Evidenced-Based Treatment

Significant advances in the treatment of various emotional disorders has taken place over the last several years. We now have a deeper and more fine-grained understanding of the psychological components of these disorders, which has resulted in more precisely targeted interventions. Most critically, research evidence has demonstrated the effectiveness of these programs.

The Center specializes in providing a number of these empirically supported treatment programs and training clinicians to use them.

The Power of Evidence Based Treatment

The Center specializes in providing a number of these empirically supported treatment programs and training clinicians to use them.

Evidence-based (also referred to as empirically supported) psychological treatment programs possess the following desirable features:

Have demonstrated their effectiveness — in comparison to other treatments — through randomized controlled trials.
Due to improvements in research methodologies, these treatment programs are directly applicable to clinical situations,
The development of the different treatment programs rests on psychological research which pinpointed the particular cognitive, emotional and behavior patterns thaujt underlie each disorder.
Thus, subtle differences in each treatment program are based on a deeper understanding of each disorder, resulting in more precise and effective treatment interventions,
The treatments are short-term (10-15 sessions) and, therefore, cost-effective.
Many approaches have been evaluated. While CBT has demonstrated its superiority for many disorders based on the evidence, other approaches (INTERNAL LINK) have proven to be beneficial with certain difficulties.

Please Note: A recent article in the New York Times, Looking for Evidence That Therapy Works, highlights the importance of evidenced-based approaches.
http://well.blogs.nytimes.com/2013/03/25/looking-for-evidence-that-therapy-works/?_php=true&_type=blogs&_r=0

The Treatments That Work Series

Although significant inroads have been made in understanding and treating a number of psychological disorders, delivery of effective treatment lags behind. Only a small percentage of practitioners have been trained in these empirically-supported programs.

However, recently some of the most effective treatment programs have been translated into manuals so that a wider range of clinicians can learn them. These manuals provide detailed, step-by-step strategies for assessing and treating specific disorders.

These manuals are published by Oxford University Press through a program called Treatments That Work. Dr. David Barlowe, perhaps the leading expert in anxiety disorders in the country, serves as Editor-in-Chief for the series.

Dr. Greenwood has provided training to mental health professionals in the Washington D.C. area based on some of the Treatments That Work manuals. Prospective supervisees or clients may learn more about these treatments by ordering therapist or client manuals from the Treatments That Work series.

Acceptance and Commitment Therapy

Steven Hayes and his colleagues, trained in behavioral analysis and relational frame theory, developed a scientifically based treatment called Acceptance and Commitment Therapy, or ACT. ACT is a leading approach in what is being called the “third wave” of cognitive and behavioral therapy since it incorporates new understandings and techniques in the human change process.

The ACT acronym captures the three basic steps or themes of the treatment:

Accept Thoughts and Feelings, particularly the unwanted ones associated with anxiety, guilt and shame. The inability to accept and struggle against painful thoughts sustains if not exacerbates such disorders as PTSD, social anxiety and OCD. Learning how to accept, with compassion, such painful thoughts and feelings through exercises like mindfulness training, is essential to change.
Choose Directions. Life is not just about reducing pain, but choosing what matters to you in life and moving in that directions. ACT provides concrete steps to help individuals determine “What do you want your life to stand for?”
Take Action. Realizing valued life goals is fulfilling but difficult. ACT focuses on this step by taking advantage of our knowledge of habit change, resistance, acceptance of painful feelings that inhibit change, and the therapeutic use of metaphors.

It should be noted that ACT differs from cognitive-behavioral therapy, both in its primary goal and most preferred techniques. ACT emphasizes the activation of value-congruent behavior; whereas CBT focuses on the reduction of painful symptomotology. ACT teaches acceptance of maladaptive thinking; whereas CBT highlights cognitive restructuring.

However, it should also be emphasized that both approaches rest on solid empirical ground and are united in seeking the goals of psychological flexibility and valued action. With a grasp of the theory of each approach, the unique techniques from ACT and CBT can be integrated to enhance each approach.

For those interested in learning about ACT, the relationship between ACT and CBT, or the application of ACT to anxiety disorders, the following books are suggested.

Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy
by Steven Hayes
Buy This This is an excellent self-help book which book also explains the philosophy underlying the ACT model.

A CBT Practitioner’s Guide to ACT
by Joseph Ciarrochi and Ann Bailey
This book is designed for practitioners who want to bridge the gap between CBT and ACT.

Acceptance and Commitment Therapy for Anxiety Disorders
by George Eifert and John Forsythe
This is a practitioner’s guide to applying ACT to anxiety disorders. Very thorough and clearly written.

Schema-Focused Therapy

Schema-Focused Therapy (SFT) was developed by Jeffrey E. Young, Ph.D. While working with Dr. Aaron Beck at the Center For Cognitive Therapy, Dr. Young noticed there was a group of clients that did not respond as quickly or strongly to traditional cognitive therapy as one would hope. These clients, who tend to have long-standing problems and entrenched, dysfunctional beliefs, what Dr. Young calls schemas, seem to respond better to a different set of treatment strategies.

What are Schemas?
Schemas can be thought of as central and enduring themes in a person’s life. Schemas reflect deep, difficult to change views of ourselves, others, and the world. Schemas also refer to a broad organizing structure that significantly influences our moment-to-moment experiences. Schemas develop early in life. The building blocks of schemas often are the important experiences of childhood, particularly how our caretakers responded to us. Schemas typically consist of thematically connected feeling states, thinking patterns, expectations, predispositions to believe and emotionally significant memories.

Schemas have a purpose: to rapidly inform us of what is important to our well-being and how we might meet our deepest needs. Maladaptive schemas, as you might guess, don’t assist is getting our needs met and typically result in painful patterns in thinking and feeling. For example, John, a 24 year old graduate, is told by a friend that a fellow female graduate student likes John and wishes he would ask her out. Upon hearing this, John experiences the following:

An anxious, jittery feeling that has the quality of vulnerability rather than excitement
Specific thoughts, such as “this can’t be true”, “she won’t like me if she gets to know me”, “I’d be a fool to ask her out”
Specific memories of other unrequited longings, instances where he perceived he was rejected, memories of his parents criticizing him for being socially awkward and “too quiet
An inclination to withdraw and forget what his friend told him

We would say that John has a Defectiveness or Unlovability Schema that was triggered by his friend’s comment.

List of Maladaptive Schemas
Perhaps the key contribution of Schema-Focused Therapy is the identification of the major maladaptive schemas that can afflict us. Dr Jeffrey Young has identified the following schemas:

Emotional Deprivation – The belief and expectation that your primary needs will never be met. The sense that no one will nurture, care for, guide, protect or empathize with you.
Abandonment – The belief and expectation that others will leave, that others are unreliable, that relationships are fragile, that loss is inevitable, and that you will ultimately wind up alone.
Mistrust/Abuse – The belief that others are abusive, manipulative, selfish, or looking to hurt or use you. Others are not to be trusted.
Defectiveness – The belief that you are flawed, damaged, or unlovable, and you will thereby be rejected.
Social Isolation – The pervasive sense of aloneness, coupled with a feeling of alienation.
Vulnerability – The sense that the world is a dangerous place, that disaster can happen at any time, and that you will be overwhelmed by the challenges that lie ahead.
Dependence/Incompetence – The belief that you are unable to effectively make your own decisions, that your judgment is questionable, and that you need to rely on others to help get you through day-to-day responsibilities.
Enmeshment/Undeveloped Self – The sense that you do not have an identify or “individuated self” that is separate from one or more significant others.
Failure – The expectation that you will fail, or belief that you cannot perform well enough.
Subjugation – The belief that you must submit to the control of others, or else punishment or rejection will be forthcoming.
Approval-Seeking/Recognition-Seeking – The sense that approval, attention an recognition are far more important than genuine self-expression and being true to oneself.
Emotional Inhibition – The belief that you must control your self-expression or others will reject or criticize you.
Negativity/Pessimism – The pervasive belief that the negative aspects of life outweigh the positive, along with negative expectations for the future.
Unrelenting Standards – The belief that you need to be the best, always striving for perfection or to avoid mistakes.
Punitiveness – The belief that people should be harshly punished for their mistakes or shortcomings.
Entitlement/Grandiosity – The sense that you are special or more important than others, and that you do not have to follow the rules like other people even though it may have a negative effect on others. Also can manifest in an exaggerated focus on superiority for the purpose of having power or control.
Insufficient Self-Control/Self-Discipline – The sense that you cannot accomplish your goals, especially if the process contains boring, repetitive, or frustrating aspects. Also, that you cannot resist acting upon impulses that lead to detrimental results.

What Can Schema-Focused Therapy Add to Cognitive Therapy?

The assessment process in SFT is more comprehensive. The therapist wants to develop a good understanding of the origin of the maladaptive schema (early interactions with significant others) and how the schema has expressed itself throughout the patient’s life (the pattern of painful feelings, self-defeating choices and unmet needs).
There is a greater emphasis on understanding the origins of the maladaptive schemas. This enables the client to see his life, especially his struggles and self-defeating behavior, and how they are influenced him to avoid certain situations or tasks that fulfill his basic desires. This kind of understanding can promote not only self-compassion, but also increase motivation to change by appreciating the “price one has paid”.
Schema-Focused-Therapy spells out powerful change techniques to “heal”maladaptive schemas. These techniques include working with painful memories and images that are an intregral part of the schema. Evoking such memories can be emotional for the client. However, it appears to be crucial to restructuring the memory and help “heal” the schema.

For What Types of Clients or Problems Would Schema-Focused-Therapy be Indicated?

For clients who do not respond well to traditional cognitive therapy or who seem to suffer frequent relapses of their problems. Clients who feel they have been entrenched in self-defeating patterns and whose thinking is rigid and harsh (e.g. “this is the way I am – I just am defective – no matter what I do, I’ll always be unloveable”). Clients who seem to fall into the same relationship traps throughout their life. Here there is almost always a maladaptive schema that needs to be identified and changed.

How to Learn More About Schema-Focused Therapy

There is a schema therapy website (www.schematherapy.com) that has a user-friendly slide show explaining the therapy model. Reinventing Your Life by Jeff Young and Janet Klosko is an excellent self-help book which identifies eleven of the most common schemas (called lifetraps in this book) and accompanying self-help strategies to understand and counteract the schema. Schema Therapy, A Practitioner’s Guide by Young, Klasko,and Weishaar is the first major ttext written for clinicians. This text describes the background and development of SFT and spells out the innovative assessment and change strategies of the mode. However, since the SFT model is straightforward and the writing is lucid, non-clinicians can easily absorb the material in the book.

Emotional-Focused Therapy

Emotion-Focused Therapy (EFT) was developed primarily by Leslie Greenberg, Ph.D. and colleagues at York University in Toronto, Ontario. Like cognitive therapy, EFT if a structured and focused treatment that has received empirical support with various disorders including depression, victims of childhood abuse, and marital dysfunction. However, EFT differs from cognitive therapy with its emphasis on:

the focus on the constructive aspects of emotions, even painful and difficult ones. EFT emphasizes that all emotions contain valuable information that need to be brought into the open and understood
making essential distinctions between emotional states.

How can EFT ADD to the Effectiveness of Cognitive Therapy?

By helping the therapist look for the constructive aspects of emotions. For example, emerging anger in a client who is often submissive in relationships probably needs to be evoked, explored, supported, and validated.
To help make clinically significant distinctions with difficult emotional states. This involves helping clients explore the full meaning of their emotional reactions. Possible benefits include assisting clients to sort through different layers of feeling; promoting emotional resilience by facing painful or dreaded feelings; determining whether feelings are adaptive and thus might guide behavior or maladaptive and therefore should be changed.
EFT has elucidated the importance of fully experiencing all of the components thoughts, feelings, memories, unmet needs) and nuances of maladaptive emotions/schemas. When clients fully access the pain in their maladaptive schemas, they recognize the unmet need in pain (e.g. the need for security in the fear of abandonment; the need for self-worth in the shame of feeling defective; the need for compassion in the contempt of self-punitiveness). Becoming aware of such needs often provides direction and motivation to transform the unhealthy feeling. Research studies validate the link between such deep experiencing and positive change

For What Types of Clients Would EFT be Particularly Indicated?
EFT seems especially helpful to clients who are “over-controlled”, that is clients who tend to disavow or dampen their feelings. Like schema-focused therapy, EFT offers innovative change strategies to clients with long-standing seemingly intractable difficulties.

How Can I Learn More About EFT?
There are two websites that provide a good deal of material on the EFT model. Les Greenberg’s website (emotionfocusedtherapy.org) provides answers to questions about the model, as well as links to other useful cites. The Process-Experiential Therapy Website (process-experiential.org) contains a brief tutorial on a recent book, Learning Emotion-Focused Therapy published by the American Psychological Association (2004). This book, written for clinicians, is a comprehensive and clear description of the theory and clinical approach of EFT.

Dr. Les Greenberg has written a number of books on EFT. His most recent effort, Emotion-Focused Therapy: Coaching Clients to Work Through Their Feelings, is a thoughtful and down-to-earth description of the critical steps in accessing and understanding important emotions and then deciding intelligently whether to regulate, express, or change particular emotions.