Selecting EffectiveTreatments

Selecting EffectiveTreatmentsA ComprehensiveSystematic Guide toTreating Mental Disorders

Fifth Edition

LOURIE W. REICHENBERG ANDLINDA SELIGMAN

Copyright © 2016 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Reichenberg, Lourie W., 1956-Selecting effective treatments : a comprehensive, systematic guide to treating mental disorders /

Lourie W. Reichenberg, Linda Seligman. – Fifth edition.pages cm

Includes bibliographical references and index.ISBN 978-1-118-79135-6 (paperback) ISBN 978-1-118-79105-9 (epdf) ISBN 978-1-118-79121-9 (epub)1. Mental illness–Treatment. 2. Psychiatry–Differential therapeutics. 3. Psychotherapy. I. Seligman, Linda. II. Title.RC480.S342 2012616.89 ′14–dc23

2015031923Cover design: WileyCover image: © paintings/shutterstock

Printed in the United States of America

FIFTH EDITION

HB Printing 10 9 8 7 6 5 4 3 2 1PB Printing 10 9 8 7 6 5 4 3 2 1

Contents

Preface ix

Acknowledgments xi

Chapter 1 Introduction to Effective Treatment Planning 1

Chapter 2 Neurodevelopmental Disorders 33

Chapter 3 Schizophrenia Spectrum and Other Psychotic Disorders 69

Chapter 4 Bipolar and Related Disorders 103

Chapter 5 Depressive Disorders 145

Chapter 6 Anxiety Disorders 175

Chapter 7 Obsessive-Compulsive and Related Disorders 219

Chapter 8 Trauma- and Stressor-Related Disorders 245

Chapter 9 Dissociative Disorders 277

Chapter 10 Somatic Symptom and Related Disorders 289

Chapter 11 Feeding and Eating Disorders 311

Chapter 12 Elimination Disorders 341

Chapter 13 Sleep-Wake Disorders 353

Chapter 14 Sexual Dysfunctions 369

Chapter 15 Gender Dysphoria 383

v

vi CON T E N T S

Chapter 16 Disruptive, Impulse Control, and Conduct Disorders 393

Chapter 17 Substance-Related and Addictive Disorders 417

Chapter 18 Neurocognitive Disorders 461

Chapter 19 Personality Disorders 479

Chapter 20 Paraphilic Disorders 535

Appendix: Suicide Assessment and Prevention 551

About the Authors 565

Author Index 567

Subject Index 591

This book is dedicated to Dr. Linda Seligman, for her commitmentto education and research, to students and clients, and for the legacy

she has left to the field of clinical psychology.

Preface

Twenty-five years ago when the first editionof Selecting Effective Treatments was published,it included a systematic approach to treatmentplanning. The Client Map was the brainchild ofDr. Linda Seligman. In her Preface to the firstedition of the text she wrote:

The comprehensive scope of thisbook, its grounding in research andin the DSM . . . its systematic andstructured approach, and its use ofcase studies and examples of treat-ment plans should help cliniciansmake better use of the knowledgecurrently available on treatmentof mental disorders, and enableclinicians to serve their clients mosteffectively.

Now, a quarter century later, with thepublication of the fifth edition of the DSM, andthe fifth version of this text, the comprehensiveapproach to treatment planning found withinthese pages has never been more relevant than itis today.

In 2013, following the publication ofDSM-5, I worked with Wiley Senior EditorRachel Livsey, to prepare a text that wouldhelp mental health providers bridge the transi-tion from DSM-IV-TR to DSM-5. Thanks toRachel, and the dedicated staff at Wiley, DSM-5

Essentials was published within 6 months andbecame a useful and popular tool for therapists.

DSM-5 Essentials and this, the fifth editionof Selecting Effective Treatments, are both designedto complement DSM-5.

To streamline the process, the fifth editionof this text has been completely reorganized tobe consistent with the new DSM-5 modifica-tions in diagnostic categories. This text followsthe newDSM-5 developmental focus and incor-porates childhood disorders into the appropriatecategory. So, Autism Spectrum Disorder cannow be found in the chapter on Neurode-velopmental Disorders along with intellectualdisability, learning disorders, and ADHD. Dis-cussions of other disorders that may have rootsin childhood (e.g., bipolar, anxiety, depression)are integrated into the specific category forthose disorders. These changes apply to the19 classifications of mental disorders. Interestedreaders will find a complete list of all the changesfrom DSM-IV to DSM-5 in DSM-5 Essentials,and in the Appendix to DSM-5 (APA, 2013,p. 809).

What has not changed in the fifth edition ofSelecting Effective Treatments is the organizationalconsistency of each disorder into the Client Mapsystem. This acronym, DO A CLIENT MAP iseven more relevant since the elimination of themultiaxial system of diagnosis. Many studentsand professionals alike have asked “How do we

ix

x PR E FAC E

diagnose in a uni-axial world?” Rest assured,those who become familiar with the ClientMap system soon come to rely on this simple,yet comprehensive method to help them assess,diagnose, and select the most effective treat-ments for their clients. Students, counselors,

social workers, and others have told me howvaluable this text is in their work with clients.The most often repeated comment I receiveis “Your book was a required text when I wasin graduate school and now, years later, I stilluse it.”

Acknowledgments

Being an author can be a very isolating expe-rience, yet in book writing, as in life, no oneis an island. I would like to acknowledge thededicated people at John Wiley and Sons whohave worked with me on the publication ofthis book. First and foremost Rachel Livsey,senior manager of content development anddelivery. This is the fourth book we have col-laborated on and I appreciate and value hercontinued support. I also wish to acknowledgethe professionalism and teamwork on the part ofPatricia Rossi, executive editor, Pamela Berk-man, production manager, and Elisha Benjamin,production editor.

I would also like to thank those whohave helped me to stay connected to themainland—more like a peninsula than themetaphorical island that book writing cansometimes become—Stephen Berns, PhD,Beth Cuje, PhD, Jeanne Evans, LMFT, GenileeSwope Parente, Laura Elizabeth Parris, and ofcourse, my husband for more than 25 years, NeilReichenberg, who reminded me the other daythat we all have to make choices in life. I appre-ciate his acceptance of the choices I have made.

Lourie W. ReichenbergFalls Church, Virginia

xi

CHAPTER

1 Introduction to Effective TreatmentPlanning

WHY IS DIAGNOSISAND ASSESSMENT IMPORTANT?

I have heard students, colleagues, interns, andlicensed professionals alike react to the diagnosisof mental disorders as a form of “labeling”clients, and insist that “Diagnosis is only for theinsurance companies.” For some reason, thesecomments seem to have increased since the

publication of DSM-5, perhaps as resistance toor avoidance of learning about new and some-times nuanced, diagnostic changes. Diagnosiscan certainly be a challenge, but without anaccurate diagnosis, how could we possibly knowwhat treatments to recommend?

Consider for a moment the followingscenarios:

Case Study 1.1Jack A., a 64-year-old man, begins couples counseling with his wife because he has become irritable anddifficult to be around. After 35 years of marriage he has begun to shout at his wife and becomes particularlyhostile at the end of the day. She is considering leaving him. They attend weekly couples counseling butrather than getting better, the situation seems to be getting worse.

Case Study 1.2Jillian is a 14-year-old girl who is being treated by a psychiatrist with SSRIs for her symptoms of OCD. She isfearful 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 perfectlyinto 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.

Case Study 1.3A 37-year-old married mother of three active boys has been diagnosed with fibromyalgia and rheumatoidarthritis. She is exhausted all the time, in pain, and recently resigned from her job so she could devote all ofher time to taking care of herself and her family. At the recommendation of her doctor, she begins to attendweekly therapy sessions. Using the Gestalt empty-chair technique, her therapist encourages her to give herillness a name and express her anger to the chair.

1

2 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

Inaccurate (or no) diagnosis, inappropriatetreatment, and poor clinical understanding onthe part of the therapist contributed to the situ-ations just described.

Months later, the first man went to thedoctor for an annual physical examination. Hiswife mentioned his increasing irritability to thedoctor, who recognized the end-of-day irri-tability as “sundowner’s,” a potential symptomof Alzheimer’s disease. The patient was referredto a neurologist where he received an accuratediagnosis.

The young girl with OCD was referredby her psychiatrist for individual counseling,which could have been an appropriate com-panion therapy to medication management, ifshe had received individual sessions of CBT tohelp reduce her obsessions and compulsions.Unfortunately, putting her in a group withother girls with anorexia provided her an oppor-tunity to learn new obsessive and compulsiveeating behaviors that she had never thoughtof before. It also brought out her competitivenature. Within a month, her weight becamedangerously low and she was hospitalized.

The young mother had a painful medicaldisorder that was exacerbated by stress. She waseventually referred to a mindfulness-based stressreduction group where she learned mindfulnessmeditation, acceptance, and relaxation tech-niques. She is now able to manage her painwithout medication and has learned how totreat herself with compassion.

As these stories illustrate, the primary goal ofdiagnosis and treatment planning is to be able tomake sound therapeutic decisions that will helpclients feel better about themselves and theirlives, return to better functioning, and achievetheir goals. Just like other medical and men-tal health professionals, doctors, psychiatrists,psychologists, counselors, social workers, andaddictions specialists must first do no harm.

But in order to follow that edict, we mustbe knowledgeable about what helps and whathas the potential for causing our clients to getworse.

For some well-researched disorders, such asgeneralized anxiety disorder, major depressivedisorder, and some of the eating disorders, re-search has found specific evidence-based treat-ments that are more effective than placeboconditions or no treatment at all. When theseinterventions are used for specific disorders theyresult in improvement over relatively short peri-ods of time, and the improvements are often of adose-by-dose nature. More importantly, treat-ment gains are maintained after counseling hasended.

But many times, little or no research is avail-able on a disorder, or despite a wealth of research,not one specific treatment modality standsout as the most effective. In other cases, as withconduct disorder, bipolar disorder, and border-line personality disorder, treatment will dependon the stage of the disorder, the most trouble-some symptoms at that time, and a long-termapproach.

Many of the diagnoses in DSM-5 do nothave evidence-based treatments. Some are toonew to have an adequate research base, andsome disorders are too rare to have garneredenough interest and funding for research. Inthose situations, case studies can often be foundin the literature that can be culled from, andapproaches that provide symptom relief can berecommended.

In these cases in particular, it helps toremember that psychotherapy is effective. Soeffective that nearly 40 years ago Smith, Glass, &Miller (1980) conducted a meta-analytic reviewon the effectiveness of psychotherapy. Theyconcluded, “The average person who receivedtherapy is better off at the end of it than 80% ofthose who do not” (p. 87).

Introduction to Effective Treatment Planning 3

AN INTEGRATED MODELFOR TREATMENT PLANNING

Treatment planning generally moves fromrecognition of the symptoms of the disorder intoconsideration of the client’s characteristics andon to the treatment approach. That sequencewill be followed throughout most of this bookwith the help of an integrated treatment modelcalled the Client Map.

All the elements necessary for effectivetreatment planning—diagnosis, objectives oftreatment, and types of interventions—will bediscussed here in terms of the DO A CLIENTMAP mneumonic. Readers who are familiarwith the Client Map method of diagnosis andassessment already know how this simple ac-ronym helps to make the process more thoroughand effective by covering all the major elementsof the treatment planning process. For thoselearning the system for the first time, each ofthe 12 letters in the DO A CLIENT MAPmneumonic helps to facilitate recall for eachof the 12 parts of the assessment and treatmentplanning process:

◾ Diagnosis◾ Objectives of treatment◾ Assessment—tools to help clarify assess-

ment may include structured clinicalinterviews, inventories, scales, neuro-logical tests, or may be as simple assymptom 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 direc-tiveness by the therapist, whether focusis cognitive, behavioral, emotional, or acombination of the three

◾ Numbers—who should participatein treatment? Is the most effectivetreatment individual therapy? Familytherapy? Group?

◾ Timing—frequency, pace, and durationof treatment

◾ Medications needed, if any◾ Adjunct services—community services,

support groups, alternative treatments◾ Prognosis

The clinician who gathers client informa-tion for each of the items in the Client Mapwill have completed the assessment and have theinformation necessary for a structured treatmentplan that informs his or her work with thatclient. The acronym is used throughout thisbook to illustrate sample case studies relevant tothe diagnoses in each chapter.

The format presented here for diagnosisand treatment has been used successfully bystudents, interns, therapists and other mentalhealth professionals for at least two decades. It iscomprehensive, provides a solid foundation onwhich evidence-based practice can be built, andhas withstood the test of time. Now, with theelimination of the multi-axial system in DSM-5,the simple Client Map acronym provides stu-dents and experienced therapists alike with aneasy-to-use diagnostic framework for their workwith clients, if they choose to use it. Let’s getstarted.

DIAGNOSIS

(DO A CLIENT MAP)Effective treatment planning begins with the

conceptualization of a diagnosis. Several differ-ent classification systems are available that reflectour current level of knowledge and the research

4 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

available. Although the best that we haveavailable at this time, these classification systemsmust be considered to be fluid documentsthat evolve with new scientific knowledge.They must be updated and revised periodi-cally to remain relevant with current medicalknowledge and changing concepts of illness(Moriyama, Loy, & Robb-Smith, 2011).

The Diagnostic and Statistical Manual of Men-tal Disorders, 5th edition (DSM-5; AmericanPsychiatric Association [APA], 2013) is theclassification system used most frequently in theUnited States.

The International Classification of Diseases andRelated Health Problems (ICD) was developed bythe World Health Organization (WHO) andis used by 117 countries around the world toreport national morbidity andmortality statistics.It is updated periodically and is currently in itstenth version, although an 11th edition is beingdeveloped. As of this writing, the United Statesis using ICD-10-CM (Clinical Modification)as the basis for medical coding and reporting.In the United States, the National Center forHealth Statistics oversees this process. As ofOctober, 1, 2015, all U.S. healthcare providerscovered under the Health Insurance Portabilityand Accountability Act (HIPAA) were requiredto use the ICD-10-CM diagnostic codes formedical and mental health procedures. Both setsof codes (for ICD 9 and ICD 10) are createdby the World Health Organization. The codesare available for use free of charge from theWHO website (www.who.int/classifications/icd/en) and are also printed in DSM-5 and inDSM-5 Essentials: The Savvy Clinician’s Guide tothe Changes in Criteria (Reichenberg, 2014).

Both the DSM and the ICD are updatedperiodically in keeping with the reality of newresearch, new statistics on prevalence rates, andnew insights into the etiology and nosology ofmental disorders. Both classification systems are

primarily diagnostic, and do not venture into thearea of treatment interventions.

Also, by their very nature, both systems areimprecise. Rather than being the final word ondiagnosis, it is more helpful to consider DSM-5and ICD-10 to be the best information that wehave at the current time, with the understandingthat classifications will change as our knowledgebase changes. Mental health professionals muststay informed and keep pace with the changesin our profession.

Other, larger philosophical questions aboutthe judgments that must be made to determinethe boundaries of normalcy versus a disorder;the standards agreed to for guiding research; evenquestions related to causation, cultural differ-ences, and what constitutes a medical illnessversus a mental disorder are all fascinating topicsfor discussion, but they have all been coveredelsewhere and are beyond the scope of this book.

Certainly care should be taken to distinguishbetween a true mental disorder and a normalreaction to stressful life events. More than 70% ofdisorders in DSM-IV included clinically signifi-cant distress or impairment as a required criterionfor diagnosis. DSM-5 provides a new definitionof a mental disorder that is slightly different:

A mental disorder is a syndromecharacterized by clinically signifi-cant disturbance in an individual’scognition, emotion regulation, orbehavior that reflects a dysfunctionin the psychological, biological, ordevelopmental processes underlyingmental functioning.Mental disordersare usually associated with significantdistress or disability in social, occupa-tional, or other important activities.(APA, 2013, p. 20)

Until we reach a point when all mentaldisorders can be measured and the underlying

Introduction to Effective Treatment Planning 5

causative factors identified, clinical judgmentwill still be necessary to determine when abehavior or sequelae of behaviors has becomedysfunctional or is associated with significantdistress. Until then, DSM-5 and ICD reflect thebest currently available information we have forthe diagnosis of mental disorders.

Another diagnostic challenge is the presenceof co-occurring or comorbid disorders. TheDSM-5 allows for multiple diagnoses to begiven at the same time, as long as the diagnosticcriteria are met. Greater comorbidity meansdiagnosis will be more difficult, and treatmentwill be more complicated as issues of personality,behavior, substance use, and other influenceswill need to be factored into the treatment plan.

Provisional diagnoses may also be given, ifthere is a strong indication that the full criteriawill ultimately be met. The provisional specifieris added following the diagnosis if not enoughinformation is available. A provisional diagnosiscan also be given if the duration criterion for adisorder has not been met.

Also important to diagnosis is an under-standing of the client’s developmental stage,and processes such as attachment, socializa-tion, gender identity, and moral and emotionaldevelopment. Understanding the client’s stageof development is particularly important whentreating children, adolescents, families, and olderadults (Levant, 2005). Of equal importance isthe developmental background of a disorder,when symptoms first began, and how it mayhave impacted the child developmentally. Somepeople with longstanding disorders may havefailed to reach important developmental mile-stones, especially in the areas of self-directionand socialization.

DSM-5 incorporates years of research dur-ing which thousands of experts participated inmore than 160 task forces and workgroups overa 12-year period to conduct research field trialsof diagnostic criteria for mental disorders. At the

end of the process, the Board of Trustees of theAmerican Psychiatric Association approved thefinal changes that now constitute DSM-5.According to the APA, all the changes wereintended to more accurately and clearly definethe criteria for mental disorders to ensurediagnostic accuracy and consistency from oneclinician to another (APA, 2013).

Following are some of the most significantchanges inDSM-5.Readers can find a completelist of changes made fromDSM-IV toDSM-5 inDSM-5 Essentials: The Savvy Clinician’s Guide tothe Changes in Criteria (Reichenberg, 2014).

1. Movement to a nonaxial diagnosticsystem (similar to WHO’s InternationalClassification of Diseases) which com-bines all diagnoses together and lists asmany diagnoses as necessary to providethe clinical picture.

2. Better clarification of the not-otherwise-specified (NOS) diagnosticcategories from DSM-IV. Instead ofthe catchall NOS category, cliniciansmay now identify presentations thatare clinically significant but do notmeet the full criteria for a disorder andexplain why the criteria have not beenmet. Or, as in emergency-room pre-sentations, clinicians may report thatinsufficient information is available,and an “unspecified” diagnosis wouldbe given. These two options are nowavailable for all disorders in DSM-5.

3. Reclassification of disorders into adimensional approach rather than thecategorical approach used in DSM-IV.For example, OCD is a new classifi-cation and is located next to anxietydisorders. DSM-5 provides dimen-sional and cross-cutting measures tohelp clarify diagnosis and increase theclinical utility of the manual.

6 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

4. Some categories have taken on a “spec-trum” approach (as in schizophreniaspectrum and other psychotic dis-orders), and may be considered onedisorder with a range of presentations.

5. The separation of some disorders, suchas agoraphobia and panic, from eachother. To provide further diagnosticclarification, panic attack is now alsoconsidered to be a specifier that can beapplied to other disorders as well.

DSM-5 also adopts a developmental andlifespan approach and incorporates disordersthat usually first begin in childhood into thechapters with adult diagnoses. For example,information on anxiety disorders in childrenand adolescents is now included with the anx-iety disorders for adults. The book also beginswith neurodevelopmental disorders, which fre-quently begin in childhood, and works throughdisorders as they occur across the lifespan upto the neurocognitive disorders that generallyoccur in older adults.

Many changes have been made in specificdisorders in DSM-5 as a result of these and otheradvances in our knowledge about mental dis-orders. A dimensional approach to diagnosis ofsubstance use, for example, eliminates the cate-gories of abuse and dependence which were usedinDSM-IV, and now determines diagnosis basedon severity levels. Adjustment disorders, someof the most frequently diagnosed disorders inDSM-IV, are now considered to be a severereaction to a stressful life event and have beenrecategorized as a trauma- or stressor-related dis-order along with PTSD and reactive attachmentdisorder. These, and other changes, will bediscussed throughout this text as we followthe new DSM-5 developmental and lifespanapproach.

For simplicity, and ease of use, Selecting Effec-tive Treatments, 5th ed. (SET-5) will be consistent

with the format of DSM-5 and can be dividedinto three parts:

Section I This section provides basic intro-ductory material, how to use this book,and introduces the Client Map systemof diagnosis and treatment planning.

Section II This section provides the 20 classi-fications of disorders in the same orderas DSM-5.

Section III This section includes an appendixof material from the fourth edition ofthis text to help clinicians with suicideassessment. Extensive author and sub-ject indexes are also included.

OBJECTIVES OF TREATMENT

(DO A CLIENT MAP)Generally, determination of treatment

objectives and goals should be a collaborativeprocess between the therapist and client. Manyvariables must be taken into account includ-ing cost considerations, and individual clientvariables such as readiness for change, clientmotivation, and expectations for treatment.Other client qualities can strengthen or weakentreatment outcomes and should be taken intoaccount when determining treatment goals andobjectives, since they are likely to have an effecton treatment outcome. They include degree ofparticipation in treatment, severity of the dis-order, willingness and ability to take action,and personality characteristics of the client(Muran & Barber, 2010; Prochaska, Norcross,& DiClemente, 2013).

Clients with very low levels of readiness tochange need therapists who can focus on con-sciousness raising, dramatic relief, and environ-mental evaluation.

Resistance to change is not directly con-fronted by the therapist; rather, it is reframed as

Introduction to Effective Treatment Planning 7

ambivalence and the therapist uses his or herskills at creating the Rogerian conditions forchange (empathy, congruence, and uncondi-tional positive regard), setting up the conditionsin which the client can explore both sides ofthe dynamic (Seligman & Reichenberg, 2013).Carl Rogers noted, “significant positive per-sonality change does not occur except in arelationship” (Rogers, 1967, p. 73). Supporting aclient’s readiness for change is the goal of motiva-tional interviewing, a person-centered approachoriginally created byMiller and Rollnick (2013).

Motivational interviewing helps the ther-apist to establish the conditions in whichthe client can choose to change and is oftenused at the beginning of treatment for con-ditions that may be treatment refractory suchas dually diagnosed disorders, eating disor-ders, substance use, and gambling. Therapistswho incorporate motivational interviewinginto their treatment interventions are morelikely to achieve success with ambivalentclients than those who do not (Stasiewicz,Herrman, Nochajski, & Dermen, 2006).

It’s a well-known fact that some peopleimprove simply as a result of having specialattention paid to them (Prochaska & Norcross,2010). This so-called Hawthorne effect canimprove self-esteem, reduce anxiety, and pro-mote improvement.

The client’s readiness to change unfoldsover five distinct stages: (1) precontemplation,(2) contemplation, (3) preparation, (4) action,and (5) maintenance (Prochaska & Norcross,2010). Each stage represents a period of timeduring which certain attitudes, behaviors, andlanguage occur. Aggregate data across studiesand populations found that the client’s readinessto change has a significant impact on whetherthey take action, based on the following:

Precontemplation People in this stage have noplan to change their behaviors, although

they may think about it or wish theycould. To move beyond this stage theymust recognize and admit they have aproblem. Coaching, on the part of thetherapist can help, and roughly 40% to45% of people will move on to the nextstage.

Contemplation During this stage of change,the person readily admits they havea problem and would like to change.Fortunately 35% to 40% of them willtake action toward significant behavioralchanges. Therapists who use Socraticquestioning are likely to encouragefurther action—even a small first step—toward behavioral change.

Preparation During this stage, behavior andintentions are aligned and 20% of peopleare prepared to take action.

Action During the action stage, peoplebegin to modify their behaviors. Thisstage may last from 1 day to 6 months,during which the person is acquiringskills and strategies to prevent relapse.The therapists in the action and main-tenance stages provide expert adviceand support when needed (Prochaskaet al., 2013).

Maintenance Maintaining behavioral changefor longer than 6 months is the hallmarkof the maintenance stage.

The next step in the ClientMap process is anoverview of assessment.

ASSESSMENT

(DO A CLIENT MAP)Much has been written in the past 20 years

about the importance of conducting a com-prehensive, measurable, clinical assessment as anecessary first step in evidence-based practice.

8 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

Over the years, clinicians have come to relyless on projective tests (e.g., TAT, Rohrschach),and become increasingly reliant on assessmenttests that are both psychometrically soundand clinically useful. In other words, they relyon tests that are standardized, reliable, haveconcurrent and predictive validity, and areeither normed or have specific criterion-relatedcutoff scores that make them easier to use inindividual settings (Hunsley, Lee, Wood, &Taylor, 2015). The development in recentyears of brief, focused assessment instrumentsfor specific symptoms and diagnoses has beenhelpful.

Ultimately, the goal of an assessment is thedevelopment of a comprehensive diagnosis andcorresponding treatment plan that is specificto the client’s needs, that is consistent withevidence-based practice, and that will be effec-tive in the treatment of that particular diagnosis.For that to occur, the therapist must first beginwith a thorough understanding of the person.The importance of the ability to truly listen tothe client and to be genuine, supportive, andflexible cannot be overly emphasized. Manyof these clinician traits have been found to bepositively associated with the development ofa strong alliance and successful treatment out-comes. One study found that even during theassessment process, a patient- and therapist-ratedalliance developed and was stronger for thoseusing a collaborative therapeutic model thanfor those receiving psychological testing asusual (Hilsenroth, Peters, & Ackerman, 2004).Therapists should keep this in mind during allstages of treatment, but especially during theinitial assessment process.

Important aspects of the initial intake assess-ment with the client will include data on thefollowing dimensions:

◾ Description of the presenting problem◾ Demographic characteristics and cul-

tural background of the client

◾ Assessment of mental status◾ Physical and medical condition of the

client◾ Therapist’s impression of cognitive

functioning, behavior, affect, and mood◾ Intelligence and executive functioning

(e.g., goal setting, planning, organiza-tional ability)

◾ Family background and support◾ Other relevant history and experiences◾ Daily functioning and quality of life

(assessed through direct observation andself-report)

◾ History of relationships, any interper-sonal problems

◾ Lifestyle◾ Educational and occupational history◾ Family history of psychiatric illness◾ History of prior violent or suicidal

behavior◾ Any other relevant information (Selig-

man, 2004; Strub & Black, 2000).

Clinicians will want to gather and reviewany relevant records, previous assessments (i.e.,psychological tests, medical evaluations), andarrange to obtain releases so they can contactcurrent medical practitioners as part of continu-ity of care.

Increasingly, mental health professionalsare making use of semi-structured diagnosticinterviews, psychological inventories, and ratingscales in the preliminary assessment of clientfunctioning. No single instrument fits all situa-tions, and clinicians must determine what bestsuits their needs, always leaving room, ofcourse, to customize questions to the specificscenario, and leaving a certain amount of flex-ibility to accommodate the client. Therapistsare reminded that fostering a positive thera-peutic alliance is far more important to thedevelopment of a facilitative relationship withthe client than the gathering of specific details.This is never more true than in the initial

Introduction to Effective Treatment Planning 9

sessions when a client may be nervous, fearfulof being judged, or uncertain of what to expectin therapy.

Structured diagnostic interviews include:

◾ Structured Clinical Interview for theDSM-5 (SCID-5; First, Williams, Karg,& Spitzer; 2015)

◾ International Personality DisorderExamination (Loranger, Janca, &Sartorius, 1997) and the SCID-5-PD(First, Williams, Benjamin, & Spitzer)for personality disorders (In Press)

◾ Symptom Checklist-90 Revised (Dero-gatis, 1994)—a 90-item checklist cover-ing 9 symptom clusters

◾ Brief Symptom Inventory (BSI; Dero-gatis & Melisaratos, 1983)—a 53 itemself-report based on the SCL-90-R; eas-ily administered in less than 10 minutes)

◾ Schedule for Affective Disorders andSchizophrenia (SADS; Endicott &Spitzer, 1978)

General personality inventories include:

◾ Millon Clinical Multiaxial Inventory-III(Millon, Millon, Davis, & Grossman,2009)

◾ Minnesota Multiphasic PersonalityInventory-2 (MMPI-2; Hathaway &McKinley, 1989)

Scales to assess suicidal ideation:

◾ Scale for Suicidal Ideation (SSI; Beck,Steer, & Ranieri, 1988)—a 21-itemrating scale that assesses suicidality.

◾ Beck Scale for Suicide Ideation (BSI;Beck & Steer, 1991)—a 21-item self-report.

Disorder-specific inventories are often usedfor diagnosis to determine the severity and fre-quency of symptoms, and as a baseline for future

measurement. Assessments specific to each diag-nosis are listed in the appropriate chapters. Someof the most commonly used include:

◾ Beck Depression Inventory (Beck,Steer, & Brown, 1996)

◾ Beck Anxiety Inventory (Beck & Steer,1990)

◾ Michigan Alcoholism Screening Test(Selzer, 1971)

◾ Conners 3rd ed. (Conners 3; Conners,2015)

◾ Behavioral Assessment System forChildren–2 (BASC-2; Reynolds &Kamphaus, 2002)

◾ Eating Disorder Examination, 16th ed.(EDE; Fairburn, 2008)

◾ Drug Abuse Screening Test (Skinner,1982)

Some measures and scales are included inDSM-5 to help with the information-gatheringprocess. Emerging measures found in SectionIII of DSM-5 (APA, 2013) can help to pro-vide cross-cutting symptom measures to aid indiagnosis; disorder-specific severity measures toassess severity, frequency, intensity, and dura-tion of symptoms for specific disorders (e.g., fordepression, PTSD); ratings of home backgroundand early childhood development; and culturalformulation interviews. These cross-cuttingtools do not have enough scientific evidencefor support but are designed to stimulate futureresearch. Clinicians can link into the eHRS(electronic health records) for more complexassessments of symptoms (APA, 2013, p. 745).

The World Health Organization Dis-ability Assessment Schedule 2.0 (WHODAS2.0) (Üstün, Kostanjsek, Chatterji, & Rehm,2010) is a 36-item self-report that provides auseful assessment scale that can be helpful intracking treatment progress. Other inventoriesand scales are also useful to assess different as-pects of the person, including intelligence,

10 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

aptitude, achievement, interests, values, andcareer aspirations.

Assessment is an important componentof treatment planning and should be under-taken with care. Effective treatment planning isunlikely unless the clinician has made an accu-rate and comprehensive diagnosis and has agood grasp of the client’s needs and strengths.This can only be acquired by taking the timeto conduct a thorough, careful diagnosticassessment.

Throughout this book assessment measureswill be discussed for each disorder, when suchmeasures are available.

CLINICIAN CHARACTERISTICS

(DO A CLIENT MAP)The therapeutic alliance—the quality of

the bond between the client and therapist andhow well they are able to work together tobring about therapeutic change—is the bestpredictor of treatment outcome (Horvath &Symonds, 1991). Individual differences betweentherapists are strongly predictive of the alliancequality (Laska, Smith, Wislocki, Minami, &Wampold, 2013).

A meta-analysis that looked at the role ofthe therapeutic alliance found that it accountedfor 8% of the variance in treatment outcomes(Horvath, Del Re, Flückiger, & Symonds,2011). Another meta-analysis of nearly 70studies confirms the effect of the therapist onthe alliance is a significant predictor of treat-ment outcome (Del Re, Flückiger, Horvath,Symonds, & Wampold, 2012) and this cor-relation may be underestimated in the litera-ture (Crits-Christoph, Connolly Gibbons,Hamilton et al., 2011). The establishmentof a collaborative relationship between thetherapist and client refers not only to thebond between them but also to their ability to

establish and agree on the goals of treatment(Hatcher, Barends, Hansell, & Gutfreund, 1995;Hatcher & Barends, 1996, 2006; Horvath &Bedi, 2002).

More than 50 years of research has provideda good deal of evidence on the characteristics,attitudes, and approaches on the part of thetherapist that are correlated with treatmentoutcomes. We have also learned which onesare not important. Gender, age, and culturalbackground, for instance, have little influenceon treatment success. Therapists who ratehigher on the Rogerian conditions of empa-thy, congruence, and unconditional positiveregard tend to develop better therapeuticalliances and have more successful outcomesthan those who rank lower. This is true re-gardless of the therapist’s theoretical orientation(Zuroff, Kelly, Leybman, Blatt, & Wampold,2010).

The stability of the alliance is also impor-tant; therefore any ruptures that occur must berecognized and repaired by the therapist beforethey become breaks. Ruptures may include mis-understandings between the therapist and clientor any feelings on the part of the client of beingcriticized, patronized, or unsupported; basicallyany feeling that raises concerns in the client’smind about the trustworthiness, sensitivity, orempathy on the part of the therapist can be con-sidered to be a potential rupture. The therapistaddresses such concerns as they arise and makes aconcerted effort to reassure the client and restorethe therapeutic alliance.

Of course, clients will vary in their abilityto form a therapeutic alliance. Those with moresevere mental disorders (e.g., schizophreniaspectrum, bipolar, severe personality disorders),those who cannot trust, and those with moresevere childhood attachment wounds may needadditional supportive therapy in order to beable to develop a positive alliance with thetherapist. In either case—whether a rupture

Introduction to Effective Treatment Planning 11

occurs or when a client has difficulty estab-lishing a trusting relationship—the therapistmust slow the pace of therapy, respond withempathy, address what is going on in the roomwith genuine concern and unconditional posi-tive regard—the foundation on which therapyis built.

It is only by actively working to maintainthe therapeutic alliance that people with severedisorders or substance abuse problems will stayin treatment and get the help they need to over-come their problems.

Other therapist variables also affect out-comes. Therapists who are emotionally healthythemselves and who are active, hopeful, opti-mistic, nonjudgmental, straightforward and yetencouraging of responsibility on the part of theclient are the most likely to achieve a positiveoutcome. Following are some of the researchfindings related to therapist attributes that helpto create and maintain a positive therapeuticalliance:

◾ Communicating empathy and under-standing

◾ Maintaining high ethical standards◾ Having strong interpersonal skills; com-

municating support, warmth, caringrespect, acceptance

◾ A reassuring and protecting attitude◾ Affirming rather than blaming clients◾ Being able to help the client access and

tolerate emotion◾ Empowering clients and supporting

their autonomy◾ Being open-minded and flexible◾ Being nonjudgmental and tolerant of

ambiguity and complexity◾ Modeling mentally healthy qualities of

self-actualization, self-fulfillment, self-development, and being able to copewith their own stress

◾ Being authentic, genuine, credible

◾ Expressing optimism and hope◾ Being culturally competent◾ Being actively engaged with and recep-

tive to clients◾ Giving some structure and focus to the

treatment process, but not being overlydirective

◾ Being authoritative but not authoritar-ian, and freeing rather than controllingof clients

◾ Being nondefensive; being aware oftheir own limitations, having a capacityfor self-criticism, always looking for thebest way to help clients

◾ Focusing on people and processes, notrules

◾ And most importantly, establishing apositive therapeutic alliance early on,and then attending to the alliance atevery stage of treatment; addressingruptures as they occur; and managingnegative processes effectively (Bowman,Scogin, Floyd, & McKendree-Smith,2001; Greenberg, Watson, Elliott, &Bohart, 2001; Lambert & Barley, 2001;Lambert & Cattani-Thompson, 1996;Meyer et al., 2002; Muran & Barber,2010; Orlinsky, Grawe, & Parks, 1994;Rimondini et al., 2010)

It should go without saying that the relation-ship between therapist and client is a professionalone. Boundaries are set that are not to be bro-ken. Clients come to therapy vulnerable and inneed of support, and therapists are responsiblefor maintaining high ethical standards.

Several meta-analyses confirm that a qualityalliance is more predictive of positive out-comes than the type of intervention used(Karver, Handelsman, Fields, & Bickman, 2006;Martin, Garske, & Davis, 2000; Shirk & Karver,2003). Therapists can learn to improve theiralliance-building behaviors through training,

12 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

supervision, and by increasing their responsive-ness with their clients (Anderson, Lunnen, &Ogles, 2010; Stiles, 2009).

Careful handling of alliance ruptures alsoprovides the client with the chance to learn inthe here-and-now of the therapy session howto relate to others and address concerns in aproductive manner. This can be used outside oftherapy in their relationships with others (Stileset al., 2004).

Little research is available on the relation-ship between therapist experience and treatmentoutcome. What research is available is inconclu-sive. Some research indicates that having moreexperience does not guarantee a better workingalliance (Hersoug, Hoglend, Monsen, & Havlik,2001), and two studies found expertise to bemore important than theoretical orientation(Eells, Lombart, Kendjelic, Turner, & Lucas,2005). To date, other therapist variables, suchas the amount of the therapist’s training, theamount of professional expertise, or the thera-pist’s professional discipline (e.g., psychologist,counselor, social worker) have not been foundto be related to treatment outcomes. One earlystudy (Berman & Norton, 1985) found thatprofessionals and paraprofessionals were equallyeffective.

Therapist demographic variables such asgender, race, and religion, and clinical expertisehave not been found to be related to therapeuticoutcome (Bowman et al., 2001; Wampold &Brown, 2005). A meta-analytic review of morethan 60 studies on therapist gender showedthat gender had no effect on treatment out-comes (Bowman et al., 2001), or drop-out rates(Cottone, Drucker, & Javier, 2003). However, itshould be noted that the gender of the therapistmay be important to some clients. Even if gen-der matching does not lead to improved out-comes, it may enhance the therapeutic alliance

to honor such requests and may be worthconsidering.

Therapist age, when linked to therapist’sinterpersonal skills, had a significant effect ontreatment outcomes in one study by Andersonand colleagues (2009). Clients seem to prefer atherapist who is old enough to understand theclient’s age-related and developmental issues,and who is mature enough to have sufficientexperience, but not so old as to have outmodedideas or beliefs about treatment.

Therapists must also be aware of how theirown worldviews and those of their clientsshape their experiences and assumptions. Everyperson, therapist and client alike, will have avariety of dimensions in which they identifythemselves (e.g., age, gender, race). Therapistsmust be culturally competent in their work withclients, recognizing that everyone is unique andwill have experiences and backgrounds thatdiffer from their own in one or more ways. Themnemonic ADDRESSING can be a good wayto remember the wide range of social “loca-tions” that we all come from. ADDRESSINGstands for Age, Disability (acquired), Disabil-ity (developmental), Religion and spirituality,Ethnicity, Socioeconomic status, Sexual orien-tation, Indigenous heritage, National origin,Gender/sex (Hays, 2001, 2008). Understand-ing a person’s culture can be as important asknowing their family background and can maketreatment more effective (Hays, 2009; Schnyder,2009).

Therapists should also be aware of any per-sonal traits, such as being too critical or demand-ing, that might detract from the development ofa solid working alliance. Defensiveness, excessiveuse of techniques, and over- or understructuringsessions can all interfere with the developmentof a therapeutic alliance (Sharpless, Muran, &Barber, 2010).

Introduction to Effective Treatment Planning 13

LOCATION OF TREATMENT

(DO A CLIENT MAP)In 2012, 34.1 million adults in the United

States (14.5% of the population) reported hav-ing used some type of mental health treatmentor counseling in the previous 12 months. Ofthose people, 12.4% used prescription medica-tions, 6.6% sought counseling or other outpa-tient mental health services, and 0.8% used inpa-tient hospitalization (SAMHSA, 2013).

The setting in which mental health treat-ment is provided varies between inpatient andoutpatient programs. In general, the treatmentlocation will be determined by the followingconsiderations:

1. The danger that the client poses to selfor others

2. Diagnosis, and nature and severity ofsymptoms

3. Goals and objectives of treatment4. Cost of treatment and consideration

of insurance coverage and the client’sfinancial resources

5. Client’s current living situation andsupport systems

6. Nature and effectiveness of prior treat-ment

7. Client preferences (Seligman, 2004)

The least restrictive setting that providesoptimal care for the person’s needs and thedisorder is often the best choice. If the settinglacks resources the person needs or is overlyrestrictive, it may not be therapeutic. Managedcare may also require the use of the most cost-effective treatment, for example, requiring thatoutpatient treatment for substance abuse isconsidered before inpatient treatment will beconsidered.

Determining the best treatment placementfor an adult, adolescent, or a child requiresweighing a variety of complicated and interre-lated factors. Often the decision is made basedon insurance coverage and other financial con-siderations. Options typically include residentialtreatment, inpatient hospitalization, partialhospitalization program (PHP), or outpatienttreatment. The research literature provides littleguidance, so decisions must be made based onsound clinical judgment. A brief description ofeach follows.

Residential Treatment

Residential treatment programs are often con-sidered for those with severe eating disorders(e.g., anorexia), chronic substance use disor-ders that have not responded to outpatienttreatments, and those who require additionalintensive treatment following inpatient psy-chiatric care. Children and adolescents withserious emotional and behavior problems maybe placed in residential treatment so they canreceive 24-hour supervision and monitoring bytrained staff. Often, educational requirementswill be maintained. Placement in a residentialtreatment program is usually for an extendedperiod of time.

Inpatient Hospitalization

Hospitalization for treatment of mental healthissues is usually required in crisis situations,when clients need to be closely monitoredand when helping to adjust or stabilizethe client’s medications. Inpatient hospital-ization is significantly shorter than residentialtreatment and may range from overnight to lessthan a few weeks in most cases. The average

14 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

length of an inpatient hospitalization for mentaldisorders was 7.2 days (Centers for DiseaseControl, 2010). Inpatient hospitalization maybe appropriate for people who are a danger tothemselves or others, as when suicidal or homi-cidal ideation is present. Treatment programsare usually highly structured. Patients are likelyto be discharged from the hospital to a lessrestrictive setting such as a PHP or outpatienttreatment as soon as practicable.

Partial Hospitalization Programs (PHPs)

PHPs and day-treatment programs are highlystructured programs focused on the specificneeds of the client (e.g., substance use, depres-sion, dual diagnosis, eating disorders). Theseprograms allow people to live at home whileattending treatment during the day. PHPs oftenserve as transitional treatment from residentialor hospitalization programs. Day treatment canbe an effective and less costly option for peoplewho do not need 24-hour care. “Stepped-down” half-day programs, or weekly groupmeetings that help to maintain treatment gainsusually follow PHP programs. Limited researchshows that day treatment is beneficial forthe treatment of psychosis, mood disorders,anxiety disorders, and borderline personalitydisorder (Lariviere, Desrosiers, Tousignant, &Boyer, 2010). Preliminary research specific toadolescents with a mood disorder found thePHP program decreased symptom severity andwas considered by the adolescents to be anacceptable form of treatment (Lenz, Del Conte,Lancaster et al., 2013). PHP treatment alsoreduces costs to third-party and private payers(Garfield et al., 2010).

Outpatient Treatment

The majority of treatment for mental healthdisorders takes place in outpatient settings that

include private practice, community mentalhealth centers, and agencies that focus on spe-cific populations or problems (e.g., domesticviolence, children, multicultural, suicide preven-tion). According to 2012 statistics, of those whosought outpatient treatment for a major depres-sive episode, the majority of people (58.5%) didso at their physician’s office. More than 34% sawa psychiatrist or psychotherapist; 24.6% wentto a counselor’s office; 24.3% saw a psycholo-gist, 19% sought religious or spiritual advice;11.6 % saw another medical doctor, 11.4% wentto a social worker, and 7% saw another mentalhealth professional (SAMHSA, 2013).

INTERVENTIONS

(DO A CLIENT MAP)The growing number of psychosocial

options for the treatment of mental healthdisorders create new possibilities for millions ofpeople. Currently, more than 400 different non-medication-related treatment interventions areknown to exist, and many more are evolving.New technology-assisted treatment deliverymethods are making it possible for more peoplethan ever before to receive treatment, even thosewho cannot leave their own homes.

New mindfulness- and acceptance-basedapproaches are helping people to control rumi-nation, anxiety, and depression, and manytherapists are moving toward transdiagnostictreatment approaches that focus on relatedsymptoms rather than theoretical orientation.

Each of these new modes of treatmentprovides additional options for more special-ized treatment geared exclusively to the clientexperiencing a specific disorder.

More and more frequently, therapists aresaying “I was trained in X, Y, or Z approach, butnow I have expanded into CBT, mindfulness,existential, or interpersonal therapy.” Many

Introduction to Effective Treatment Planning 15

prefer to work together with the client to estab-lish a solid working relationship in which theycan collaboratively determine what approachwill work best.

In the 1980s, much was revealed about theimportance of the therapeutic alliance in the cre-ation of evidence-based treatments. Then cameresearch on common factors that are found in allsuccessful therapies, regardless of the diagnosis,such as the therapeutic alliance, client motiva-tion, therapist skill, and the effect of the col-laborative relationship on treatment success. Itis becoming more and more difficult to advo-cate for one theoretical orientation or treatmentmodality, as the research begins to make clearthat most treatments are effective, if certain con-ditions are met. One of the most widely studiedcommon factors is the therapeutic alliance. Thatthe strength of the alliance is related to treat-ment outcome has been verified over the yearsin numerous studies and meta-analyses (Del Reet al., 2012; Gaudiano, Dalrymple,Weinstock, &Lohr, 2015; Martin et al., 2000).

Today, the experienced therapist, knowl-edgeable in evidence-based practice, knows thefollowing truths:

◾ The alliance is responsible for a largepart of the success of therapy.

◾ The alliance consists of the therapistand the client, and the relationship thatdevelops between them.

◾ Some treatments are evidence-based foruse with certain disorders (e.g. exposuretherapy for specific phobias; dialecticalbehavior therapy [DBT] for borderlinepersonality disorder).

With case formulation providing the foun-dation, treatment recommendations should firstconsider evidence-based treatments that areavailable (Chorpita, Daleiden, & Weisz, 2005).A wealth of treatment intervention options are

available, and setting goals and objectives fortreatment should be a collaborative exercisewith the therapist providing the expertise abouttreatment recommendations, while being flex-ible enough to tweak the recommendations tothe needs of the client. In some cases, comor-bid disorders will need to be addressed beforetreatment can begin in earnest. For others,relationship issues, emotional dysregulation, orsymptoms of personality disorders may need tobe addressed.

Empirically Supported Treatments

The American Psychological Association begantracking empirically supported treatments(ESTs) in 1993 through its Division of ClinicalPsychology. In 1995, the first list of ESTs wascreated that met the criteria for different levels ofsupport. “Well-established treatment” requireseither of the following: (1) two randomizedtrials that demonstrated efficacy compared witha placebo or another established treatment or (2)a large series of single-case design experiments.“Probably efficacious treatment” has fewerrestrictions.

American Psychological Association’s Pres-idential Task Force on Evidence-Based Practice(2006) established a website listing the bestavailable research evidence which, when com-bined with clinical expertise of the therapist,and client characteristics and values, providesthe best evidence-based practices available. Thelist can be sorted by disorder or by 75 treatmentsthat have met the criteria for empirically sup-ported treatment. When the Division 12 TaskForce published its first list of ESTs in 1995,only 18 treatments were identified as havingempirical support; today there are over 75, manyof them with well-established research support.

Many of the research-supported psycho-logical treatments (e.g., social skills trainingfor schizophrenia and stress inoculation

16 SE L E C T I N G E F F E C T I V E TR E ATM E N T S

training), have become standards in mosttherapist’s repertoire. Other ESTs are treatmentsrecently added, such as acceptance and commit-ment therapy for chronic pain, CBT for socialanxiety, and prolonged exposure for PTSD.Some of the other ESTs are listed here. Thecomplete list is available online at www.div12.org, along with information on clinical trials,bonus material, and links to training manualsand interactive content.

◾ Acceptance and commitment therapyfor chronic pain, depression, mixedanxiety, psychosis, and OCD

◾ Cognitive behavioral therapy forADHD, eating disorders, generalizedanxiety disorder (GAD), specific pho-bias, social anxiety, panic-disorder,schizophrenia, and PTSD

◾ Behavioral couples therapy for alcoholuse disorders and depression

◾ Dialectical behavior therapy for border-line personality disorder

◾ Eye movement desensitization and re-processing (EMDR) for PTSD

◾ Emotion-focused therapy for depression◾ Family-focused therapy for bipolar

disorder◾ Family-based treatments for anorexia

and bulimia nervosa◾ Interpersonal therapy for binge-eating

disorder, bulimia nervosa, and depression◾ Exposure and response prevention

(E/RP) for OCD◾ Exposure therapies for specific phobias◾ Schema-focused therapy for borderline

personality disorder◾ Social learning/token economy pro-

grams for schizophrenia◾ Social skills training for schizophrenia◾ Supported employment for schizo-

phrenia

The American Psychological Asso-ciation’s Division 53 maintains a list ofevidence-supported treatments for childrenand adolescents. The most well established are:

◾ CBT and interpersonal psychotherapy(IPT) for depression

◾ Behavior therapy for ADHD and autismspectrum disorders

◾ Family therapy for eating disorders◾ Trauma-focused CBT for anxiety◾ Parent management training for opposi-

tional defiant disorder and conduct dis-order

The website (effectivechildtherapy.org)contains other promising treatments and is up-dated on a regular basis as a community serviceto the public.

Other resources for evidence-based treat-ments include the National Institute for Healthand Clinical Excellence (NICE) and theNational Registry of Evidence-Based Programsand Practices (NREPP). Each of these organi-zations is listed in the resources section at theend of this chapter.

Although ESTs have been identified formany disorders, a comprehensive list of effectivetreatments for every disorder does not exist.In some cases, several different treatments havebeen found to be effective (as is the case withanxiety and mood disorders, schizophrenia, andborderline personality disorder). In other cases,no treatment approaches have received strongresearch support. In this text, the focus is pri-marily on what treatment interventions areefficacious and offer the best treatment optionsfor clients. When that research is not available,case reports in the literature can help to providesome guidance, as can related treatments fromsimilar disorders be used to extrapolate potentialoutcomes. The interventions section for each