Stephen M. Saunders

Clinical Psychologists' Perceptions of Persons With Mental Illness

Clinical psychologists have an ethical responsibility to monitor the nature and appropriateness of theirattitudes toward persons with mental illness. This article presents the results of a survey of randomlyselected clinical psychologists who were asked to rate the effectiveness, understandability, safety,worthiness, desirability, and similarity (to the rater) of persons with moderate depression, borderlinefeatures, and schizophrenia. The results show that psychologists perceive these individuals differentlywith respect to these characteristics. The results also suggest that psychologists disidentify or distancethemselves from persons with personality and psychotic conditions. Implications for quality improve-ment and stigma reduction in the field of professional psychology are discussed.Keywords: disidentification, mental health attitudes, professional bias, attitudes of psychologists

APPLICANTS' EXPERIENCE OF THE PROCESS OF SEEKING THERAPY

This study assessed the process of seeking psychotherapy, conceptualized as four steps: recognizing the problem; deciding therapy might help; deciding to seek therapy; and contacting the mental health system. The Process of Seeking Therapy Questionnaire (PSTQ) was completed by 275 therapy applicants. It ascertained problem duration, alternative coping strategies, difficulty achieving and time needed to achieve the steps, and whether the applicant had informal help achieving the steps. Results indicated that problems tended to be long-standing, that therapy applicants attempted a variety of coping strategies before seeking therapy, and that informal help was important throughout the process. Problem recognition was the most difficult, time-consuming step. Difficulty achieving the first three steps was significantly, curvilinearly related to symptomatic distress, as the least and most distressed reported the most difficulty. Utilizing social support was related to experiencing greater difficulty deciding therapy might help. Time

Trials and Tribulations in the Meta-Analysis of Treatment Differences: Comment on Wampold et al. (1997)

A fair test of the Dodo bird conjecture that different psychotherapies are equally effective would entail separate comparisons of every pair of therapies. A meta-analysis of overall effect size for any particular set of such pairs is only relevant to the Dodo bird conjecture when the mean absolute value of differences is 0. The limitations of the underlying randomized clinical trials and the problem of uncontrolled causal variables make clinically useful treatment differences unlikely to be revealed by such heterogeneous meta-analyses. To enhance implications for practice, the authors recommend an intensified focus on patient-treatment interactions, cost-effectiveness variables, and separate metaanalyses for each pair of treatments.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patients response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Methodological background of decision rules and feedback tools for outcomes management in psychotherapy

Abstract Systems to provide feedback regarding treatment progress have been recognized as a promising method for the early identification of patients at risk for treatment failure in outpatient psychotherapy. The feedback systems presented in this article rely on decision rules to contrast the actual treatment progress of an individual patient and his or her expected treatment response (ETR). Approaches to predict the ETR on the basis of patient intake characteristics and previous treatment progress can be classified into two broad classes: Rationally derived decision rules rely on the judgments of experts, who determine the amount of progress that a patient has to achieve for a given treatment session to be considered “on track.” Empirically derived decision rules are based on expected recovery curves derived from statistical models applied to aggregated psychotherapy outcomes data. Examples of each type of decision rule and of feedback systems based on such rules are presented and reviewed.

Measuring the discrepancy between current and ideal spiritual and religious functioning in problem drinkers.

The idea that spiritual and religious functioning (SRF) is associated with alcohol misuse is generally supported, but problems with typical research methods limit the utility of findings. Problems in SRF were conceptualized as discrepancies between current and ideal SRF. Two separate studies were conducted to develop and evaluate a scale to measure the subjective importance and adequacy of aspects of SRF that seem to be associated with alcohol problems. The 1st study suggested that a questionnaire developed to evaluate self-reported ratings of current and ideal SRF is both internally consistent and temporally stable. In the 2nd study, the questionnaire was administered to persons seeking treatment for alcohol problems and persons who indicated that they had never sought treatment for an alcohol problem. Results indicate that those with a drinking problem were more likely to report substantial discrepancies between current and ideal SRF, supporting the validity of the measure as an indicator of problems in SRF. The usefulness of this method for treatment and research is discussed.

Measuring the role of psychological inflexibility in Trichotillomania

Psychological Inflexibility (PI) is a construct that has gained recent attention as a critical theoretical component of Acceptance and Commitment Therapy (ACT). PI is typically measured by the Acceptance and Action Questionnaire-II (AAQ-II). However, the AAQ-II has shown questionable reliability in clinical populations with specific diagnoses, leading to the creation of content-specific versions of the AAQ-II that show stronger psychometric properties in their target populations. A growing body of the literature suggests that PI processes may contribute to hair pulling, and the current study sought to examine the psychometric properties and utility of a Trichotillomania-specific version of the AAQ-II, the AAQ-TTM. A referred sample of 90 individuals completed a battery of assessments as part of a randomized clinical trial of Acceptance-Enhanced Behavior Therapy for Trichotillomania. Results showed that the AAQ-TTM has two intercorrelated factors, adequate reliability, concurrent validity, and incremental validity over the AAQ-II. Furthermore, mediational analysis between emotional variables and hair pulling outcomes provides support for using the AAQ-TTM to measure the therapeutic process. Implications for the use of this measure will be discussed, including the need to further investigate the role of PI processes in Trichotillomania.

Comorbidity and quality of life in adults with hair pulling disorder

Hair pulling disorder (HPD; trichotillomania) is thought to be associated with significant psychiatric comorbidity and functional impairment. However, few methodologically rigorous studies of HPD have been conducted, rendering such conclusions tenuous. The following study examined comorbidity and psychosocial functioning in a well-characterized sample of adults with HPD (N=85) who met DSM-IV criteria, had at least moderate hair pulling severity, and participated in a clinical trial. Results revealed that 38.8% of individuals with HPD had another current psychiatric diagnosis and 78.8% had another lifetime (present and/or past) psychiatric diagnosis. Specifically, HPD showed substantial overlap with depressive, anxiety, addictive, and other body-focused repetitive behavior disorders. The relationships between certain comorbidity patterns, hair pulling severity, current mood and anxiety symptoms, and quality of life were also examined. Results showed that current depressive symptoms were the only predictor of quality of life deficits. Implications of these findings for the conceptualization and treatment of HPD are discussed.

Empirically certified treatments or therapists: The issue of separability.

Forms of psychotherapy treatment are not neatly separable from one another in actual practice. They differ behaviorally in what they emphasize, but nevertheless they overlap and so cannot be unambiguously compared for effectiveness. Furthermore, forms of psychotherapy are not separable in practice from the therapists who apply them, so apparent differences in effectiveness between forms of treatment are always confounded by differences in effectiveness between therapists. Therapists, however, are separable from one another, and it is therapists not treatment forms that actually treat patients. Therefore, what should primarily be given preference in practice is not treatments empirically certified on the basis of their results in randomized clinical trials but psychotherapists empirically certified to practice on the basis of their results in actual practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

An Evaluation of the Utility of Statistical Versus Clinical Significance in Determining Improvement in Alcohol and Other Drug (AOD) Treatment in Correctional Settings

Despite widespread endorsement from researchers focusing on treatment, clinical significance methodology remains underutilized in treatment evaluations. Using data collected from a treatment program for persons jailed for alcohol and other drug (AOD)-related offenses, clinical significance methodology is demonstrated and contrasted with traditional significance testing across a variety of symptom and dysfunction areas. A total of 124 participants completed a self-report questionnaire (Health Dynamics Inventory; Saunders & Wojcik, 1997) at intake and discharge from treatment. Consistent with previous research utilizing clinical significance methodology, each participant appeared to have a unique treatment experience characterized by a specific pattern of symptom-level change across the areas assessed. The level of pretreatment functioning and the potential for symptoms to worsen during treatment are discussed as important factors to consider when using clinical significance methodology.