opportunities to tell others how they overcame their problems and celebrate the changes they've made in their lives
brief, evidence-based treatment that integrates principles of attachment theory, humanistic-experiential approaches, and systems theory

originally developed by Greenburg and Johnson ('88) as a treatment for couples but has since been applied to families and individuals
--(emotionally focused therapy and emotion-focused therapy are sometimes used interchangeably but that the 2 differ, with the laster referring to various therapies that emphasize emotion as the target of change

based on assumptions that:
-a. emotions are essential to the organization of attachment behaviors and influence how people experience themselves and their partners in intimate relationships
-b. the attachment needs of partners are essentially healthy and adaptive but problems arise when needs are enacted in the context of attachment-related insecurities
-c. relationship distress is maintained by the ways in which interactions between partners are organized and by the dominant emotional experiences fo each partner

practitioners assume that helping partners express and deal with their emotions is the fastest and most effective way to solve problems, and primary goal of therapy is to expand and restructure the emotional experiences partners have with each other so they can develop new interactional patterns and experience attachment security within their current relationship

therapy involves 3 stages:
-assessment and cycle de-escalation, changing interactional positions and creating bonding events, and consolidation and integration
evidence-based treatment that was originally developed for adolescent offenders at risk for out-of-home placement and their families but has subsequently been adapted for adolescents with other serious clinical problems including psychiatric disturbances, substance abuse, and childhood maltreatment

based on Brofenbrenner's (04) ecological model which views individuals as being embedded in and influenced directly and indirectly by mx systems

focuses on the specific individual, family, peer, school, and social network variables that contribute to a youth's presenting problems, and on interactions between these factors linked with the presenting problems

includes nine treatment principles that are applied using an analytic process that structures the development, implementation, and evaluation of the treatment plan
-core principles are finding the fit between identified problems and their broader systemic context; focusing on positive and strengths; increasing responsibility; being present-focused, action-oriented, and well-defined; targeting behavior sequences; using developmentally appropriate interventions; encouraging continuous effort; stressing evaluation and accountability; and promoting generalization

therapy is provided in the family's home and in community settings where problems occur

interventions derived from strategic and structural family therapy, behavior therapy, and CBT and target factors that are driving problem behaviors
-ex. assessment might indicate that the drivers of an adolescent's daily marijuana use (and targets of treatment) are a high level of family conflict, low parental monitoring of the adolescent's behavior and ineffective discipline, the adolescent's poor social skills and friendships with peers who use drugs, opportunities for the adolescent to use drugs at school, and availability of drugs in the adolescent's neighborhood

therapy is delivered by multidisciplinary team that's tailored to the adolescent's and family's problem behaviors
-for someone with academic, conduct problems, frequent use of marijuana/cocaine, and a recent arrest for cocaine possession
---team may consist of a caseworker, family therapist, substance abuse counselor, and 2 other people who will work with the adolescent in their school and neighborhood
each type consists of a triad that includes a consultant, a consultee (therapist or program administrator), and a client or program

1. Client-Centered Case Consultation: focuses on a particular client of the consultee who is having difficulty providing the client with effective services (ex. having trouble identifying an appropriate treatment)
-consultant's goal is to provide the consultee with a plan that will benefit the client

2. Consultee-Centered Case Consultation: focuses on the consultee with the goal of improving their ability to work effectively with current and future clients who are similar in some way (ex. with TBI, specific minority group, etc.)
-goal is to improve the consultee's knowledge, skills, confidence and/or objectivity
-several factors contribute to a consultee's lack of objectivity: ex. theme interference - happens when a consultee's biases and unfounded beliefs interfere with their ability to be objective when working with certain types of clients

Program-Centered Administrative Consultation: involves working with program administrators to help them clarify and resolve problems they're having with an existing mental health program
-goal is to provide administrators with recommendations for dealing with the problems they've encountered in developing, administering, and/or evaluating the program

Consultee-Centered Administrative Consultation: focuses on improving the professional functioning of program administrators so they're better able to develop, administer, and evaluate mental health programs in the future

Mental health consultations differs from collaboration in several ways
-ex. consultant has little or no direct contact with a consultee's client and is not responsible for the client's outcomes
--collaborator usually has direct contact with the client and shares responsibility for the client's outcomes
best known for conclusions about intelligence and personality

proposed that intelligence is due primarily to heredity, with about 80% of variability in IQ scores being due to genetic factors

his personality theory also stresses the role of heredity and distinguishes between 3 major personality traits: extroversion, neuroticism, and psychoticism

Also known for controversial conclusions about effectiveness of psychotherapy - based on his review of 24 empirical studies that reported treatment outcomes for "neurotic" patients who participated in psychoanalytic or eclectic psychotherapy
-because studies didn't include no-treatment control groups, he used other studies to estimate the spontaneous remission rates of neurotic patients who received custodial care in an inpatient facility or medical care from a physician
--based on this data, concluded that 44% of patients who participated in psychoanalytic psychotherapy, 64% of patients who participated in eclectic psychotherapy, and 72% of patients who didn't participate in psychotherapy experienced an improvement in symptoms
---proposed that results not only showed that psychotherapy is ineffective but that it may have actually caused detrimental effects since the average recovery rates for psychotherapy patients were lower than average spontaneous remission rate for patients who didn't receive psychotherapy

his conclusions were challenged by advocates of psychotherapy for teh methodological flaws
-ex. patients not randomly assigned to groups, criteria for recover were questionable - found that different criteria produced recovery rate of 83% for patients who participated in psychotherapy vs 30% for patients who didn't receive psychotherapy
research has found that utilization rates of mental health care services vary, depending on clients' gender, age, sexual orientation, and race/ethnicity

2018 National Survey of Drug Use and Health found that utilization rates were higher for female adults than for male adults
-found that, for all adult respondents, utilization rates were highest for respondents ages 26 to 49 followed by, in order, those 50 and older and those ages 18 to 25, which is consistent with the results of yearly surveys conducted since 2002

studies generally find that sexual minority men and women utilize mental health care services at higher rates than sexual majority (heterosexual) men and women do
-National Health Interview Surveys: sexual minority men and women were 2-4x more likely than heterosexual men and women to have talked with a mental health professional in the past year
-Hughes found that lesbians in their sample were more likely than heterosexual women to report being in recovery or having received treatment for alcohol-related problems
-Koh and Ross found that lesbians more likely than heterosexual women to seek therapy for depression

2018 National Survey of Drug Use and Health indicated that among all adult survey respondents, the use of outpatient mental health services in the past year was highest for respondents who identified themselves as belonging to 2 or more racial groups and lowest for respondents who identified themselves as Asian
-for inpatient mental health services, use was highest for those who identified themselves as American Indian or Alaska Native and lowest for those who identified themselves as Asian

National Survey of Drug Use and Health in 2015 collected data on use of mental health services by individuals ages 18+
-found that annual average use of outpatient mental services from 2008-12 were highest for respondents reporting two or more races, followed by, in order, those who identified themselves as being Black or African American, two or more races, Hispanic American, White, or Asian
involves using info about program costs and benefits to inform decision-making

Cost benefit analysis: used to compare the costs and benefits of one or multiple interventions
-costs and benefits are both expressed in monetary terms
--ex. compared individual placement and support (IPS) and standard vocational rehab for helping people with severe mental disorders obtain employment - when costs of implementing interventions and their benefits (as measured by expected earnings) were compared, IPS produced a greater net benefit

Cost-effectiveness analysis: used to compare the costs and benefits of two or more interventions when benefits can't be expressed as monetary values
--ex. used this to compare cost and benefits of IPS and standard vocational rehab, with benefits being measured as percent or participants who worked for at least 1 day during the follow-up period, percent of participants who dropped out of the program, percent of participants who had to be readmitted to the hospital
---IPS found to be more effective than vocational rehab for all 3 benefits

Cost-utility analysis: used to compare the costs of 2 or more interventions on quality-adjusted life-years (QALYs) which combines measures of gain in the health-related quality and quantity (duration) of life
--ex. one study compared costs and benefits in terms of QALYs of three treatments for depression, cognitive therapy, rational-emotive behavior therapy, and fluoxetine (Prozac)
---results indicated that CT and REBT both had greater cost-utility than Prozac but didn't differ significantly from each other
designed to address a range of diagnoses that not onlly share symptoms but also biological, psychological, and environmental mechanisms that increase the risk for and maintain those symptoms

premise underlying transdiagnostic treatments is that the commonalities across disorders outweigh the differences and that targeting the commonalities may have a number of important benefits compared to diagnosis-specific approaches

ex. treatments can reduce the cost and amount of time associated with training psychologists to deliver numerous diagnosis-specific interventions and they're better suited than single-diagnosis treatments for addressing comorbidities

some treatments (a) combine evidence-based strategies that are applicable to disorders within a single diagnostic category, while others (b) combine strategies that are applicable to disorders from different categories
-ex. of b is the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders - an emotion-focused, cognitive-behavioral intervention for anxiety, depression, and related disorders
--views neuroticism as the core characteristic shared by these disorders and focuses on mechanisms associated with neuroticism, including defecits in emotion regulation and avoidance of intense emotional experiences
---treatment consists of 8 modules: motivational enhancement, psychoeducation, emotional awareness, cognitive flexibility, emotion avoidance, interoceptive exposures, emotional exposures, and relapse prevention
--preliminary research found that UP produces substantial short-and long-term improvement in the symptoms of both principal and comorbid disorders as well as the underlying mechanisms associated with those disorders
benefits: decreases patients' and providers' costs, increases access to psychotherapy, and reduces stigma and embarrassment that some people have when receiving psychotherapy at treatment facilities
-research found that in most cases, technology-delivered evidence-based practices provides roughly equivalent outcomes for members of diverse populations and a variety of disorders

a. Anxiety disorders: evidence that telehealth is effective for treating individual anxiety disorders but also for treating comorbid anxiety and mood disorders
--Berryhill did a review of effectiveness of psychotherapy, most often CBT - for treating panic disorder with agoraphobia, GAD, and SAD through telehealth - found sig improvement in anxiety symptoms, with controlled studies finding no sig differences between telehealth and in person
--another study compared telehealth CBT to in person CBT and found they to be similarly effective for reducing comorbid anxiety and depression and improving quality of life

b. PTSD: most studies evaluating use of telehealth for treating PTSD found it to be comparable to face-to-face in terms of effectiveness
-one study found that trauma-focused therapies in person and telehealth were similar in terms of reduction of PTSD, attendance and dropout rates, client satisfaction, and therapist fidelity to treatment protocols
--studies included in their review did not provide entirely consistent results with regard to the therapeutic alliance
---therapists providing telehealth said they didn't have trouble developing rapport with clients, but some reported barriers to developing a therapeutic alliance like the inability to detect nonverbal communications

c. MDD: Berryhill found that most studies reported stat sig decreases in depressive symptoms following telehealth with no stat differences between tele and in person groups receiving the same intervention
-also evidence that telehealth is useful for alleviating the insomnia and chronic pain that often accompany depression
-while a study evaluating the effectiveness of telephone-administered CBH found it to have a lower attrition rate than in-person CBT had, other studies have found that attrition rates for other modes of telehealth vary, depending on the population and type of intervention

d. Bulimia Nervosa: research found that it has beneficial effects but isn't necessarily as effective as in-person treatments
-ex. Mitchell compared telehealth to in-person delivered versions of manual-based CBT for BN - overall results showed that 2 versions had similar attrition rates and that both produced beneficial effects on outcome measures following treatment
--some differences: patients getting in-person CBT had non-sig higher rates of abstinence from binge eating and purging and sig greater reductions in eating disordered cognitions and depression
-Zerwas compared manualized version of CBT group therapy for BN via internet chat group and the same treatment delivered via traditional face-to-face group therapy
--found that patients in both groups experienced a decrease in bine eating and purging and comorbid symptoms of depression and anxiety by the end of treatment but some differences: immediately after treatment ended, patients with F2F therapy had a greater decrease in abstinence rates and anxiety symptoms but the gap between the 2 groups on these measures narrowed at the 12-mo follow-up, indicating that the pace of recovery was slower for patients who got therapy via the internet
model of healthcare delivery with 2 fundamental features:
1. recommended treatment within a stepped care model should be the least restrictive of those currently available, but still likely to provide significant health gain
2. stepped care model is self-correcting, which means that the results of treatments and decisions about treatment provision are monitored systematically and changes are made ('stepping up') if current treatments aren't achieving significant health gain

primary goals are to increase the efficiency of health care services and the accessibility of effective treatments through better allocation of scarce mental health resources

Several models of stepped care: some apply to specific disorders, while others are non-specific and can be applied to various disorders and conditions

Commonly cited models for depression usually include 4 steps that are similar to these:

1. Assessment and Monitoring: evaluating the patient's symptoms and "watchful waiting" which is appropriate for patients with minor depressive symptoms and involves monitoring their symptoms

2. Interventions requiring minimal practitioner involvement: include psychoed about symptoms and course of depression, treatment options, and signs of relaps
-bibliotherapy as a preventative technique for patients who at high risk for depression or are experiencing an increase in symptoms as an adjunct to other treatments
-computer-based interventions that track patients' symptoms and use multimedia with interactive components designed to help patients cope with depression and anxiety

3. Interventions requiring more intensive care and specialized training: may include group therapy, individual psychotherapy, and/or medication
-some models identify group psychotherapy and brief individual psychotherapy as initial choices for this step followed by long-term psychotherapy with or without antidepressant medication for patients who don't adequately respond to group or brief individual thearpy)

4. most restrictive and intensive forms of care: step for patients with severe depressive symptoms and consists of voluntary or mandated inpatient care
refers to the strength of a culture's social norma and tolerance for deviant behaviors

Tight cultures: have strong social norms and low tolerance for deviant behaviors
-greater conformity to social norms, tendency to engage in risk avoidance behaviors, and a preference for stability

Loose cultures: have weak social norms and high tolerance for deviant behaviors
-greater willingness to act in ways that deviate from social norms and engage in risk-taking and innovative behaviors and a greater openness to change

tightness-looseness is related to the ecological and human-made challenges that nations and states have historically encountered
-ex. those with a history of high population density, greater vulnerability to natural disasters and disease, and scarcity of resources are likely to become tight because they need strong norms and punishments for deviant behaviors to ensure their survival
--while nations and states without these challenges survive with weaker norms and acceptance of deviant behaviors

Gelfand and colleagues looked at 33 nations and 50 states
--Pakistan, Malaysia, and India as three "tightest" countries and Estonia, Hungary, and Israel as the three "loosest" countries
--Mississippi, Alabama, and Arkansas were the three "tightest" states and California, Oregon, and Washington were classified as the three "loosest" states

people living in tight states have higher levels of conscientiousness and lower levels of openness to experience than individuals living in loose states, while the opposite is true for those living in loose states
Evidence-based practices: the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences

Empirically supported treatments: slightly differ from above, refer only to treatments that have been found to be effective by scientific research that meets certain criteria

Culturally adapted interventions: involve the systematic modification of an evidence-based treatment (EBT) or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client's cultural patterns, meaning, and values
-adaptations may include incorporating content that's culturally appropriate and relevant (ex. issues related acculturation, racism, and religion and spirituality) and/or altering the format and delivery of treatment so that it's culturally compatible (ex. delivering the treatment in a client's native language, adopting a culturally compatible interpersonal time, and including indigenous healers in treatment delivery)

Adaptations of EBTs has created a fidelity-adaptation dilemma that requires psychotherapists to what degree they will adopt the standardized top-down approach that demands fidelity in its implementation and the idiographic bottom-up approach that demands sensitivity and responsiveness to each person's unique needs

some research has concluded that evidence shows that culturally adapted interventions provide benefit to intervention outcomes, but this added value is more apparent in the research on adults than on children and youths
-studies have found that adaptations are more effective when they involve adding features to an intervention than when they involve replacing a component of an intervention and that culturally adapted interventions are more beneficial for clients who have the greatest need for them
--ex. clients who are not fluent in English and clients with low levels of acculturation
guidelines for working with members of several culturally diverse groups are below:

African Americans:
-consider the client's cultural identity, level of acculturation, and worldview
-keep in mind that racism and other environmental factors may be contributors to the client's presenting problems
-be aware that the client's extended kinship network is likely to include nuclear and extended family members, friends, members of their church and community
-know that roles within African American families are often flexible and that male-female relationships tend to be egalitarian
-empower the client by, for example, helping the client acquire the problem-solving and decision-making skills they need to control their own life

interventions: African American clients usually prefer an egalitarian therapist-client relationship and a time-limited, problem-solving approach
-Boyd-Franklin recommends using a multisystems approach which involves intervening in numerous systems and at multiple levels that include the individual, their immediate and extended family, non-blood relatives and friends, church and community services, and social service agencies

American Indians:
-consider the client's cultural identity, level of acculturation, and worldview
-identify possible environmental contributors (e.g., discrimination, poverty, acculturation conflicts) to the client's presenting problems
-be aware that American Indians often adhere to a collateral social system that incorporates the family, community, and tribe
-recognize that cooperation, sharing, and generosity are important cultural values and that the interests of the family and tribe take priority over the interests of the individual
-be aware that American Indians are likely to regard wellness as depending on the harmony of mind, body, and spirit and illness as the result of disharmony
-eep in mind that American Indians tend to place more emphasis on nonverbal than verbal communication, consider listening to be more important than talking, and view direct eye contact as a sign of disrespect and a firm handshake as a sign of aggression
-foster a collaborative therapeutic relationship and build trust by demonstrating familiarity with and respect for the client's culture and admitting any lack of knowledge

Interventions: collaborative, problem-solving, client-centered approach that avoids highly directive techniques and incorporates American Indian values and traditional healers is usually preferred
-LaFronboise, Trimble, and Mohatt recomment using network therapy, which helps empower clients to cope with life stresses by mobilizing relatives, friends, and tribal members to provide support and encouragement

Hispanic/Latino Americans:
-consider the client's cultural identity, level of acculturation, and worldview
-identify possible environmental contributors (e.g., discrimination, poverty, acculturation conflicts) to the client's presenting problems
-determine the client's beliefs about the nature of their presenting problems and be aware that Hispanic Americans often express psychological symptoms as somatic complaints
-consider how a client's religious and spiritual beliefs might inform assessment, diagnosis, and treatment decisions
-keep in mind that Hispanic/Latino Americans tend to emphasize family welfare over individual welfare
-be aware that Hispanic/Latino American families may be patriarchal and stress machismo (male dominance) and marianismo (female submissiveness)
-adopt a formal style (formalismo) in the initial therapy session but a more personal style (personalismo) in subsequent sessions

Interventions: likely to prefer CBT, solution-focused therapy, family therapy, and group therapy
-therapy may be most effective when it incorporates culturally congruent techniques like cuento therapy (use of folktales to present models of adaptive behavior and dichos (use of proverbs and idiomatic expressions to help clients express their feelings)

Asian Americans:
-consider the client's cultural identity, level of acculturation, and worldview
-identify environmental factors that may be contributors to the client's presenting problems
-be aware that differences in acculturation within families may be a source of conflict
-determine the client's beliefs about the contributors to his or her presenting problems and be aware that Asian Americans often have a holistic view of mind and body and express psychological problems as somatic symptoms
-be aware that Asian American families tend to be hierarchical and patriarchal, adhere to traditional gender roles, and emphasize family needs over individual needs
-keep in mind that a fear of losing face and shame are powerful motivators for Asian Americans and may affect their willingness to discuss personal problems and express emotions
-maintain a formal style during the course of therapy
-be aware that, for Asian American clients, periods of silence and avoidance of eye contact are expressions of respect and politeness.

Interventions: likely to prefer CBT and other brief structured goal-oriented, problem-focused approaches that focus more on the family than the individual
-also likely to expect the therapist to be a knowledgeable expert who gives advice and suggests specific courses of action while also encouraging their participation in identifying goals and solutions to their problems

LGBTQ: men and women are 2x more likely to have a mental disorder in their lives (especially anxiety, depression, and substance misuse) than heterosexual men and women
-also have unique concerns that may be a target of therapy
--coming out and internalized heterosexism
---most LGB individuals report being aware they were different than others during childhood, but median age for being aware of sexuality is between 13-15 - some studies found the more wider they disclosed their identity, the greater their self-esteem and positive affectivity and lower their anxiety, other studies found that disclosure to students/staff associated with greater in-school victimization but also higher levels of self-esteem and decreased depression
--internalized heterosexism (internalized homophobia): internalization of negative messages by LGBTQ about their own identity - identified as a component of minority stress and linked to anxiety, depression, increased risk for suicide, alcoholism, and other substance misuse

-Be aware of the effects of stigmatization and heterosexism on the lives of LGB individuals.
-Recognize that same-sex attractions and behaviors are normal variants of human sexuality but avoid adopting a "sexual orientation blind" perspective that ignores or denies the unique experiences of LGB individuals.
-Consider how your own attitudes toward and knowledge of LGB issues might impact your assessment, diagnosis, and treatment of lesbian, gay, and bisexual clients.
-Distinguish issues related to sexual orientation from those related to gender orientation, and be aware that lesbian, gay, and bisexual individuals may act in gender conforming or gender non-conforming ways.
-Recognize the effects of intersectionality on the lives of LGB individuals - i.e., the effects of such factors as race/ethnicity, culture, gender, age, class, and disability and the interaction of these factors with sexual orientation.

Experts stress of combining EBP with culturally competent services - for LGBTQ clients, means providing affirmative therapy (integration of knowledge and awareness by the therapist of the unique development and cultural aspect of LGBTQ individuals, therapist's own self-knowledge, and translation of this into effective and helpful therapy skills at all stages)
--ex. when using CBT with someone, important to distinguish between maladaptive thoughts and thoughts that reflect a normal response to stigmatization they have experienced

Older Adult Clients: with exception of neurocognitive disorder, the rates of mental health disorders are lower among older adults than their younger and middle-aged counterparts
-many older adults experience mental health problems (anx/dep most common) and their symptoms may differ from younger adults
--ex. with depression, older adults more likely to complain about physical and cognitive symptoms than emotional distress and to report irritability, insomnia, weight loss, and other symptoms associated with anxiety

-Consider how your own attitudes and beliefs about aging might impact your assessment and treatment of older adults.
-Be aware that the heterogeneity among older adults surpasses that seen in other age groups, and recognize how gender, age, race/ethnicity, sexual orientation, and other factors may affect the experience and expression of psychological problems of older adults.
-Be familiar with normal biological changes associated with increasing age (e.g., changes in sensory acuity and cognitive functioning) and be able to distinguish between normative changes and changes due to physical illness or medications.
-Be aware that older adults respond favorably to a variety of types of psychotherapy but that some interventions have been found to be particularly effective for older adults with certain disorders (e.g., cognitive-behavior therapy and reminiscence therapy for depression).
-Acquire the knowledge and skills needed to make culturally sensitive adaptations to interventions that increase their effectiveness for older adults
--ex. modifying an intervention process and/or content (slowing pace of therapy, increasing number of sessions/decreasing frequency, accommodating heating loss, addressing physical illness/grief/cog decline and other problems that are experienced more often by older than younger adults)

Treatment: research found that effects of psychotherapy are comparable for older and younger adults but that older adults may respond more slowly to therapy and benefit most when treatment is tailored to their cognitive, sensory, and physical needs
distinguishes between five stages of identity development:
1. Conformity:
-People have either neutral or negative attitudes toward members of their own minority group and other minority groups
-positive attitudes toward members of the majority group
-accept negative stereotypes of their own group and consider the values and standards of the majority group to be superior
-prefer a therapist from the majority group and view a therapist's attempts to help them explore their cultural identity as threatening.

2. Dissonance: As the result of exposure to information or events that contradict their worldview, people in this stage question their attitudes toward members of their own minority group, other minority groups, and the majority group.
-they're aware of the effects of racism and are interested in learning about their own culture
-may prefer a therapist from the majority group but want the therapist to be familiar with their culture, and they're interested in exploring their cultural identity.

3. Resistance and Immersion:
-People in this stage have positive attitudes toward members of their own minority group, conflicting attitudes toward members of other minority groups, and negative attitudes toward members of the majority group.
-unlikely to seek therapy because of their suspiciousness of mental health services
--When they do seek therapy, they're likely to attribute their psychological problems to racism and prefer a therapist from their own minority group.

4. Introspection: During this stage, people question their unequivocal allegiance to their own group and are concerned about the biases that affect their judgments of members of other groups.
-They've become comfortable with their cultural identity but are also concerned about their autonomy and individuality.
-may prefer a therapist from their own minority group but are willing to consider a therapist from another group who understands their worldview, and they're interested in exploring their new sense of identity

5. Integrative Awareness:
-People are aware of the positive and negative aspects of all cultural groups.
-They're secure in their cultural identity and are committed to eliminating all forms of oppression and becoming more multicultural.
-Their preference for a therapist is based on similarity of worldview, and they're most interested in strategies aimed at community and societal change.
has been revised several times

original model was known as the Nigrescence Model (Cross, 1971) and distinguished between five stages:
1. Pre-Encounter: People idealize and prefer White culture. They have negative attitudes toward their own Black culture and may view it as an obstacle and source of stigma.

2. Encounter: People question their views of White and Black cultures as the result of exposure to events that cause them to become aware of the impact of racism on their lives. These individuals are interested in learning about and becoming connected to their own culture.

3. Immersion-Emersion: People reject White culture and idealize and become immersed in their own culture.

4. Internalization: During this stage, defensiveness and emotional intensity related to race decrease. People in this stage have a positive Black identity and tolerate or respect racial and cultural differences.

5. Internalization-Commitment: People have internalized a Black identity and are committed to social activism to reduce all forms of oppression.

Cross reduced the number of stages to four by combining the internalization and internalization-commitment stages.

Cross and Vandiver then changed its name to the Black Racial Identity Development Model and reduced it to three stages, with each stage including multiple identity subtypes.

1. Pre-encounter stage - includes assimilation, miseducation, and self-hatred subtypes

2. Immersion-emersion stage - consists of intense Black involvement and anti-White subtypes
3. internalization stage - consists of Black nationalist, biculturalist, and multiculturalist subtypes.
does not describe sequential stages of identity development but, instead, proposes that a person's racial identity may vary across time and situations.
-developed for African American individuals and defines African American racial identity as the significance and qualitative meaning that individuals attribute to their membership within the Black racial group within their self-concepts

Also distinguishes between four dimensions of racial identity:
-Racial salience: the extent to which a person's race is a relevant part of his/her self-concept at a particular point in time and in a particular situation.
--ex. race may become more salient for a person when they witnesses or experiences discriminatory behavior or is the only African American in a restaurant, classroom, or other social setting.
-Racial centrality: the extent to which a person normatively defines themselves in terms of race and is affected by the importance of race to the person relative to other identities such as gender and religion.
--ex. for some African American women, gender may be more important than race for their identities while, for others, the opposite may be true. ---In contrast to salience, centrality is relatively stable across situations.
-Racial regard includes private and public regard.
--Private regard refers to the extent to which a person feels positively or negatively toward African Americans and how positively or negatively they feel about being an African American.
--Public regard refers to the extent to which a person feels that others view African Americans positively or negatively.
---Private and public regard are not necessarily related and a person can have, for example, negative private and public regard or positive private regard and negative public regard.
-Racial ideology: refers to a person's beliefs and opinions about the ways African Americans should live and interact with society.
--(a) nationalist ideology: view the African American experience as being unique and believe African Americans should control their own destinies with minimal input from other groups.
--(b) oppressed minority ideology: emphasize the similarity of the oppression experienced by African Americans and members of other minority groups, and they're interested in forming coalitions with other groups.
--(c) assimilationist ideology: emphasize similarities between African Americans and the rest of American society and believe that African Americans should work within the system to change it.
--(d) humanist ideology: emphasize the similarities of all humans, give race low centrality, and are more concerned with issues facing the human race such as peace, poverty, and climate change.

a person's ideology may depend on the context
-ex. believe that African Americans should patronize African American-owned businesses as often as possible (nationalist ideology) but also think that African Americans should have more social contact with White individuals (assimilationist ideology)

propose that the four dimensions of racial identity can help clarify why individuals respond to similar situations differently.
--ex. two African American adults with similar regard and ideology may act differently in the same situation because race has high salience for one person in that situation but low salience for the other person.
consists of two phases - abandonment of racism and defining a nonracist White identity.
-Each phase includes three statuses, and each status is characterized by a different information processing strategy (IPS) that people use to think about race-related issues.

1. Contact: characterized by a lack of awareness of racism and satisfaction with the racial status quo
-usually have had limited contact with people from racial minority groups and may describe themselves as being colorblind.
-IPS: obliviousness.

2. Disintegration: transition to this status when they become aware of contradictions that create race-related moral dilemmas (ex. a conflict between the belief that all people are created equal and their unwillingness to live in an integrated neighborhood) These dilemmas cause confusion and anxiety.
-IPS: suppression and ambivalence.

3. Reintegration: attempted to resolve the dilemmas of the previous status by believing that Whites are superior to minority group members and blaming minority group members for their own problems.
-IPS: selective perception and negative out-group distortion.

4. Pseudo-Independence: transition to this status when faced with an event that makes them question their beliefs about Whites and members of minority groups.
-characterized by a superficial tolerance of minority group members that may be accompanied by paternalistic attitudes and behaviors that perpetuate racism.
-IPS: reshaping reality and selective perception.

5. Immersion-Emersion: search for a personal meaning of racism and an understanding of what it means to be White and to benefit from White privilege.
-IPS: hypervigilance and reshaping.

6. Autonomy: develop a nonracist White identity, value diversity, and can explore issues related to race and racism without defensiveness.
-IPS: flexibility and complexity.

a White therapist's identity status impacts their effectiveness when working with clients from minority groups.
-a progressive therapist-client relationship is optimal for the development of a positive therapeutic alliance and occurs when the therapist has a more integrated and flexible racial identity than the client has.

Evidence for the impact of White identity status has been provided by several studies, including research showing that White therapists with higher racial identity statuses also have higher levels of multicultural counseling competence
gay and lesbian identity development are most fully realized when self-identity, perceived identity, and presented identity coincide

distinguishes between four stages:
1. Sensitization: occurs during childhood and is characterized by feeling different from same-sex peers.
-ex. Young girls may feel that they're not feminine or pretty and are more independent and aggressive than other girls are
-ex. young boys may say they're less interested in sports and less aggressive than other boys and are more interested in art, reading, and other solitary activities.

2. Identity Confusion: begins in middle or late adolescence when individuals start to feel sexually attracted to individuals of the same sex and suspect that they're gay or lesbian.
-This suspicion leads to uncertainty and anxiety which they attempt to alleviate with denial, avoidance, repair (attempting to change), redefinition (viewing homosexual feelings as a phase), or acceptance.

3. Identity Assumption: The transition occurs when the person begins to accept a gay or lesbian identity
-usually between 19 and 21 years of age for males and between 21 and 23 years of age for females.
-Individuals in this stage seek out social and sexual relationships with gays or lesbians and disclose their sexual orientation to gay and lesbian peers and adults and to some heterosexual family members and friends.

4. Identity Commitment: People in this stage have internalized a gay or lesbian identity, accepted homosexuality as a way of life, and are comfortable disclosing their sexual orientation to heterosexual individuals including family members, friends, and coworkers.
originally developed as an intervention for depression and is now considered an evidence-based treatment not only for depression but also for bipolar disorder, generalized anxiety disorder, anorexia nervosa, bulimia nervosa, schizophrenia, obsessive-compulsive disorder, PTSD, and a number of other disorders

based on the assumption that psychological disturbance is due largely to maladaptive cognitive schemas, automatic thoughts, and cognitive distortions:
-(a) Cognitive schemas: core beliefs that develop during childhood as the result of experience and certain biological factors such as biological reactivity to stress.
--Schemas are enduring, can be maladaptive or adaptive, and are revealed in automatic thoughts.
--proposed that different disorders are associated with different maladaptive schemas, which are also known as cognitive profiles.
---ex. the cognitive profile for depression consists of negative beliefs about oneself, the world, and the future.
-(b) Automatic thoughts: verbal self-statements or mental images that come to mind spontaneously when triggered by circumstances and intercede between an event or stimulus and the individual's emotional and behavioral reactions
--can be positive or negative.
---Negative automatic thoughts are characterized by a distortion of reality, emotional distress, and/or interference with the pursuit of life goals and can contribute to psychological distress
----Practitioners of CBT often have clients record negative automatic thoughts outside therapy in a Dysfunctional Thought Record (DTR) whenever they feel their mood is worsening. When using a DTR, the client records the event or situation that led to an unpleasant emotion, the automatic thoughts that preceded the emotion, the type of emotion and its intensity on a scale from 0 to 100, an alternative rational response to the automatic thought, and the outcome (the emotion and any change in behavior elicited by the rational response).
-(c) Cognitive distortions are systematic errors in reasoning that often affect thinking when a stressful situation triggers a dysfunctional schema that, in turn, affects the content of automatic thoughts.
-Common distortions include arbitrary inference, selective abstraction, dichotomous thinking, personalization, and emotional reasoning:
--Arbitrary inference involves drawing negative conclusions without any supporting evidence.
--Selective abstraction involves paying attention to and exaggerating a minor negative detail of a situation while ignoring other aspects of the situation.
--Dichotomous thinking is the tendency to classify events as representing one of two extremes - for example, as a success or a failure.
--Personalization involves concluding that one's actions caused an external event without evidence for that conclusion.
--emotional reasoning is reliance on one's emotional state to draw conclusions about oneself, others, and situations.

The primary goals of CBT are to correct faulty information processing and to help patients modify assumptions that maintain maladaptive behaviors and emotions

Practitioners of CBT adopt an active, structured approach and use a variety of cognitive and behavioral techniques to achieve these goals.
-Cognitive techniques include redefining the problem, reattribution, and decatastrophizing
-behavioral techniques include activity scheduling, behavioral rehearsal, exposure therapy, and guided imagery (which is used to facilitate relaxation and decrease anxiety and pain).

An essential feature of CBT is its reliance on collaborative empiricism, which is a collaborative therapeutic alliance between the therapist and client in which they become coinvestigators as they examine the evidence to accept, support, reevaluate, or reject the client's thoughts, assumptions, intentions, and beliefs

Another feature is the use of Socratic dialogue, which involves asking the client questions that are designed to clarify and define the client's problems, identify the thoughts and assumptions that underlie those problems, and evaluate the consequences of maintaining maladaptive thoughts and assumptions.
based on the assumptions that psychological pain is both universal and normal and is part of what makes us human and that psychological inflexibility causes psychological problems and is characterized by a rigid dominance of psychological reactions over chosen values and contingencies in guiding action

distinguishes between clean and dirty pain:
-Clean pain is also known as clean discomfort and refers to natural levels of physical and psychological discomfort that are inevitable and cannot be controlled.
-Dirty pain is also known as dirty discomfort and refers to the emotional suffering that's caused by attempts to control or resist clean pain.

The main goal of ACT is to increase psychological flexibility, which involves addressing six core processes that foster acceptance, mindfulness, commitment, and behavior change and counter the processes that contribute to psychological inflexibility:
-Experiential acceptance counters experiential avoidance and is the active and aware embrace of private experiences without unnecessary attempts to change their frequency or form
-Cognitive defusion counters cognitive fusion and is the ability to distance oneself from one's thoughts and feelings and view them as experiences rather than reality.
-Being present counters attentional rigidity to the past and future and involves being in contact with whatever is happening in the present moment.
-Awareness of self-as-context counters attachment to the conceptualized self. It's the ability to view oneself as the context in which one's thoughts and feelings occur rather than as the thoughts and feelings themselves.
-Values-based actions counter unclear, compliant, or avoidant motives and depend on the ability to use one's freely chosen values to guide one's behaviors.
-committed action counters inaction, impulsivity, and avoidant persistence and refers to a commitment to continue to act in ways consistent with one's values in the future, even when faced with obstacles.

Interventions target these six processes and include metaphors, mindfulness strategies, and experiential exercises. ACT is considered to be an evidence-based treatment for a number of conditions including chronic pain, psychosis, depression, anxiety disorders, and obsessive-compulsive disorder.
Mindfulness refers to moment-to-moment awareness of one's experience without judgment

has been incorporated into several therapeutic approaches including ACT and DBT and is the core strategy of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).

MBSR was originally developed to make mindfulness meditation available and accessible in a Western medical setting while remaining true to the essence of Buddhist teachings
-It's used to help people cope with stress, pain, and illness and consists of an eight-session group program that focuses on teaching participants several mindfulness meditation practices including awareness of breathing, yoga, and sitting and walking meditation.

MBCT combines elements of MBSR and CBT.
-It was originally developed as a method for treating recurrent depression and research has confirmed that it's an effective treatment not only for depression but also for a number of other conditions including anxiety, chronic pain, and insomnia.
-The primary goal of MBCT is to enable clients to become self-aware, so they can learn to de-centre from distressing thoughts, feelings, bodily sensations and behaviours.
- It incorporates psychoeducation, mindfulness meditation practices, and cognitive-behavioral techniques and, like MBSR, usually consists of an eight-session group program.

Based on their meta-analysis of research on mindfulness-based interventions, Khoury and his colleagues (2013) have concluded that they're effective for treating both psychological disorders and physical/medical conditions but are more effective for psychological disorders, especially depression, anxiety, and stress.
-There's no clear consensus about the mechanisms that are responsible for the effectiveness of mindfulness-based interventions, but several mechanisms have been proposed and received some research support.

Holzel and her colleagues (2011) conclude that the primary mechanisms are attention regulation, emotion regulation, body awareness, which is awareness of one's internal states, and decentering, which is also known as reperceiving and is the ability to separate oneself from one's thoughts and emotions and view them objectively as transient mental events.