Research Are You Getting Exposure Therapy? Just Testing The Grounds...

[PTSD sufferer]

I have a list of very interesting, eye-opening research articles on this subject that might interest you.

Would love to see your eye-opening research!

We don't want to go to the other extreme, and have organisations like the APS keep close surveillance through video tapes or audio transcripts, of everything clinical psychologists do.

I think that this would also negate the client privilege relationship that is required. How is anyone able to talk about their 'issues' if they know they are under surveillance - even if it is the therapist and not the patient being monitored (could you imagine a DD or PD patient in the scenerio? :eek::D). I think that legally as well as psychologically such an idea would be quite dangerous. It opens too many cans of worms to go to that extreme....

The other possible monitoring option is peer reviews of patient case files. It helps the therapist to discuss issues within peer settings, and peers can then flag up any concerns about the patient health and progress. A cross-pollination type approach, such as used by my Psychiatrist and Psychologist, where they sit down with some peers and discuss my case and the progress. The point is, surely there is a different approach that can be applied to self-regulate, particularly where therapists are not independent contractors. Like an audit scenario of patient files and progress, and timescale to remission.

Where there are concerns from the patient, these can be addressed through complaints systems and professional bodies. But unfortunately, patients can be labelled in such a way (damn that stigma) that complaints can be dismissed. Maybe requirements of investigation of complaints should be given more weight in these situations. There are psychology and law associations in Australia, but most focus on getting the psychologists out of trouble than about assisting patient complaints. Too often it requires a whistle blower, if there is a problem in the industry.

As far as Psychotherapy (counselling) is concerned, there is a professional body for psychotherapists in Australia (PACFA??), but this is a not-for-profit professional association concerned with self regulation of the profession. There is no Law or Constitution regulating, Psychotherapists - as opposed to Psychologists and Psychiatrists who are regulated. However, with PACFA (?) and Psychotherapy, some of the policies they have as far as minimum clinical hours of monitoring required to be a member, are ok. Although, again, the trust issue goes out the window when you bring an observer into the room with a PTSD patient....

....tough one isn't it.....I am sure there is a better solution but finding it would probably require a bunch of experts sitting down and brainstorm an a few ideas, asking patients about the impact of these ideas on them, and then trialing and revising the best ideas of the bunch....personally, I think that we won't find a 'suitable' solution to this...

....I ramble sometimes...sorry :p

 

[Nicolas Connault]

Here are some references I have gathered. Please let me know if you'd like to read the full article (send me a Private Message).

Becker, C. B., C. Zayfert, et al. (2004). "A survey of psychologists' attitudes towards and utilization of exposure therapy for PTSD." Behaviour Research and Therapy 42(3): 277-292.
Although research supports the efficacy of exposure therapy for PTSD, some evidence suggests that exposure is under-utilized in general clinical practice. The purpose of this study was to assess licensed psychologists' use of imaginal exposure for PTSD and to investigate perceived barriers to its implementation. A total of 852 psychologists from three states were randomly selected and surveyed. An additional 50 members of a trauma special interest group of a national behavior therapy organization were also surveyed. The main survey results indicate that a large majority of licensed doctoral level psychologists do not report use of exposure therapy to treat patients with PTSD. Although approximately half of the main study sample reported that they were at least somewhat familiar with exposure for PTSD, only a small minority used it to treat PTSD in their clinical practice. Even among psychologists with strong interest and training in behavioral treatment for PTSD, exposure therapy is not completely accepted or widely used. Clinicians also appear to perceive a significant number of barriers to implementing exposure.

Craig, C. D. and G. Sprang (2010). "Factors associated with the use of evidence-based practices to treat psychological trauma by psychotherapists with trauma treatment expertise." Journal of Evidence-Based Social Work 7(5): 488-509.
This paper investigates 10 socio-demographic and case characteristic variables as predictors of use of evidence-based practice and non-evidence-based practice in the treatment of psychological trauma. A national random sample of 2,400 trauma treatment specialists in all 50 states and the District of Columbia were sent surveys with a response rate of 29.6% (N = 711) usable surveys returned. Stepwise regressions conducted on evidence-based practice use indicated that special trauma training, older age, and higher percentage of PTSD on the case load were the only significant predictors of evidence-based practice use. Implications for trauma practices are indicated.

Jaeger, J. A., A. Echiverri, et al. (2009). "Factors associated with choice of exposure therapy for PTSD." International Journal of Behavioral Consultation and Therapy 5(3): 294-310.
Exposure therapy, despite its demonstrated efficacy for chronic PTSD, remains underutilized across clinical settings. One suggested cause is that traumatized clients may not prefer exposure treatment. This paper reviews the current literature on factors associated with treatment preference for exposure therapy. Contrary to expectations, exposure-based therapy is not only perceived as a viable therapy but is well regarded amon current therapy choices by potential clients. In particular, we highlight the central role of client beliefs about the need to talk about problems, the efficacy of treatment, and perceived need for help as crucial factors potentially impacting preference for exposure therapy. Importantly, fear of exposure treatment does not appear to play a significant role. To increase utilization, clinicians should provide clients information to address factors believed to increase preference for effective treatment.

Stobie, B., T. Taylor, et al. (2007). "“Contents may vary”: A pilot study of treatment histories of OCD patients." Behavioural and Cognitive Psychotherapy 35(03): 273-282.
Definitions of treatment failure and the labelling of patients as non-responsive typically require treatments to have been offered and failed. For pharmacological treatments, treatment quality is relatively easy to define; this is much more difficult with psychological treatments. This study examined patient recollections of previous therapy for obsessive compulsive disorder (OCD). A Treatment History Questionnaire was administered to a sample of 57 apparently treatment refractory OCD patients from a specialist national OCD treatment unit and a national charity for OCD sufferers. On average, respondents reported an 8 and half year wait between the obsessional symptoms interfering significantly with their lives and being diagnosed. Forty-three percent recalled having received either cognitive behaviour therapy (CBT) or behaviour therapy as the first treatment; 31% of the group did not know what type of therapy they had received. The components of therapy that respondents recalled were analysed and contrasted with minimal therapy criteria. These criteria appear not to have been met in most patients who understood that they had received “CBT”. The implications of this study for assessment of treatment integrity and the classification of patients as “treatment resistant” are discussed.

Waller, G. (2009). "Evidence-based treatment and therapist drift." Behaviour Research and Therapy 47(2): 119-127.
Cognitive-behavioural therapy (CBT) has a wide-ranging empirical base, supporting its place as the evidence-based treatment of choice for the majority of psychological disorders. However, many clinicians feel that it is not appropriate for their patients, and that it is not effective in real life-settings (despite evidence to the contrary). This paper addresses the contribution that we as clinicians make to CBT going wrong. It considers the evidence that we are poor at implementing the full range of tasks that are necessary for CBT to be effective – particularly behavioural change. Therapist drift is a common phenomenon, and usually involves a shift from ‘doing therapies’ to ‘talking therapies’. It is argued that the reason for this drift away from key tasks centres on our cognitive distortions, emotional reactions, and use of safety behaviours. A series of cases is outlined in order to identify common errors in clinical practice that impede CBT (and that can make the patient worse, rather than better). The principles behind each case are considered, along with potential solutions that can get us re-focused on the key tasks of CBT.

Cook, J. M., P. P. Schnurr, et al. (2004). "Bridging the gap between posttraumatic stress disorder research and clinical practice: The example of exposure therapy." Psychotherapy: Theory, Research, Practice, Learning 41(4): 374-387.
There are notable challenges in translating empirically supported psychosocial treatments (ESTs) into general routine clinical practice. However, there may be additional unique dissemination and implementation obstacles for ESTs for trauma-related disorders. For example, despite considerable evidence from randomized clinical trials that attests to the efficacy of exposure therapy for posttraumatic stress disorder, front-line clinicians in real-world settings rarely use this treatment. Perceived and actual barriers that interfere with adoption include clinician misconceptions about what exposure entails and complex cases to which ESTs may not be readily applicable. Specific suggestions for bridging the science-into-service gap in trauma ESTs (in general) and in exposure therapy (in particular) are proposed

Shafran, R., D. M. Clark, et al. (2009). "Mind the gap: Improving the dissemination of CBT." Behaviour Research and Therapy 47(11): 902-909.
Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.

Westen, D., C. M. Novotny, et al. (2004). "The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials." Psychological Bulletin 130(4): 631-663.
This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.

 

[anthony]

I understand that VETs may be missing out on CBT Anthony, but is that because DVA is ill equip (still) to address PTSD? Maybe its DVA cutting corners on VET care, by not demanding qualified CBT trained psychologists?

Not in Australia, not with veterans. Veterans with recognised and accepted PTSD have unlimited access to any range of mental health care they want. The limit is them, nothing else. If they wanted to see a shrink once weekly, they can. The majority of veterans I know just won't go near mental health professionals, even though they're quite ill. They don't care about the card they have, they just refuse to seek treatment typically.

Actually, there is zero difference in therapeutic methods regardless the persons training, from counsellor to social worker, nurse, GP, psychologist or psychiatrist, the actual content and learning of psychotherapeutic techniques do not differentiate between qualification levels. There are other facets uniquely within each qualification tailored to the role of that qualification.

If you learn prolonged exposure, you learn prolonged exposure, period. If you learn cognitive trauma therapy, you learn CTT, period.

The difference is obvious with psychiatrists, being a medical doctor. Nurses obviously have extensive medical training as well, though they still do therapeutic techniques.

Psychologist is an additional 12 month course here in Australia, post grad. Nicolas could clarify that, as I believe he is a minor in psychology, as his primary degree is in computing if I am correct! Yes, I do my research to ensure validy Nicolas.

You can be a psychologist, social worker or counsellor, all in 3 years. All 3 are near identical in subjects. You need a further 3 years practicable experience to be a licensed psychologist, I believe the training is here, OR, you can do a masters, taking another 3 years in university, and leave as a licensed psychologist. You can be a counsellor or social worker in 3 years, then do a post grad 12 months to hold psychology as well.

I believe all psychologists can diagnose, but only a licensed psychologist can prescribe! Clarify please Nicolas? Or do you need to be a licensed psychologist to diagnose as well?

A counsellor cannot, nor a social worker to my knowledge. A nurse actually has more qualifications than all 3, yet they also cannot diagnose to my knowledge unless you hold a psychology.

There are other facets as well, like you must be a psychologist, or licensed psychologist (one or the other) to be able to perform EMDR. I know there are rules surrounding who can become an EMDR practitioner from all the associated degrees.

It doesn't matter what profession you assume here, all therapeutic training is delivered the same, the therapies don't change, regardless your qualification.

You could take five people off the street, train them all with CBT basic therapies, being the cognitive, exposure and stress management therapies, and then send a group of people to them, all experiencing all five.

Every person will experience a different delivery of each therapy, even though you taught 5 people the same thing, because there are five different personalities delivering those therapies, all putting their own unique personality into the therapy.

Education level has zero to do with the majority of therapeutic deliveries. They don't change across qualifications.

Its all about the person delivering the therapy and the experience they have.

DVA for example, have a range of counsellors, social workers, nurses and psychologists, all of whom do the same roles in counselling veterans. Its like any therapy, you have to find the right therapist for the right client... when you get that right, you typically get a good result at the end.

As for regulation... yes, counsellors here don't have to be licensed, however; if they are charging for a service they still must comply with relevant laws, have relevant insurances by law, etc etc. But yes, I don't believe they have a licensing board like licensed psychologists do.

PTSD is not outside of the treatment regime for all mentions above, however; if the person has suspected more severe issues, ie. personality disorders and such, then a psychologist / psychiatrist are the people to handle such things here.

I believe the laws here are quite clear with roles, and that is simply if the person has something outside your scope of abilities, then you refer them to the person who can handle the matter. If you continue to treat someone for something you don't have the ability to treat, then you are in breach of laws here and could get spanked hard.

Nicolas could no doubt put more clarity on that though... being a psychologist.

 

[Nicolas Connault]

Wow, so much to answer in this post :)

Actually, there is zero difference in therapeutic methods regardless the persons training, from counsellor to social worker, nurse, GP, psychologist or psychiatrist, the actual content and learning of psychotherapeutic techniques do not differentiate between qualification levels.

That's correct, but longer (and more effective) education leads to a deeper understanding of theory, which can help in clinical decision-making. This is not a given though, just a factor that has some influence.

Nicolas could clarify that, as I believe he is a minor in psychology, as he has primary degree is in computing if I am correct! Yes, I do my research to ensure validy Nicolas.

I don't have any qualification in computing, I'm 100% self-taught, although it has been my main bread-winner for the past 6 years. I do have a 4-year undergraduate degree in psychology, though, graduated with first-class honours last year (still trying to get my research published!).

You can be a psychologist, social worker or counsellor, all in 3 years. All 3 are near identical in subjects. You need a further 3 years practicable experience to be a licensed psychologist, I believe the training is here, OR, you can do a masters, taking another 3 years in university, and leave as a licensed psychologist.

That's not entirely accurate. Here is the breakdown as I understand it:

What you call "licensed" in Australia is the appellation "psychologist". You don't need to do any qualification whatsoever to call yourself a counsellor, and you can do anything you want as a counsellor (and many do!), including CBT, hypnotherapy, or psychoanalysis. The 3-year undergraduate degree with an APAC-certified course (major in psychology) is required only as a prerequisite for the 4th "honours" year, which is like an extension to the undergraduate degree, and required for entry in post-graduate programmes.

So, once you've got your 4 years under your belt, you still have zero experience with real clients, everything you've learned has been from textbooks. You're basically useless as a therapist, you've got no training in any therapeutic technique whatsoever, you haven't even started uncovering your own psychological issues that need to get sorted before you can help other people.

After the 4th year, you need a minimum of an extra 2 years in a Masters program (in one of the branches of psychology like clinical, counselling, forensic etc.), which is the official "hands-on" training, with actual experience with real clients. That's the training for becoming a psychologist. Once you've finished that, you can register as a psychologist and officially call yourself a psychologist. But you need 2 years of practice under supervision if you want to call yourself a "clinical" or "counselling" (or whatever) psychologist. That's called an "endorsement", and you can have several of them. It's a bit like a specialist title, showing that you have extra experience in a particular broad domain of psychology.

No psychologist or counsellor of ANY kind in Australia is allowed to prescribe medications. This is the sole domain of psychiatrists (and maybe psychiatric nurses but I doubt it).

I believe all psychologists can diagnose, but only a licensed psychologist can prescribe! Clarify please Nicolas? A counsellor cannot, nor a social worker to my knowledge. A nurse actually has more qualifications than all 3, yet they also cannot diagnose to my knowledge unless you hold a degree in psychology.

There are other facets as well, like you must be a psychologist, or licensed psychologist (one or the other) to be able to perform EMDR.

Anyone who has a copy of the DSM or ICD-10 can diagnose, it's not regulated in Australia. However, whether this diagnosis will hold in a court of law, or as valid documentation for Centrelink pension payments, depends a whole lot on the therapist's qualifications and experience (and ability to write a coherent report!). This is an important distinction. Some people self-diagnose but it doesn't help them get the financial help they need :)

Education level has zero to do with the majority of therapeutic deliveries. They don't change across qualifications.

Its all about the person delivering the therapy and the experience they have.

DVA for example, have a range of counsellors, social workers, nurses and psychologists, all of whom do the same roles in counselling veterans. Its like any therapy, you have to find the right therapist for the right client... when you get that right, you typically get a good result at the end.

This is currently a point of debate. I think it's mostly true, but education level and experience do play some part, just not as much as getting "the right therapist" for the right client.

 

[Nicolas Connault]

Actually I just remembered that I took a minor in computing as part of my bachelor's degree in psychology :-) But I didn't learn very much, it was just to get easy credits!

 

[anthony]

I'm 100% self-taught, although it has been my main bread-winner for the past 6 years. I do have a 4-year undergraduate degree in psychology, though, graduated with first-class honours last year (still trying to get my research published!).

Ah... that clarifies that one. Still nice... computers and psychology :D

You don't need to do any qualification whatsoever to call yourself a counsellor, and you can do anything you want as a counsellor (and many do!), including CBT, hypnotherapy, or psychoanalysis.

Are you shitting me? I didn't think it was legal to do counselling for a fee unless you held a diploma or degree in counselling, both of which are offered through certifying authorities Australia wide!

I thought you would hang if you did counselling for a fee without any qualification. Not so?

No psychologist or counsellor of ANY kind in Australia is allowed to prescribe medications. This is the sole domain of psychiatrists (and maybe psychiatric nurses but I doubt it).

Nice... I was wondering about that, as I was viewing the difference for my own jump from counselling to do a post grad in psychology, and neither course had anything to do with medications. Speaking with doctors, they do one whole year nearly just on medications. Good to know that...

Anyone who has a copy of the DSM or ICD-10 can diagnose, it's not regulated in Australia. However, whether this diagnosis will hold in a court of law, or as valid documentation for Centrelink pension payments, depends a whole lot on the therapist's qualifications and experience (and ability to write a coherent report!).

I thought you had to put a license number on such things here?

Interesting... being ex Army, I had no choice but through a shrink, as the Government won't take anything less than a shrink. I've never had the pleasure of experiencing the civilian mental health system... well, other than getting to choose who I wanted providing they took DVA.

 

[anthony]

That doesn't sound right to me about counselling though, as I have a law module which requires a qualification to provide a mental health service for a fee... you also need it to get the insurance to cover your backside.

I know its not regulated with a licensing board... but I still think you need the actual qualification when charging a fee for services.

 

[Nicolas Connault]

It would be interesting to know what organisation regulates this then. I thought there were plenty of unqualified counsellors out there, including a good number of quacks.

 

[Nicolas Connault]

Are you shitting me? I didn't think it was legal to do counselling for a fee unless you held a diploma or degree in counselling, both of which are offered through certifying authorities Australia wide!

I thought you would hang if you did counselling for a fee without any qualification. Not so?

Check out this story then: [DLMURL]http://bit.ly/rs4I0h[/DLMURL]

 

[anthony]

Ok... but that still says she did have a qualification, it was just a dodgy one via some overseas company when she lived overseas, then moved to Australia and practiced, however; they did shut her down because she didn't hold equivalent qualifications here.

As the law stands in NSW, anyone can work as a counsellor or psychotherapist, regardless of their qualifications. The same lack of regulation applies to related professions such as sex therapy, family therapy, couples counselling and life coaching.

That above statement is correct, but you still must have a minimum qualification, not just zero qualification. The problem is that Australia recognises overseas qualifications without any examination, hence how this person got away with being called a doctor when they have no real doctorate to Australian education standards.

I found the loophole today is that to provide a mental health service in Australia, you must have indemnity insurance. To get indemnity insurance, you must hold a diploma or equivalent, minimum to get it. No indemnity insurance, you cannot practice by law.

I find that is possibly the loophole that closes blase statements that media article proposed.

I certainly empathise with the problem though, especially for people such as yourself. You have spent years at uni to get your degree, then people from overseas come in with an existing qualification that can be dubious to check at times.

I see this as the same problem that we have with overseas licenses right now. They can speed, do what they want, get fined, but they actually don't hold an Australian license, so therefore they don't have points and never lose points, so they keep offending and paying the fines with zero real consequences to traffic infringements. I seriously hope they close that hole sooner rather than later as well.

I don't understand that there is a law requiring you to change your license within x months if moving states, otherwise it is an offence, yet the same does not apply for overseas licenses!

I would hope to see some type of closure with mental health though... not sure which is more a problem right now out of those two!!! A little scary reading overseas qualifications like that getting away with practicing for such a duration here...

 

[Nicolas Connault]

Yeah... I'm still not convinced that you need any qualifications or even insurance to advertise yourself as a psychotherapist or counsellor, and to do what you want with people who come to see you (including taking their money). I'd like to see the legislation that forbids this or imposes the conditions of qualifications and indemnity insurance.

Here are two more stories: [DLMURL]http://bit.ly/t3IJxf[/DLMURL] and [DLMURL]http://bit.ly/uwl85D[/DLMURL]

 

[anthony]

That first one is scary, yet also Apr 2010... and the second is from 2003.

I think you might find recent changes, not to regulation of counselling, but qualification requirements to stop such things occurring... well, hopefully.

I do know there is no requirement to be a member of any counselling body once qualified as a counsellor, unlike I believe you must be as a psychologist!!!

I know this law about indemnity insurance is recent, this year... for any practicing counsellor in their own business. To get the insurance you must send them your qualification. Otherwise, you must be listed under the employed business, which one would presume a business checks qualifications. Then I guess we know what presumption does though!

I do agree, counselling isn't regulated through a licensing board, but I know the above has changed, because I had to check it all out for when I have my qualification, costs of opening my own counselling business specific for PTSD, etc. Then the law module about duty of care, confidentiality, referring, etc.

I don't know how that person didn't get dragged through court and sued for everything, especially as they had no qualification and charged a fee for service.

I had to check out the legal consequences for all this when I started this forum... hence how I ended up with that specific legal policy and also as long as I wasn't qualified and not charging any fee for any personal one on one type discussion, then all is well to have a mental health community of discussion, advice, etc etc. I was informed the moment a fee changes hand with the intent of fee for mental health service, is the same moment a person puts their lifestyle at risk for being sued for unlawful practice.

Like how could a person charge a fee for psychology services if not a psychologist? I don't get it. That is a regulated and licensed qualification. Would that not be against the law to pass yourself of as a psychologist without being one? I don't get how these people aren't in jail.

I must say though... not sure implanting false memories is exclusive to the few nut jobs out there passing them off for something they're not, when reading literature from leading experts on PTSD citing there is plenty of this going on from licensed professionals within the industry already, through suggestive questioning and manipulation. I put this down to equally disturbing as these therapists who use the power of therapy to sleep with clients and such. I see that is just as evil and counter productive to the clients mental health.

The world just really is messed up!