Thesis (M.S.)--University of Michigan, 1983.

Mental health disorders are a leading cause of disability and mortality worldwide. Mental health services do not meet demand due to accessibility issues, financial burden, and increasing needs. Technology can provide affordable, accessible mental health care and some research suggests internet-delivered Cognitive Behavior Therapy (iCBT) may be an effective treatment. In iCBTs, participants typically complete Cognitive Behavior Therapy modules and videos and are supported by a therapist. Advantages of iCBT over face-to-face therapy include lower cost, no travel time, easy access, no waitlists, and trackable progress. To our knowledge there have been no naturalistic studies of iCBT programs. Therefore, this study will evaluate the usage and effectiveness of one iCBT program, SilverCloud, in a university counseling center. Participants (N=5568) were students at a large, private western university. Participants were either self-referred to the program, chose to enroll at intake as a standalone intervention, or were referred by their treating clinician as an adjunct to regular treatment. We compared the outcomes and usage of participants using SilverCloud concurrently with psychotherapy to participants using SilverCloud alone, and participants in psychotherapy alone.

Homework assignments that patient work with between sessions is a key component in both face-to-face and Internet-based Cognitive Behavior Therapy (CBT). However, adherence to assignments is often low and it is largely unclear what factors predict or affect treatment adherence, and in the end, treatment outcomes. The overall aim of this thesis was to investigate if treatment presentation and therapist support can affect adherence and treatment outcome in internet-based CBT, whether adherence can be predicted by motivation variables and to compare differences in face-to-face and online conditions in this regard. A randomized controlled trial with a brief online relaxation program for people with stress and anxiety symptoms was conducted (n = 162). Participants in the enhanced support conditions completed a larger proportion of the online treatment but adherence was not affected by enhanced treatment presentation (Study I). Participants reported reduced symptoms of stress and anxiety after the relaxation program but there were no significant additional effects of enhanced presentation or support (Study II). Participants who adhered to the prescribed assignments reported lower symptom levels at study end, regardless of treatment conditions. Adherence to the online treatment was predicted by subject factors such as treatment credibility prior to the treatment and intrinsic motivation during the treatment (Study III). To further elucidate how motivation may affect adherence, an experiment with a one-session psychotherapy model was subsequently conducted (n = 100). Participants who were randomized to the face-to-face condition reported higher motivation for the assignment and completed significantly more of the homework compared to participants in the online condition (Study IV). Self-reported intrinsic motivation could predict adherence in both conditions while new motivational variables were identified specifically for the online condition. The results from these studies confirm that adherence to assignments in Internet-based CBT is difficult to affect with treatment features but can be predicted early in treatment by subject factors such as treatment credibility and motivation. How such motivational variables can be affected to improve treatments is still unclear.

Rational-emotive therapy was proposed as a therapeutic treatment approach to romantic jealousy. It was hypothesized that rational-emotive therapy would be significantly more effective than an attention placebo group in the reduction of romantic jealousy with undergraduate single female subjects. It was also hypothesized that reductions in romantic jealousy would be sustained to a significantly greater extent in the rational-emotive therapy group rather than the attention placebo group on a follow-up evaluation after a 2-month period. Advertisements soliciting single females who were romantically jealous and who felt that this was a problem in their love relationships yielded 18 female subjects from the North Texas State University campus. The pre-treatment, post-treatment, and follow-up assessments consisted of two self-report questionnaires. The pre- and post-treatment also included a physiological measurement (heart rate) while the subject was imagining a jealousy scene. Both of the self-report questionnaires (Sexual Jealousy, Irrational Beliefs) were given to a significant other (such as a boyfriend or lover). Results support the hypothesis that rational-emotive therapy is more effective than an equally credible placebo in the reduction of female romantic jealousy.

Accidental behavior chains are a common problem in dog training. Many handlers inadvertently reinforce undesirable behaviors. The behavior analytic literature already contains articles describing methods of breaking chains; however, those methods either are not used in dog training for practical purposes or are ineffective in dog training. This experiment investigated two ways to break a behavior chain, including extending the chain and introducing a delay into the chain. The results of extending the chain showed that it is possible to decrease the target behavior using this method, but it was not eliminated in this study. Adding a delay into the behavior chain resulted in a quick elimination of the target behavior.

Purpose: Therapists are often charged with the seemingly impossible task of predicting their client’s future behavior, particularly behavior that may result in harm or death. Adverse events (AE) refer to a constellation of behaviors or events that interfere with treatment and exhibit a risk to the safety of the patient, which include suicide attempts, non-suicidal self injury (NSSI) and suicidal ideation. This is the first study that seeks to identify and associate in-session markers in DBT prior to AEs. Method: The proposed study sought to identify whether ruptures in therapeutic alliance (3RS; Eubanks-Carter, Muran & Safran, 2015), the frequency and intensity of negative-self referential speech (LIWC2015; Pennebaker, Booth, Boyd & Francis, 2015) and periods of psychomotor agitation are associated with AEs within a course of Dialectical Behavior Therapy (DBT). By coding videotaped psychotherapy sessions (n = 98) across 21 patients diagnosed with Borderline Personality Disorder (BPD), the researchers prospectively examined the association between in-session phenomena during the session prior to an AE. Exploratory logistic multilevel modeling, mean comparison and latent profile analysis (LPA) techniques were used to identified in-session markers associated with adverse events across the course of DBT treatment. Results: Using a multilevel model building approach to account for the nested structure, increases in content/affect split was associated with increased likelihood (36% increase in log-odds) of NSSI occurrence reported in the subsequent session when controlling for frequency of past NSSI episodes. When controlling for prior suicide attempts, withdrawal and confrontation ruptures did not predict the occurrence of suicide attempts in the subsequent session. To further examine the heterogeneity of the Level 1 variables (i.e., in-session markers), the LPA fitted afive-profile solution that captured relative differences in mean frequencies of coded markers.The latent “session types” were named based on their in-session characteristics, with AEs identified post-hoc within the identified profiles. While AEs were distributed across multiple profiles, visual inspection aligned with the findings in the multilevel model. Sessions characterized by elevations in content/affect split and behaviors that distance from the therapist preceded NSSI during treatment. The majority of the sessions prior to suicide attempts (70%) during the study period were assigned to the profile with the lowest mean frequency of in-session markers. Clinical implications: The strength of the therapeutic alliance in DBT is an essential component of effective treatment. Therapeutic ruptures, particularly withdrawal ruptures, occur frequently in DBT treatment. Attending to these ruptures, especially occasions when a patient’s affect and verbal content are not congruent, may signal to the therapist that the patient requires additional support. In-session content/affect split may represent a vulnerability factor that puts the patient at increased risk of NSSI behavior due difficulty attuning to their internal experiences and limitations in their emotional flexibility. Limitations: Similar to other studies that examine self-harm, the low base-rate of suicide attempts and NSSI behavior complicates empirical study. Since the study utilized strict inclusion criteria for only individuals diagnosed with BPD, findings cannot be generalized to patients with other psychiatric diagnoses. While some therapist effects are controlled for in the study since one therapist treated all the patient included in the study, the study does not account for therapist factors that may influence the therapy dyad. Given the limited sample size, there was not adequate power to fit more complicated models (e.g., inter-level and intra-level interactions, random effect predictor variables, etc.).

Em psicoterapia, à medida que o terapeuta cria as condições necessárias para que um relacionamento íntimo seja construído com o cliente, comportamentos problema, da mesma classe daqueles que são emitidos em seu ambiente natural, podem aparecer em sessão, podendo constituirse em respostas improdutivas para o processo terapêutico (sejam elas respostas agressivas ou de esquiva). O modo como o terapeuta responde a esses comportamentos pode ter efeitos diferentes na aliança terapêutica, que é tida como preditora de resultados terapêuticos. Estudos indicaram que terapeutas apresentariam tendência a responder a clientes resistentes ou hostis com contrahostilidade, frieza e distanciamento. Os terapeutas que obtiveram bons resultados em manejar tais situações realizaram intervenções interpretativas e não diretivas, focando na relação terapêutica. Entretanto, houve dificuldade de se encontrar trabalhos que tenham analisado o comportamento do terapeuta por meio de observação direta em situações que eliciam nele sentimentos negativos. O presente trabalho se propõe a investigar esse tipo de interação. Nesta linha, pretendeu-se verificar (1) se o terapeuta altera, no decorrer do processo terapêutico, sua resposta aos comportamentos do cliente que eliciam sentimentos negativos, demonstrando que está sensível ao impacto de suas intervenções no comportamento do cliente e vice-versa; e (2) se houve diminuição desses comportamentos do cliente, sendo, mesmo que indiretamente, uma medida de eficácia das intervenções terapêuticas. Para isso, foram filmadas sessões de três terapeutas analíticocomportamentais (T1, T2a e T2b) e uma estudante de psicologia (T3) e seus clientes. As terapeutas responderam a questionário pós-sessão durante todo o período de coleta de dados com o objetivo de identificar a ocorrência de sentimentos negativos nas sessões. Os comportamentos de terapeuta foram categorizados com o Sistema Multidimensional de Categorização da Interação Terapêutica. Para os comportamentos de clientes foram elaboradas categorias com o auxílio das transcrições dos áudios das supervisões. Os resultados indicaram que quatro comportamentos foram observados como eliciadores de sentimentos negativos para todas as terapeutas: Falta de Diálogo, Fala Superficial, Oposição e Atenuar. De maneira geral, as interações desse tipo corresponderam a um pouco mais de um terço do total da sessão. Houve uma prevalência das categorias Facilitação, Empatia e Solicitação de Relato nas intervenções de todas as terapeutas a esses comportamentos, confirmando dados da literatura para clientes difíceis. Facilitação e Empatia apresentaram muitas vezes padrões de ocorrência diferenciados, entendendo-se que Empatia é uma intervenção mais ativa que Facilitação. Ainda, a categoria Facilitação indicaria problemas na condução do caso, quando apresenta predominância muito acentuada entre as categorias ou quando tem percentuais muito baixos. Nas situações que produziram melhores resultados a Facilitação apresentava proporções próximas de outras categorias do terapeuta. As demais categorias foram agrupadas em Interventivas e apresentaram diferentes tendências dependendo do resultado da terapia. T1 apresentou tendência de aumento na categoria Interventivas no decorrer das sessões, sendo este o único caso que continuou em atendimento e que apresentou comportamentos de melhora expressivos. As respostas das terapeutas foram diferentes de acordo com a categoria de cliente, em que é possível inferir que cada uma delas lida melhor com alguns comportamentos das clientes que com outros / In psychotherapy, as the therapist creates the necessary conditions for an intimate relationship with the client, some problem behaviors may appear in session, which can be of the same class of those that the clients display in their natural environment. These behaviors may be unproductive responses to the therapeutic process (aggressive or avoidance responses). The way the therapist responds to these behaviors may have different effects on the therapeutic alliance, which is regarded as a predictor of therapeutic results. Studies have indicated that therapists would present a tendency to respond to resistant and hostile clients with counter-hostility, coldness and detachment. Therapists who have been successful in handling such situations made interpretative and non directive interventions, focusing on the therapeutic relationship. However, it was difficult to find studies which investigated the therapist behavior through direct observation in situations in which he had negative feelings. This study proposed to investigate the therapeutic interaction in sessions which produce negative feelings in therapist. Thus it intends to examine (1) whether the therapist, having supervision, changes his behavior over the course of the therapeutic process, in response to the clients behaviors that generate negative feelings and (2) whether these clients behaviors decrease, which can be an indirect measure of efficacy of therapeutic interventions. Sessions of three behavior-analytic therapists and a psychology student were videotaped. The therapists completed a questionnaire after each session in order to identify if any adverse situation had occurred. The therapist behaviors were coded with the Multidimensional System for Coding Behaviors in Therapist-Client Interaction. Clients behaviors categories were developed based on audio transcripts of supervisions. The results indicated that four behaviors were observed as eliciting negative feelings for all therapists: Lack of Dialogue, Superficial Talk, Opposition and Attenuation. In general, interactions of this type correspond to a third part of the session. There was a prevalence of categories Facilitation, Empathy and Request Report for all therapists in response to these behaviors, confirming literature data for difficult clients. Facilitation and Empathy often showed different patterns of occurrence, being Empathy a more active intervention than Facilitation. The category Facilitation indicates problems in conducting the case, when it presents very marked predominance among the categories or when it presents very low percentages. In situations with better results Facilitation had proportions similar to other therapist categories. The remaining categories were grouped into Interventional and showed different trends depending on the outcome of therapy. T1 tended to increase the Interventional category during the sessions, and it was the only case that has continued in therapy and showed significant improvement during sessions. The therapists responses differed according to client categories. It is possible to infer that each therapist deals best with some client behaviors than with others

Há interesse crescente não só no estudo dos resultados de psicoterapias, mas também nos processos responsáveis pelos resultados obtidos. De uma perspectiva analítico-comportamental discute-se se o processo de mudança psicoterápica se dá por formulação (e seguimento) de novas regras ou pela conseqüenciação direta de comportamentos emitidos na interação terapêutica. Mudanças ocorridas devido a orientação do terapeuta seriam governadas por regras. Por orientação entende-se uma descrição do comportamento feita pelo falante a ser executada pelo ouvinte com descrição explícita ou implícita das conseqüências da ação. A auto-orientação seria uma descrição feita pelo o cliente a ser executado pelo próprio cliente. A pesquisa teve por objetivo analisar quatro variáveis sobre o comportamento de orientar: a) formação teórica comportamental; b) experiência; c) clientes; d) flutuações entre sessões. Participaram desta pesquisa seis terapeutas comportamentais pouco experientes e três experientes. Cada um gravou três sessões com três clientes adultos com diagnóstico variado. As sessões foram transcritas e categorizadas, tendo sido contados o número de palavras e de falas com orientação e auto-orientação e seus subtipos. Os terapeutas comportamentais experientes orientaram significativamente mais seus clientes que os pouco-experientes. No entanto os terapeutas experientes apresentaram maior variabilidade em relação ao uso dessa estratégia. Apenas um dos terapeutas experientes orientou bastante todos seus clientes em todas as sessões. Os clientes de outro dos terapeutas experientes se auto-orientaram significativamente mais que os clientes dos outros terapeutas experientes e pouco-experientes. Quanto aos subtipos de orientações tanto terapeutas experientes como pouco-experientes orientaram mais para ação específica do que para ação genérica, encobertos ou tarefas. Entre os experientes e pouco-experientes ocorreram diferenças significativas referentes aos subtipos orientação para ação específica e orientação para tarefa, mas não houve diferenças significativas para os subtipos orientação para ação genérica e orientação para encoberto. Os terapeutas experientes emitiram significativamente mais orientação para ação específica e os terapeutas pouco-experientes significativamente mais orientação para tarefa. Os resultados sugerem que terapeutas comportamentais tendem a ser diretivos, ou seja, utilizam a estratégia de orientar seus clientes, mas em média menos de 20% das sessões dos terapeutas experientes e menos de 10% das sessões dos terapeutas pouco-experientes são usados com a estratégia de orientação / Increasing interest is being evinced not only in the study of psychotherapeutic results but also in the processes responsible for those outcomes. From a behavior analytical standpoint, discussions are focusing on whether the process of psychotherapeutic change takes place through the formulation (and following) of new rules or through the consequences for behaviors occurring in therapeutic interaction. Changes that take place just the therapist´s orientation are assumed to be governed by rules. Orientation refers to a description of the behavior made by the speaker to be executed by the listener, with an explicit or implicit description of the consequences of the action. Self-orientation is a description made by the client to be executed by himself. The purpose of the research was to analyze the effect of four variables on the behavior of giving orientation: a) a behavioral theoretical education; b) experience; c) clients; and d) fluctuations between sessions. Six inexperienced and three experienced behavior therapists participated in this research. Each of these therapists recorded three sessions with three adult clients with varied diagnosis. The sessions were transcribed and categorized, counting the number of words and of dialogues containing orientation and self-orientation and their subtypes. The experienced behavior therapists oriented their clients significantly more than the inexperienced ones did, although the former displayed a greater variability in relation to the use of this strategy. Only one of the experienced therapists gave substantial orientation to all his clients in every session. The clients of another experienced therapist self-oriented themselves significantly more than the clients of the other two experienced and the inexperienced therapists. As for the subtypes of orientation, both experienced and inexperienced therapists gave more orientation for specific action than for generic action, covert behavior or tasks. The experienced and inexperienced therapists displayed significant differences regarding the subtypes of orientation for specific action and for tasks, but no significant differences in the subtypes of orientation for generic action and covert behavior. The experienced therapists gave more orientation for specific action while the inexperienced ones gave more task-related orientation than the experienced. The findings suggest that behavior therapists tend to be directive, i.e., they use strategies to orient their clients, but that, on average, less than 20% of the experienced therapists´ sessions and less than 10% of the inexperienced therapists´ sessions make use of orientation strategy.

Em psicoterapia, à medida que o terapeuta cria as condições necessárias para que um relacionamento íntimo seja construído com o cliente, comportamentos problema, da mesma classe daqueles que são emitidos em seu ambiente natural, podem aparecer em sessão, podendo constituirse em respostas improdutivas para o processo terapêutico (sejam elas respostas agressivas ou de esquiva). O modo como o terapeuta responde a esses comportamentos pode ter efeitos diferentes na aliança terapêutica, que é tida como preditora de resultados terapêuticos. Estudos indicaram que terapeutas apresentariam tendência a responder a clientes resistentes ou hostis com contrahostilidade, frieza e distanciamento. Os terapeutas que obtiveram bons resultados em manejar tais situações realizaram intervenções interpretativas e não diretivas, focando na relação terapêutica. Entretanto, houve dificuldade de se encontrar trabalhos que tenham analisado o comportamento do terapeuta por meio de observação direta em situações que eliciam nele sentimentos negativos. O presente trabalho se propõe a investigar esse tipo de interação. Nesta linha, pretendeu-se verificar (1) se o terapeuta altera, no decorrer do processo terapêutico, sua resposta aos comportamentos do cliente que eliciam sentimentos negativos, demonstrando que está sensível ao impacto de suas intervenções no comportamento do cliente e vice-versa; e (2) se houve diminuição desses comportamentos do cliente, sendo, mesmo que indiretamente, uma medida de eficácia das intervenções terapêuticas. Para isso, foram filmadas sessões de três terapeutas analíticocomportamentais (T1, T2a e T2b) e uma estudante de psicologia (T3) e seus clientes. As terapeutas responderam a questionário pós-sessão durante todo o período de coleta de dados com o objetivo de identificar a ocorrência de sentimentos negativos nas sessões. Os comportamentos de terapeuta foram categorizados com o Sistema Multidimensional de Categorização da Interação Terapêutica. Para os comportamentos de clientes foram elaboradas categorias com o auxílio das transcrições dos áudios das supervisões. Os resultados indicaram que quatro comportamentos foram observados como eliciadores de sentimentos negativos para todas as terapeutas: Falta de Diálogo, Fala Superficial, Oposição e Atenuar. De maneira geral, as interações desse tipo corresponderam a um pouco mais de um terço do total da sessão. Houve uma prevalência das categorias Facilitação, Empatia e Solicitação de Relato nas intervenções de todas as terapeutas a esses comportamentos, confirmando dados da literatura para clientes difíceis. Facilitação e Empatia apresentaram muitas vezes padrões de ocorrência diferenciados, entendendo-se que Empatia é uma intervenção mais ativa que Facilitação. Ainda, a categoria Facilitação indicaria problemas na condução do caso, quando apresenta predominância muito acentuada entre as categorias ou quando tem percentuais muito baixos. Nas situações que produziram melhores resultados a Facilitação apresentava proporções próximas de outras categorias do terapeuta. As demais categorias foram agrupadas em Interventivas e apresentaram diferentes tendências dependendo do resultado da terapia. T1 apresentou tendência de aumento na categoria Interventivas no decorrer das sessões, sendo este o único caso que continuou em atendimento e que apresentou comportamentos de melhora expressivos. As respostas das terapeutas foram diferentes de acordo com a categoria de cliente, em que é possível inferir que cada uma delas lida melhor com alguns comportamentos das clientes que com outros / In psychotherapy, as the therapist creates the necessary conditions for an intimate relationship with the client, some problem behaviors may appear in session, which can be of the same class of those that the clients display in their natural environment. These behaviors may be unproductive responses to the therapeutic process (aggressive or avoidance responses). The way the therapist responds to these behaviors may have different effects on the therapeutic alliance, which is regarded as a predictor of therapeutic results. Studies have indicated that therapists would present a tendency to respond to resistant and hostile clients with counter-hostility, coldness and detachment. Therapists who have been successful in handling such situations made interpretative and non directive interventions, focusing on the therapeutic relationship. However, it was difficult to find studies which investigated the therapist behavior through direct observation in situations in which he had negative feelings. This study proposed to investigate the therapeutic interaction in sessions which produce negative feelings in therapist. Thus it intends to examine (1) whether the therapist, having supervision, changes his behavior over the course of the therapeutic process, in response to the clients behaviors that generate negative feelings and (2) whether these clients behaviors decrease, which can be an indirect measure of efficacy of therapeutic interventions. Sessions of three behavior-analytic therapists and a psychology student were videotaped. The therapists completed a questionnaire after each session in order to identify if any adverse situation had occurred. The therapist behaviors were coded with the Multidimensional System for Coding Behaviors in Therapist-Client Interaction. Clients behaviors categories were developed based on audio transcripts of supervisions. The results indicated that four behaviors were observed as eliciting negative feelings for all therapists: Lack of Dialogue, Superficial Talk, Opposition and Attenuation. In general, interactions of this type correspond to a third part of the session. There was a prevalence of categories Facilitation, Empathy and Request Report for all therapists in response to these behaviors, confirming literature data for difficult clients. Facilitation and Empathy often showed different patterns of occurrence, being Empathy a more active intervention than Facilitation. The category Facilitation indicates problems in conducting the case, when it presents very marked predominance among the categories or when it presents very low percentages. In situations with better results Facilitation had proportions similar to other therapist categories. The remaining categories were grouped into Interventional and showed different trends depending on the outcome of therapy. T1 tended to increase the Interventional category during the sessions, and it was the only case that has continued in therapy and showed significant improvement during sessions. The therapists responses differed according to client categories. It is possible to infer that each therapist deals best with some client behaviors than with others

Sex offenders are often required by the court to enter therapy and receive help so they can stop deviant sexual behaviors. Mental health professionals must have some means of evaluating a mandated client's progress in therapy, however, there are currently no valid criteria available. A survey form was developed containing 73 items which professionals identified as having possible utility in evaluating progress.