Selecting Effective Treatments

A Comprehensive, Systematic Guide to Treating Mental Disorders

Lourie W. Reichenberg, Linda Seligman

• Publisher: Wiley
• Year: 2016
• ISBN:
  9781118791219
• Edition: 5
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

The bestselling treatment guide, updated to reflect changes to the DSM-5

Selecting Effective Treatments provides a comprehensive resource for clinicians seeking to understand the symptoms and dynamics of mental disorders, in order to provide a range of treatment options based on empirically effective approaches. This new fifth edition has been updated to align with the latest changes to the DSM-5, and covers the latest research to help you draw upon your own therapeutic preferences while constructing an evidence-based treatment plan. Organized for quick navigation, each disorder is detailed following the same format that covers a description, characteristics, assessment tools, effective treatment options, and prognosis, including the type of therapy that is likely to be most successful treating each specific disorder. Updated case studies, treatments, and references clarify the latest DSM-5 diagnostic criteria, and the concise, jargon-free style makes this resource valuable to practitioners, students, and lay people alike.

Planning treatment can be the most complicated part of a clinician's job. Mental disorders can be complex, and keeping up with the latest findings and treatment options can itself be a full time job. Selecting Effective Treatments helps simplify and organize the treatment planning process by putting critical information and useful planning strategies at your fingertips

• Get up to speed on the latest changes to the DSM-5
• Conduct evidence-based treatment suited to your therapeutic style
• Construct Client Maps to flesh out comprehensive treatment plans
• Utilize assessment methods that reflect the changes to the DSM-5 multiaxial system

Effective treatment begins with strategic planning, and it's important to match the intervention to your own strengths, preferences, and style as much as to the client's needs. Selecting Effective Treatments gives you the latest information and crucial background you need to provide the evidence-backed interventions your clients deserve.

Chapter 1
Introduction to Effective Treatment Planning

Why Is Diagnosis and Assessment Important?

I have heard students, colleagues, interns, and licensed professionals alike react to the diagnosis of mental disorders as a form of “labeling” clients, and insist that “Diagnosis is only for the insurance companies.” For some reason, these comments seem to have increased since the publication of DSM-5, perhaps as resistance to or avoidance of learning about new and sometimes nuanced, diagnostic changes. Diagnosis can certainly be a challenge, but without an accurate diagnosis, how could we possibly know what treatments to recommend?

Consider for a moment the following scenarios:

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Case Study 1.1

Jack A., a 64-year-old man, begins couples counseling with his wife because he has become irritable and difficult to be around. After 35 years of marriage he has begun to shout at his wife and becomes particularly hostile at the end of the day. She is considering leaving him. They attend weekly couples counseling but rather than getting better, the situation seems to be getting worse.

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Case Study 1.2

Jillian is a 14-year-old girl who is being treated by a psychiatrist with SSRIs for her symptoms of OCD. She is fearful of eating food that has been touched or prepared by others, and now weighs less than 100 pounds. The psychiatrist refers the girl for individual therapy, but her new counselor decided she would fit perfectly into a weekly support group she runs for adolescent girls with anorexia. Instead of getting better, however, Jillian lost another 5 pounds in the first month.

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Case Study 1.3

A 37-year-old married mother of three active boys has been diagnosed with fibromyalgia and rheumatoid arthritis. She is exhausted all the time, in pain, and recently resigned from her job so she could devote all of her time to taking care of herself and her family. At the recommendation of her doctor, she begins to attend weekly therapy sessions. Using the Gestalt empty-chair technique, her therapist encourages her to give her illness a name and express her anger to the chair.

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Inaccurate (or no) diagnosis, inappropriate treatment, and poor clinical understanding on the part of the therapist contributed to the situations just described.

Months later, the first man went to the doctor for an annual physical examination. His wife mentioned his increasing irritability to the doctor, who recognized the end-of-day irritability as “sundowner's,” a potential symptom of Alzheimer's disease. The patient was referred to a neurologist where he received an accurate diagnosis.

The young girl with OCD was referred by her psychiatrist for individual counseling, which could have been an appropriate companion therapy to medication management, if she had received individual sessions of CBT to help reduce her obsessions and compulsions. Unfortunately, putting her in a group with other girls with anorexia provided her an opportunity to learn new obsessive and compulsive eating behaviors that she had never thought of before. It also brought out her competitive nature. Within a month, her weight became dangerously low and she was hospitalized.

The young mother had a painful medical disorder that was exacerbated by stress. She was eventually referred to a mindfulness-based stress reduction group where she learned mindfulness meditation, acceptance, and relaxation techniques. She is now able to manage her pain without medication and has learned how to treat herself with compassion.

As these stories illustrate, the primary goal of diagnosis and treatment planning is to be able to make sound therapeutic decisions that will help clients feel better about themselves and their lives, return to better functioning, and achieve their goals. Just like other medical and mental health professionals, doctors, psychiatrists, psychologists, counselors, social workers, and addictions specialists must first do no harm. But in order to follow that edict, we must be knowledgeable about what helps and what has the potential for causing our clients to get worse.

For some well-researched disorders, such as generalized anxiety disorder, major depressive disorder, and some of the eating disorders, research has found specific evidence-based treatments that are more effective than placebo conditions or no treatment at all. When these interventions are used for specific disorders they result in improvement over relatively short periods of time, and the improvements are often of a dose-by-dose nature. More importantly, treatment gains are maintained after counseling has ended.

But many times, little or no research is available on a disorder, or despite a wealth of research, not one specific treatment modality stands out as the most effective. In other cases, as with conduct disorder, bipolar disorder, and borderline personality disorder, treatment will depend on the stage of the disorder, the most troublesome symptoms at that time, and a long-term approach.

Many of the diagnoses in DSM-5 do not have evidence-based treatments. Some are too new to have an adequate research base, and some disorders are too rare to have garnered enough interest and funding for research. In those situations, case studies can often be found in the literature that can be culled from, and approaches that provide symptom relief can be recommended.

In these cases in particular, it helps to remember that psychotherapy is effective. So effective that nearly 40 years ago Smith, Glass, & Miller (1980) conducted a meta-analytic review on the effectiveness of psychotherapy. They concluded, “The average person who received therapy is better off at the end of it than 80% of those who do not” (p. 87).

An Integrated Model for Treatment Planning

Treatment planning generally moves from recognition of the symptoms of the disorder into consideration of the client's characteristics and on to the treatment approach. That sequence will be followed throughout most of this book with the help of an integrated treatment model called the Client Map.

All the elements necessary for effective treatment planning—diagnosis, objectives of treatment, and types of interventions—will be discussed here in terms of the DO A CLIENT MAP mneumonic. Readers who are familiar with the Client Map method of diagnosis and assessment already know how this simple acronym helps to make the process more thorough and effective by covering all the major elements of the treatment planning process. For those learning the system for the first time, each of the 12 letters in the DO A CLIENT MAP mneumonic helps to facilitate recall for each of the 12 parts of the assessment and treatment planning process:

• Diagnosis
• Objectives of treatment
• Assessment—tools to help clarify assessment may include structured clinical interviews, inventories, scales, neurological tests, or may be as simple as symptom check lists and self-reports
• Clinician characteristics
• Location of treatment
• Interventions to be used
• Emphasis of treatment—for example level of support needed, level of directiveness by the therapist, whether focus is cognitive, behavioral, emotional, or a combination of the three
• Numbers—who should participate in treatment? Is the most effective treatment individual therapy? Family therapy? Group?
• Timing—frequency, pace, and duration of treatment
• Medications needed, if any
• Adjunct services—community services, support groups, alternative treatments
• Prognosis

The clinician who gathers client information for each of the items in the Client Map will have completed the assessment and have the information necessary for a structured treatment plan that informs his or her work with that client. The acronym is used throughout this book to illustrate sample case studies relevant to the diagnoses in each chapter.

The format presented here for diagnosis and treatment has been used successfully by students, interns, therapists and other mental health professionals for at least two decades. It is comprehensive, provides a solid foundation on which evidence-based practice can be built, and has withstood the test of time. Now, with the elimination of the multi-axial system in DSM-5, the simple Client Map acronym provides students and experienced therapists alike with an easy-to-use diagnostic framework for their work with clients, if they choose to use it. Let's get started.

Diagnosis

(DO A CLIENT MAP)

Effective treatment planning begins with the conceptualization of a diagnosis. Several different classification systems are available that reflect our current level of knowledge and the res...