10/29/24
COGNITIVE
THERAPY
1
HISTORY
• Risen in popularity in recent decades
• Historically, was a reaction to both behavioral and
psychodynamic therapy
• Epic debates between behaviorists and cognitive theorists
• Now, people often refer to “CBT” and combine cognitive and
behavioral techniques
2
1
10/29/24
APPLICATIONS
• Initially developed for depression. Now there is evidence
that it is effective for a wide range of conditions
• Social anxiety
• PTSD
• Schizophrenia
• Substance abuse
• Weight loss
3
COGNITIVE THEORY
Key ideas attributed to Albert Ellis and Aaron Beck
1. It is not events, but our interpretations of events that
produce our responses, including maladaptive ones.
2. Our interpretations can be accurate or inaccurate
3. Inaccurate and maladaptive interpretations result from
prior experiences and are often patterned and habitual
4. Inaccurate and maladaptive thoughts often occur
automatically and lead to a variety of negative emotions
and problematic behaviors
4
2
10/29/24
ABCS
Situation
Thoughts
Reactions
A = Activating Event
B = Belief
C = Consequences
Reading the
textbook
studying for
midterm
This is too hard,
I’ll never
understand this
Sadness
Closes book
5
SCHEMAS / CORE BELIEFS
• Schema: organized knowledge structures that influence
how we perceive, interpret, and recall information
• Schemas provide filters for our interpretation of the
world around us.
6
3
10/29/24
SCHEMAS
•
A depressed person who feels worthless is likely to interpret new
information and events in ways consistent with that schema.
•
For example, if someone invites you to a party:
• They must feel sorry for me
• They must feel socially obligated
•
Someone swipes left on Tinder:
• I must be ugly.
• I’m unlovable.
7
BECK’S COGNITIVE TRIAD
I’m incompetent /
helpless
Negative
beliefs about
the self
Things will never
get better
Negative beliefs
about the future
I’ll never be good at anything
I’m unlovable /
worthless
No one cares
about me
Negative beliefs
about the world
Everyone is against me
8
4
10/29/24
9
CASE
CONCEPTUALIZATION
Intervene
10
5
10/29/24
Critical mother. Compared self with older brothers and peers
I’m inadequate
EXAMPLE
(positive) If I work very hard, I can do okay.
(negative) If I don’t do great, then I’ve failed
Develop high standards, work very hard, overprepare, look
for shortcomings to correct, avoid seeking help
Reading math text
Intervene
I won’t make it through the course
I’m inadequate
Sad
Closed book, stopped studying
11
Common Cognitive
Distortions
12
6
10/29/24
GOALS
• Promote logical / adaptive thinking patterns
• Identify, refute, & replace distorted cognitions
• People often don’t realize how they speak to themselves
and need to learn to “catch” these cognitions
• People often become fixated on one explanation without
exploring alternatives
• Faulty cognitions need to be replaced with more logical /
adaptive beliefs (not just optimistic / positive thoughts)
13
THOUGHT LOG
Event
Automatic
Thoughts
Emotion (Intensity)
Distortions &
Rational Cognitive
Alternatives
Outcome (of
trying more
adaptive
techniques)
At work today,
everyone left the
soon after I came
into the lunchroom
Everybody hates
me
Anger (70%)
Personalizing
I walked in the
lunchroom and
asked Joe if I
could sit with him.
I came in at 12:30, so
people probably had
to get back to work
Tomorrow I’ll consider
sitting with someone
I’m not a likeable
person
Sadness (95%)
Overgeneralizing
Only one person here
really dislikes me, and
that’s his problem. I
don’t need everyone
to like me
14
7
10/29/24
RATIONAL EMOTIVE BEHAVIOR
THERAPY
• REBT therapist is active, challenging, demonstrative, and
often abrasive.
• Ellis used strong, direct communication to get clients to
give up irrational ideas.
15
16
8
10/29/24
BECK’S COGNITIVE THERAPY
• A gentler approach
• Focuses on asking questions to help patients come
to their own conclusions
• Encourage patients to examine their own thoughts
like scientists
17
18
9
10/29/24
SOCRATIC QUESTIONING
•
Socrates used an educational method focused on discovering
answers by asking questions of his students
•
The goal of Socratic questioning in Cognitive Therapy is “guided
discovery”
• Help the client discover a new perspective with a series of
questions
•
A fundamental principal of CT is collaborative empiricism:
• The therapist and patient together examine the automatic thought,
test its validity/utility, and develop a more adaptive response
19
WHY USE SOCRATIC QUESTIONING?
• There is much more power if the patient comes to their
own conclusion
• Often thoughts are not completely erroneous and contain
a grain of truth that is important to acknowledge
20
10
10/29/24
QUESTIONING AUTOMATIC
THOUGHTS
•
What is the evidence that supports this idea? What is the evidence
against this idea?
•
Is there an alternative explanation?
•
What is the worst that could happen? Could you life through it?
What is the best that could happen? What is the most realistic
outcome?
•
What is the effect of believing in the automatic thought? What could
be the effect of changing my thinking?
•
What would I tell a friend if he/she were in the same situation?
21
11
11/7/24
THE THIRD WAVE
1
OVERVIEW
• Mindfulness
• ACT
• DBT
2
1
11/7/24
THE THIRD WAVE
First Wave
Second Wave
Third Wave
Behavior
Therapy
Cognitive
Therapy &
CBT
Mindfulness,
ACT, DBT
Focus on behavior
modification
Focus on maladaptive
thinking / information
processing
Focus on individual’s
relationship to their
thoughts and emotions
rather than the content
3
FOCUS OF THE THIRD WAVE
• Strategies derived from the Buddhist tradition
•
↑ Metacognition – awareness and understanding of one’s
own thought processes
•
↑ Mindfulness – attention to the present moment in a nonjudgmental and accepting way
•
↓ Experiential avoidance – attempts to avoid thoughts,
feelings, memories, physical sensations, and other internal
experiences
4
2
11/7/24
MINDFULNESS
5
MINDFULNESS MEDITATION
6
3
11/7/24
MINDFULNESS-BASED STRESS
REDUCTION
• Developed by Jon Kabat-Zinn
• 8 week evidence-based treatment program
• Includes both “formal” and ”informal” practice
7
MINDFULNESS-BASED STRESS
REDUCTION
Uses a combination of mindfulness meditation, body scanning, simple
yoga postures
Studies show that MBSR effectively reduces stress, depression,
anxiety, and pain and improves quality of life
8
4
11/7/24
WHAT IS MINDFULNESS?
9
HOW DOES MBSR WORK?
• Increased mindfulness
• Disengagement with repetitive negative thinking
• Self-compassion
• Reduced cognitive and emotional reactivity
• Psychological flexibility
10
5
11/7/24
REFLECTION PAPER #4
1. Select a meditation exercise that is at least 7 minutes
long. If you meditate regularly, select a new exercise.
2. Complete the mindfulness exercise on 3 separate days.
3. Write a reflection paper responding to the specific
prompts in the grading rubric
11
ACCEPTANCE &
COMMITMENT
THERAPY (ACT)
12
6
11/7/24
ACT
• Developed by Steven Hayes
• Emphasizes that all humans experience pain
• Experiential avoidance creates suffering
• Goal is to learn to accept (not avoid) internal psychological
experience and commit to living in ways consistent with your
values
13
ACCEPTANCE AND WILLINGNESS
• Acceptance means taking in the moment without
defense. It does not mean approval.
• Willingness means being open to the pain and
letting go of the struggle.
14
7
11/7/24
COGNITIVE DEFUSION TECHNIQUES
• Strategies to promote acceptance
• The Mind-Train – observing thoughts and letting go
• Labeling / buying thoughts – “I’m having the thought that…”;
“ I’m guess I’m buying the thought that…”
• Mental appreciation – thank your mind
• Monsters on the bus
15
16
8
11/7/24
WHAT ARE VALUES?
• Values are what we find meaningful and important in life
• Values are not goals
• Goals can be achieved
• Values are directions that we want to head in
• Everyone’s values are different and they can change over
time
• People hold multiple values that sometimes conflict and must
therefore be prioritized
17
18
9
11/7/24
IDENTIFY YOUR VALUES
Pick your top 5 in order
a. Balance in life
i. Power / influence
b. Challenge / risk taking
j. Achievement
c. Creativity
k. Relationships
d. Fame / Recognition
l. Physical health
e. Hard work
m. Self-examination
f. Honesty & integrity
n. Serving others
g. Independence
o. Spirituality
h. Personal Growth
p. Wealth
i.
q. Safety / comfort
Leisure
19
20
10
11/7/24
21
DIALECTICAL
BEHAVIOR THERAPY
22
11
11/7/24
DBT
• Developed by Marsha Linehan
• Treatment for Borderline Personality Disorder
• Linehan’s Biosocial Theory
• Biologically based emotion dysregulation interacts with an
invalidating environment to produce symptoms of BPD
• Skills deficits contribute to ongoing dysfunction
• Gold standard includes weekly individual therapy sessions,
weekly group skills training sessions, and a therapist
consultation team meeting
23
CORE DBT PRACTICES
• Validation
• Communicate that the patient’s feelings are important
and a sensible reaction to their situation
• Problem solving
• Being right vs. being effective
• Dialectics: balancing opposites
• Need to balance change-oriented and acceptance
strategies
24
12
11/7/24
DEVELOPING DBT
25
ACCEPTANCE
26
13
11/7/24
EMOTION REGULATION
27
DEARMAN: A STRATEGY FOR ASKING FOR
WHAT YOU WANT
Describe
Describe the current situation. Tell the person what you are
reacting to. Stick to the facts.
Express
Express your feelings about the situation. Assume your feelings
are not self-evident.
Assert
Assert yourself by asking for what you want or saying no clearly.
Assume others cannot read your mind.
Reinforce
Reinforce or reward the person ahead of time by explaining the
positive effects of getting what you want. Explain the negative
affects of you not getting it.
Mindful
Keep focus on your objective. Maintain your position. Be a
“broken record” using a calm voice. Ignore if the person attacks,
threatens, or tries to change the subject.
Appear
Appear effective and competent. Using a confident voice tone
and physical manner. Make good eye contact.
confident
Negotiate
Be willing to give to get. Offer and ask for alternative solutions
to the problem. Reduce your request. Maintain no but offer to do
something else. Turn the problem to the other person.
28
14
11/7/24
DEARMAN: A STRATEGY FOR ASKING FOR
WHAT YOU WANT
Describe
I noticed you’ve had the same dirty dishes in the sink for the past
3 days.
Express
It makes it really difficult for me to clean my own dishes and I
end up feeling really irritated and frustrated. I don’t like feeling
this way because I care about our friendship and want us to get
along.
Assert
I would like you to have your dishes clean by the end of the day
so they don’t stay in the sink overnight.
Reinforce
If you clean up the dishes I would feel a lot better
Mindful
You can keep saying the same thing. The strength is in the
persistence of maintaining a position in a calm way. Do not
respond to attacks or criticisms.
Appear
Don’t backpedal or undermine previous statements. Don’t
apologize for making the request.
confident
Negotiate
If you are able to clean up the dishes, I would be happy to talk
about other ways I can pitch in around the house.
29
15
11/11/24
ETHICS
1
APA CODE OF ETHICS
• The American Psychological Association (APA) is the
primary professional organization of psychologists in
the United States.
• First version of the Ethics Code published in 1953.
• Most recent version published in 2002.
• Sections of the APA Code
• General Principles: aspirational
• Ethical Standards: enforceable
2
1
11/11/24
PURPOSE OF ETHICS CODE
• Establishing the integrity of a profession
• Public trust
• Enforcement value
3
APA ETHICAL PRINCIPLES
Principle A: Beneficence and Nonmaleficence
• maximize benefit and minimize harm
Principle B: Fidelity and Responsibility
• to accept responsibility for one’s professional behavior, set and
follow high professional standards, form relationships of trust, and
consult with colleagues
Principle C: Integrity
• the general obligation to be truthful and honest
Principle D: Justice
• fairness and justice entitle all people to access and benefit from
competent and unbiased contributions of psychology
Principle E: Respect for People’s Rights and Dignity
• self-determination, confidentiality and privacy
4
2
11/11/24
STANDARDS OF ETHICS
10 categories:
1. Resolving of ethical issues
2. Competence
3. Human relations
4. Privacy and confidentiality
5. Advertising and other public statements
6. Record keeping and fees
7. Education and training
8. Research and publication
9. Assessment
10. Therapy
5
FISHER’S MODEL OF ETHICAL
DECISION MAKING
1. Make a commitment to doing what is ethically appropriate
2. Become familiar with APA ethical code
3. Consult any law or professional guidelines
4. Understand the perspectives of various parties affected by the
5.
6.
7.
8.
actions you take. Consult with colleagues for input and
discussion!!
Generate and evaluate alternatives
Select and implement course of action that seems most
appropriate
Monitor and evaluate effectiveness of course of action
Modify and continue to evaluate the plan as needed
6
3
11/11/24
PSYCHOLOGISTS’ BELIEFS ABOUT
ETHICS
Pope et al., 1987
• 450 members of APA Div 29 (Psychotherapy) rated the ethicality of
83 behaviors that psychologists might perform with a client
• Few behaviors seen as blatantly unethical
• Sex with clients
• Socializing with current clients
• Disclosing confidential information without permission
• Few behaviors seen as unquestionably ethical
• Shaking hands with clients
• Addressing clients by first name
• Breaking confidentiality if clients are suicidal / homicidal
• Most are in the “gray area”!
7
CONFIDENTIALITY
•
Refers to the ethical responsibility of psychologists and
other health professionals to protect clients and research
participants from unauthorized disclosure of protected
information.
•
Important but can create many tricky situations
•
Family members concerned about a patient
•
Seeing a patient in public
8
4
11/11/24
ETHICAL DILEMMA: CONFIDENTIALITY
Danica a 17-year-old girl is seeing Dr. Terry, a clinical
psychologist. Danica’s parents believe that Danica deserves
some confidentiality with Dr. Terry, and they agree that Dr. Terry
need not repeat the full contents of their sessions; however, they
understandably insist that they be informed of any harm or
danger that Danica may experience. As the sessions progress,
Danica begins to reveal details about her life of which her
parents are unaware. She drinks alcohol about once a week (but
does not get drink), she intentionally cut her forearm with a razor
blade once a few months ago, and one night she was a
passenger in a car driven by a friend who was stoned.
9
10
5
11/11/24
LIMITS TO CONFIDENTIALITY
3 cases where psychologists are required to breach
confidentiality
Suicidality
2. Homicidality
3. Child/Elder abuse
1.
11
DUTY TO WARN
• “Protective privilege ends where the public peril begins”
• Psychologists have a duty to warn people toward whom
their clients make a credible, serious threat
12
6
11/11/24
TARASOFF V. REGENTS OF THE
UNIVERSITY OF CALIFORNIA
• In 1969, Prosenjit Poddar was a student at UC Berkeley
• He was romantically interested in Tatiana Tarasoff
• When their relationship did not advance, he sought counseling from
Dr. Moore
• During a session, Poddar told Moore that he intended to kill Tarasoff
• Dr. Moore broke confidentiality and called campus police
• Campus police interviewed Poddar but did not hold him
• Poddar never returned to therapy, then killed Tarasoff
• Tarasoff’s parents sued Dr. Moore and won
• This set the precedent for the “duty to warn”
13
CHALLENGES OF DUTY TO WARN
• How credible are client’s threats?
• What kinds of threats merit warnings?
14
7
11/11/24
INFORMED CONSENT
•
Ethical and legal obligation
•
Informed consent, implies having access to and
comprehending all the information that might reasonably
influence a person’s decision.
•
Client must be competent to give consent, age of majority
(age 18), cognitive ability, and psychological maturity to
comprehend potential risks and benefits.
•
Documentation required. Written and verbal consent.
15
INFORMED CONSENT
Consent should include:
• Limits to confidentiality
• Involvement of any third parties
• The nature, purpose, and duration of the psychological
assessment and/or intervention
• Issues pertaining to billing.
Consent in practice
• Consent is a process, not a one-time event
• Consent is an early part of a strong therapeutic relationship
16
8
11/11/24
ETHICS CHECK: INFORMED
CONSENT
Dr. Jones saw a new client whose presenting problems
appeared to be related to a debilitating social phobia. The
client was to pay privately for treatment because her health
plan did not cover psychotherapy. The client asked the
psychologist how long she might have to be in therapy
before she saw some relief from her symptoms. Dr. Jones
responded, “We’ll just see how it goes.”
Is Dr. Jones’s behavior ethical or unethical?
17
MULTIPLE RELATIONSHIPS
Occurs when a psychologist is in a professional role with a
person (patient) and…
1. At the same time is in another role with the same
person
2. At the same in is in another role with a person closely
associated with or related to the patient
3. Promises to enter into another relationship in the future
with the person or a person closely associated with or
related to the person
18
9
11/11/24
MULTIPLE RELATIONSHIPS
• Multiple relationships are not strictly prohibited
• Unethical when it might reasonably affect objectivity,
competence, or effectiveness
• Unethical when exploitation or harm could result
• This restriction is unique for psychologists compared to
many other medical providers
19
MULTIPLE RELATIONSHIPS
• Many different types of challenging situations exist
• Running into people
• Creating business / professional connections
• Attending special ceremonies
• Accepting favors / gifts
20
10
11/11/24
SEXUAL RELATIONSHIPS
• NO sexual relationship with current client or with close
relatives of client
• Do not engage previous sexual partners as clients
• Do not engage in sexual intimacies with former clients for at
least two years after cessation
• Burden of responsibility is on the psychologist
• What about physical touch in the therapeutic relationship?
21
SMALL COMMUNITIES
• Small communities can be rural areas or defined by
ethnicity, religion, or other variables
• Multiple relationships can be unavoidable in small
communities
• Discuss up front with clients
• Clarify boundaries
• Avoid impaired judgment and exploitation
22
11
11/11/24
ETHICAL DILEMMA: MULTIPLE
RELATIONSHIPS
23
Deborah is an intern at a university counseling center. She has been
working with John, a 30-year-old ABD graduate student in the
humanities, for the past 6 months. Therapy has largely focused on
John’s inability to move forward with his dissertation. Deborah suspects
that John’s academic difficulties are related to other aspects of his life,
primarily having to do with his disappointment and anxiety over not
having found a committed relationship. Two weeks ago, John came into
therapy and described to Deborah someone whom he’d met at a
campus bar who is also in the humanities, though not in John’s
department. John was almost giddy as he described this person to
Deborah and his excitement for an upcoming date on Saturday night.
As John describes the woman, it becomes clear that he is almost
certainly talking about a friend of Deborah’s. At that moment, Deborah
recalls running to this friend at a coffee shop and her friend remarking
that she had recently met an interesting guy.
23
COMPETENCE
•
Sufficiently capable, skilled, experienced, and expert to
complete the professional tasks they undertake
•
Having a degree or license does not make you
competent in all areas
•
Psychologists should know their limits and seek
additional training or supervision when necessary
•
Ethical obligation for continued education.
•
Obligation for continuing awareness of own personal
functioning and refrain from offering services when
competence is compromised.
24
12
11/11/24
ETHICAL DILEMMA: COMPETENCE
Dr. Smith has been seeing Jane in his practice for approximately 6
months. Dr. Smith had been using cognitive-behavioral therapy to work
with Jane on issues related to depression and interpersonal difficulties.
Dr. Smith had treated many patients with depression using CBT and felt
confident he could treat Jane. Jane then disclosed that she had been
hiding a serious eating disorder from Dr. Smith because she was
ashamed by it. Dr. Smith had learned about eating disorders in
graduate school and knew that some CBT treatments could be effective
for some eating disorders, but he had never treated someone with an
eating disorder. Jane said that she wanted to continue working with him
because it took so long for her to build enough trust to share this with
him.
25
ETHICS IN RESEARCH
Institutional Review Board (IRB) protects interests of
research participants through oversight and regulation
based on ethical, scientific, and legal standards
26
13
11/11/24
ETHICS IN RESEARCH
•
3 Guiding Principles
•
Respect for Persons: Protecting autonomy, treating
people with courtesy and respect
•
•
Beneficence: Maximize benefit and minimize risks
•
•
Informed consent
Benefit can be to individual and society
Justice: Non-exploitative, fair distribution of costs and
benefits to potential research participants
•
Compensation, Inclusion/Exclusion, Recruitment
27
CLINICAL TRIALS
Importance of equipoise – a state of genuine uncertainty
on the part of the investigator regarding the comparative
therapeutic merits of each arm in a trial
Group A
Group B
28
14
11/11/24
SUICIDE
1
TERMINOLOGY CHECK
Terms to avoid
• Committed suicide
• Completed suicide
• Successful / Unsuccessful suicide
Preferred terms
• Died by suicide
• Took his/her own life
• Ended his/her own life
2
1
11/11/24
3
4
2
11/11/24
5
6
3
11/11/24
7
8
4
11/11/24
SUICIDE MYTHS
1. Once someone is suicidal, he or she will always remain
suicidal
2. Only people with mental disorders are suicidal
3. Most suicides happen suddenly without warning
4. Talking about suicide is a bad idea and can be interpreted as
encouragement
5. Someone who is suicidal is determined to die
6. People who talk about suicide do not mean to do it
9
10
5
11/11/24
AGE
Men
Women
11
12
ADOLESCENTS
• Suicide is the 3rd leading cause of death among
adolescents
• Suicidal ideation is particularly high among adolescents
• CDC 2015 survey: 17.7% of high school students seriously considered
attempting suicide within the past year
• Far more teens attempt suicide than die by suicide
• Ratio may be as high as 200:1
12
6
11/11/24
13
THE ELDERLY
• Men ages 75+ have the highest rates of suicide in the
country
• Suicide attempts by older adults are much more likely
to result in death than among younger persons
13
GENDER
14
7
11/11/24
GENDER
• Women are more likely to think about and attempt suicide (3x
men)
• Men are more likely to die by suicide (3x women)
• Men account for ~ 78% of suicide deaths
• Historically, men tended to use more lethal methods (shooting)
than women (poisoning)
15
GENDER
Men
Women
16
8
11/11/24
RACE & ETHNICITY
Men
Women
17
SEXUAL ORIENTATION & GENDER
IDENTITY
•
Difficult to determine rates of suicide deaths by sexual orientation and
gender identity because these are often not included in death records
•
LGB youth seriously contemplate suicide at almost 3x the rate of
heterosexual youth.
•
LGB youth are almost 5x as likely to have attempted suicide compared
to heterosexual youth.
•
In a national study, 40% of transgender adults reported having made a
suicide attempt. 92% of these individuals reported having attempted
suicide before the age of 25.
•
Family rejection and LGBT victimization are important risk factors
18
9
11/11/24
VETERANS
Although, Veterans constitute only 9% of the US population,
they represent 18% of suicides
19
INTERPERSONAL THEORY OF
SUICIDAL BEHAVIOR JOINER, 2005
•
Thwarted belongingness + perceived burdensomeness = desire for
suicide (Suicidal Ideation)
•
Acquired capability = Fearlessness of pain, injury, and death acquired
from experience of repeated painful events
•
Desire + Capability = fatal attempts
•
Explains disparities between suicidal ideation and suicidal behavior
20
10
11/11/24
EVIDENCE TO SUPPORT
JOINER’S THEORY
•
Suicide rates correlate with final national rankings of local college
football teams; fewer suicides occurred on the day of the “Miracle on
Ice” than on any other Feb 22; and fewer suicides occurred on Super
Bowl compared to other Sundays
•
History of suicide attempts is a strong predictor of future behavior and
death by suicide
•
Individuals with past attempt experience more serious forms of future
suicidality
•
Individuals with past attempt have higher pain tolerance
•
Likelihood of suicide attempts is greater in individuals who have a
longer history of self-injury, use a greater number of methods, and
report absence of physical pain during self-injury
21
RISK FACTORS
•
•
•
•
•
•
•
•
Previous suicide attempt(s)
Suicidal thoughts
Family history of suicide
Family history of child
maltreatment
History of mental disorders,
particularly clinical depression
History of alcohol and
substance abuse
Feelings of hopelessness
Impulsive or aggressive
tendencies
•
•
•
•
•
•
•
Local epidemics of suicide
Isolation, a feeling of being
cut off from other people
Barriers to accessing
mental health treatment
Loss (relational, social,
work, or financial)
Physical illness / pain
Easy access to lethal
methods
Unwillingness to seek help
because of the stigma
22
11
11/11/24
PROTECTIVE FACTORS
•
Social supports – family, friends, community
•
Responsibilities and duties to others
•
Engagement in meaningful / enjoyed activities
•
Skills in problem solving, conflict resolution, and nonviolent ways of
handling disputes
•
Cultural and religious beliefs about value of life
•
Access to quality care for mental, physical, and substance abuse
disorders
• **Majority of individuals who die by suicide have had no contact
with the mental health system
23
WARNING SIGNS
•
Talking or posting about wanting to die
•
Express feelings of hopelessness, purposelessness, being trapped
•
Increased substance use
•
Aggressive behavior, anger, or rage
•
Social withdrawal from family, friends
•
Dramatic mood swings
•
Talking, writing, or thinking about death
•
Impulsive or reckless behavior
•
Putting affairs in order and giving away possessions
•
Saying goodbye to friends and family
•
Mood shifts from despair to calm
•
Planning behaviors – e.g., acquiring a gun, collecting pills
24
12
11/11/24
25
THE CONTAGION OF SUICIDE
Some research indicates that a person is more likely to take their life
after hearing about someone else dying by suicide
• As many as 5% of adolescent suicides may be due to contagion
Media accounts may worsen the problem by
• Sensationalizing/romanticizing suicide
• Describing lethal methods of suicide
• Describing suicide as escape for troubled person
25
RECOMMENDATIONS FOR MEDIA
REPORTING ON SUICIDE
26
13
11/11/24
SCREENING AND CRISIS
INTERVIEWING
•
Screening should be conducted for all patients as part of intake
including current thoughts/behaviors and history
•
Any indications of increased risk for suicide should result in a crisis
interview to determine level of risk
• Intent
• Means
• Plan
• History
• Motivations to die
• Reasons to live
• Sources of support
27
DECISION MAKING
If current risk is very low, provide resources and encourage continued
discussion
• Goal is not to overpathologize suicidal ideation
If current risk is moderate but not imminent, develop a safety plan
• Goal is to promote coping skills and strategies to manage acute
distress if it arises
• Note: Safety contracts are NOT recommended
If risk is imminent, encourage voluntary hospitalization and use
involuntary civil commitment if needed
• Goal is to ensure immediate safety
28
14
11/11/24
SAFETY PLAN
• Recognize warning signs of crisis
• Utilize internal coping strategies
• Use social contacts as means of distraction & to help
resolve crisis
• Contact mental health professionals / agencies
• Restricting access
29
30
15
11/11/24
PREVENTION
Gatekeeper training
Outreach
campaigns
Teaching
warning signs
Improve access
Screening
Self-help tools
Referral protocols
Respond effectively
and compassionately
Emergency services
to suicide death
Hotlines / helplines
Safe messaging
Gun locks /
storage
Evidence-based
treatment
Interagency
communication
Reduce barriers
to care
Patient/family
education
Stress management
Med packaging
Critical
thinking
Bridge barriers
Coping skills
Supportive
relationships
Community
Connectedness
http://www.sprc.org/effective-prevention/comprehensive-approach
31
MEANS RESTRICTION
• Reducing easy access to means
• Negotiate different levels of access (e.g., locked,
unloaded)
• Consider temporary removal or restricted access
• Enlist support person to aid in this process
• Incorporate removal in safety plan
32
16
11/11/24
INTERVENING ON THWARTED
BELONGINGNESS AND PERCEIVED
BURDENSOMENESS
Short et al., 2019
• RCT evaluating a computerized intervention in veterans
• Psychoeducation using cognitive-behavior principles to
correct problematic ideas related to thwarted belongingness
and perceived burdensomeness
• E.g., If you are around other people, you shouldn’t feel lonely
• Talking about your problems makes you a burden to others
• Examples of behavioral activation techniques (e.g., talking to
a friend, share your feelings with someone you trust)
• Training people to generate positive outcomes to ambiguous
scenarios
33
RESOURCES
National Suicide Prevention Lifeline: (800) 273-TALK (8255)
Crisis Chat: http://www.suicidepreventionlifeline.org
Crisis Text Line: Text HOME to 741741
#BeThe1To: http://www.bethe1to.com
TrevorLifeline (for LGBTQ youth): 1-866-488-7386
*Also TrevorChat and TrevorText
Veterans Crisis Line: 1-800-273-8255
*Also has Text and Chat options
34
17
11/18/24
FAMILIES &
CHILDREN
1
ASSESSING AND
TREATING FAMILIES
2
1
11/18/24
FAMILY THERAPY
•
Family therapy often begins with focus on one family member who is
having particularly noticeable problems (identified patient)
•
Systems Approach
• The system is the source of the problem, even if psychopathology
is largely manifested in one individual
• Circular causality: events influence one another in a reciprocal way
• This means problems are thought to be maintained through
ongoing interactions between family members
• Family members worked together with a therapist to improve their
interactions, which in turn strengthened the mental health of each
member
3
SYSTEMS APPROACH PRINCIPLES
• Unhealthy communication patterns are key source of
problems within the family
• Psychological symptoms serve a function within the family
environment (functionalism)
• Homeostasis: families have emotional or behavioral “comfort
zones”
• Feedback: Family members make take actions to bring other
family members back to homeostasis if they perceive tension
4
2
11/18/24
BOWEN’S FAMILY SYSTEMS THEORY
1. Triangles
2. Differentiation of self
3. Nuclear family emotional process
4. Family projection process
5. Multigenerational transmission process
6. Emotional cutoff
7. Sibling position
8. Societal emotional process
5
6
3
11/18/24
7
ASSESSMENT OF FAMILIES
• Genogram
• What is the family configuration?
8
4
11/18/24
ASSESSMENT OF FAMILIES
• Family life cycle
• What is the family’s current developmental phase?
9
WAYS TO CONDUCT FAMILY THERAPY
• Most of the approaches to individual therapy have been
applied in the family context
• 3 Broad Categories
1. Ahistorical: Emphasizes current functioning, deemphasizes
family history
2. Historical: Emphasizes family history, typically longer in
duration
3. Experiential: Emphasizes personal growth and emotional
experiencing
10
5
11/18/24
MINUCHIN’S STRUCTURAL
FAMILY THERAPY
•
Treatment principles:
• Context organizes us
• The family is the primary context
• The family’s structure consists of recurrent patterns of interaction that
members develop over time as they accommodate each other
•
Therapist goals:
• Enter, or "join", the family system to understand the invisible rules
which govern its functioning
• Map the relationships between family members or between subsets
of the family
• Disrupt dysfunctional relationships within the family, causing it to
stabilize into healthier patterns
11
ASSESSING AND
TREATING CHILDREN
12
6
11/18/24
CLASSIFICATION OF
CHILDHOOD DISORDERS
13
At least 20% of kids & adolescents in U.S. have diagnosable psychological
disorder
13
14
ASSESSING CHILDREN
•
Behavior rating scales
•
Generally list of child problem behaviors
• E.g. fidgets, easily distracted, shy and withdrawn
•
Child, parent, or teacher usually rate each behavior
•
Some focus on specific disorder (e.g. Child Depression-Inventory-2);
some cover various areas of child behavior problems (e.g. Child
Behavior Checklist)
14
7
11/18/24
15
ASSESSING CHILDREN
•
Clinical Interviews:
•
71% of clinical child and adolescent psychologists said clinical
interview was most important aspect of clinical assessment
•
Goals of unstructured child interview:
1. Establish rapport
2. Evaluate child’s understanding of problem and reason for
referral
3. Evaluate child’s explanation of problem
4. Obtain description of feelings
5. Observe child during interview
15
PSYCHOTHERAPY WITH CHILDREN
• All major approaches to therapy have generated applications
for children as well as adults
• Children are not just miniature adults. This means substantial
adjustments are made from the adult model.
• Cognitive-behavioral therapies for children are on the rise
• Interventions adapted into games (e.g., bravery bingo)
• Homework reinforcement more clear
16
8
11/18/24
APPLIED BEHAVIOR ANALYSIS
(ABA)
• Evidence-based therapy for children with autism spectrum
disorders
• Relies heavily on operant conditioning principles
(reinforcement, punishment, shaping, and extinction)
• Therapist helps a child identify and define a specific target
behavior to increase or decrease
• Contingency management is applied
• You can be an ABA technician with a high school diploma!
17
PARENT-CHILD INTERACTION
THERAPY
• Evidence-based behavioral intervention designed to treat
behavior problems in children ages 2-7
• Teaches parents play-therapy and operant conditioning skills to
reinforce positive child behavior
• Uses live coaching of parents (one-way mirror, bug in the ear)
• PRIDE skills
• Praise appropriate behavior
• Reflect appropriate talk
• Imitate appropriate play
• Describe appropriate behavior
• Enthusiasm / Enjoyment
18
9
11/18/24
SPECIAL ISSUES
WORKING WITH
CHILDREN
19
DEVELOPMENTAL AGE
• Chronological and developmental age
is the FIRST consideration when
selecting appropriate assessment
and treatment strategies
• Children have less ability to critically
examine, or even discuss, their
thoughts and feelings.
• Must be creative in terms of finding
ways to help them examine mental
processes (role play, using
metaphors, feeling charts).
20
10
11/18/24
DEVELOPMENTAL AGE
• Children 2-4 fear imaginary creatures and dark; 5-7 fear
natural disasters; 8-11 fear poor academic & athletic
performance; 12-18 fear peer rejection
• By age 5, most kids do not wet bed
• Overwhelming majority of adolescent girls experience
poor body image – normative discontent
21
THERAPEUTIC ALLIANCE AND
RESISTANCE
• Typically parents make the decision for children to come to
therapy
• Enhancing children’s motivation to engage in therapy must
often be the first treatment goal (or engaging children in
identifying their own treatment goals)
• Tapping into youth “culture” to build rapport and encourage
engagement in treatment
• Playing games
• Drawing
• Playing with toys
• Facebook/Tumblr/Instagram/texting
22
11
11/18/24
CONFIDENTIALITY
• Approach depends on kids’ age, type of treatment, etc..
• In general, good to encourage a trusting relationship between
the therapist and child. This means rules of confidentiality
should be clear from the start.
• Create a pre-treatment contract re: child patient
confidentiality, when to breach confidentiality, how much of
session will include parent, etc.
23
PARENTS
• Kids always come with parents, so inevitably when you’re
working with kids, you’re also working with their parents (this
means you may have 3 clients instead of 1)
• Extremely important to incorporate parents into the treatment
planning and case conceptualization
• Parents can be part of the solution or part of the problem
(you want them to be part of the solution, so best to make it
that way from the start)
24
12
11/18/24
PARENTS
25
• Parent-child interactions are bidirectional
• Child’s temperament & behavior influences parent’s behavior
• Parental tolerance and responses alter child’s behavior
• Reinforcement trap
• Parent reinforces child’s poor behavior by giving reward
• Parent’s behavior is reinforced because child has stopped
misbehaving
25
PARENTS
26
• Interparental Conflict
• Parents’ verbal arguments and fighting are associated
with increased emotional and behavioral problems,
especially externalizing problems.
• Triangulation makes it worse.
• Sometimes divorce is best for kids.
26
13
11/18/24
COLLABORATION
•
Collaboration with other professionals
• Important to have open lines of communication with
school, teacher, physicians, etc.
• Collaboration, getting them involved in tx, is often key.
• Must be open to collaborating with psychiatrists and
to discussing parents’ concerns re: meds.
27
28
TEMPERAMENT
•
Largely genetically determined
•
Children with more difficult temperaments more likely to have:
• Stormy peer relationships
• Academic difficulties in first grade
• Conduct problems from 4-13
• Increased behavioral problems at 14
• Challenging personality traits by 26
• Generalized anxiety disorder (GAD) at 32
28
14
11/21/24
FORENSIC
PSYCHOLOGY
1
DEFINITION
• Forensic psychology is the application of psychological
methods and principles within the legal system
• Training involves:
• Elective courses in doctoral programs
• Specialized forensic track
• Joint graduate degrees (JD and PhD)
• Predoctoral / postdoctoral internships
2
1
11/21/24
ASSESSMENT ACTIVITIES
• Predicting dangerousness
• Not guilty by reason of insanity (NGRI)
• Child custody evaluations
• Competency to stand trial
• Commitment to mental institutions
3
TREATMENT & OTHER ACTIVITIES
• Treatment of forensic clients
• Expert witnesses
• Patient’s rights
• Consultations with law enforcement
4
2
11/21/24
THE THERAPEUTIC RELATIONSHIP
• Role of the psychologist is not as clear as in more common
clinical situations
• Important to determine and clarify who is the client, as well as
limits of confidentiality
• Malingering
• Occurs with greater frequency in forensic psychology than
clinical
• The person being evaluated exaggerates or “fakes”
symptoms to achieve an external benefit
5
6
3
11/21/24
MENENDEZ BROTHERS
• Erik & Lyle Menendez brutally murdered parents in 1989
• Confessed to psychologisy Dr. L. Jerome Oziel
• Oziel’s patient / mistress listened in on sessions and
recorded sessions with Oziel’s consent
• Later reported it to police
7
MENENDEZ BROTHERS
• California Supreme Court ruled some of the tapes admissible
due to “dangerous patient exception”
• Oziel lost license in 1997
• Dual roles / sexual relationships
• Violating confidentiality
• Administering drugs
8
4
11/21/24
MENENDEZ BROTHERS
• Defense hired Dr. William Vicary as treating and forensic
psychiatrist
• Rewrote pages of his clinical notes deleting potentially
damaging material, knowing that his rewritten notes would be
provided to prosecutors and used in court as though they were
originals
• Said he was directed by attorney to do so
• 3 Year probation
9
MENENDEZ BROTHERS
• Vicary surrendered his license in 2019 for:
•
•
•
•
Gross negligence
Repeated negligent acts
Prescribing without appropriate exam
Excessive prescribing
10
5
11/21/24
MENENDEZ BROTHERS UPDATE
• Subject of 2024 Netflix documentary
• 5Current L.A. D.A. recommends clemency for brothers
• Governor Newsome will wait for new D.A. to complete
investigation before making a decision
11
ASSESSMENT TOOLS
• Forensic assessments include assessment tools used by clinical
psychologists in general
• Some specialized instruments are also used
• Multimethod approach is encouraged
Opinions of Forensic Experts
Type of Assessment Recommended Test
Unacceptable Tests
Not guilty by reason
of insanity
MMPI-2; WAIS
Projective drawings; TAT; sentence
completion tests
Predicting
dangerousness
Psychopathy Checklist –
Revised
Projective drawings; TAT; Rorschach;
sentence completion tests
Competency to stand
trial
WAIS; MacArthur
Competence Assessment
Tool – Criminal Adjudication
Projective drawings; TAT; Rorschach;
sentence completion tests; Millon
Clinical Multiaxial Inventory
Adapted from Lally (2003), 491-498
12
6
11/21/24
ASSESSMENT SKILLS
• Knowledge of the legal issues
• E.g. understanding of criminal responsibility, definition of
competency, definition of insanity
• Addressing the demands of the legal system
• E.g., striving for neutrality regarding a client, predicting the
future as well as possible, gathering data in unbiased way
• Skill related to litigation
• E.g., understanding each attorney’s strategy, providing
appropriate testimony, deferring to others when
appropriate
13
PREDICTING DANGEROUSNESS
• Judge / jury often consider the likelihood that the defendant will
behave violently or dangerously in the future
• Clinical psychologists perform assessments to estimate this
dangerousness
• Clinical prediction methods
• Interviews, tests, clinical experience, and judgment of psychologist
• Statistical prediction methods
• Also know as actuarial prediction methods
• Involve only objective characteristics, no subjective judgments
• Relevant variables include age, arrest record, weapon availability,
social support, substance abuse, psychosis, and psychopathy
14
7
11/21/24
15
PREDICTING DANGEROUSNESS
• Base rate problem refers to the difficulty in predicting
dangerousness because it happens so infrequently
• The mistakes the psychologist might make include false
positives (overestimating dangerousness) and false negatives
(underestimating dangerousness)
• Research has shown that mental health professionals can
make better than chance predictions of violence
16
8
11/21/24
INSANITY DEFENSE
• Not Guilty by Reason of Insanity (NGRI)
• Insanity is a legal term
• Suffering from serious mental disease or defect at the
time of the crime and: (a) lacked the capacity to
understand criminality or wrongfulness of act; OR (b)
could not regulate behavior according to law
• Clinical psychologists assess defendants’ mental states at
the time of the crime
17
INSANITY DEFENSE
• Infrequently used and infrequently successful
• Occurs in less than 1% of felony jury trials and only about 25%
of those trials result in an NGRI verdict
• If found NGRI, hospitalized until no longer mentally ill and not
dangerous
• Typically are hospitalized as long as prison sentence - many are
never released
18
9
11/21/24
JOHN HINCKLEY JR.
• In 1981, Hinckley attempted to assassinate President Ronald Reagan.
Hinckley shot Ronald Reagan and press secretary James Brady,
paralyzing Brady.
• He was obsessed with Jodi Foster and the movie “Taxi Driver”
• He hoped she would be impressed if he shot the president
• Ruled NGRI in 1982 and was committed to St. Elizabeth’s Hospital in
Washington.
• Starting around 2004, Hinckley’s restrictions were gradually loosened.
He was finally released from the hospital by a judge in 2016 under
strict conditions.
19
20
10
11/21/24
INSANITY DEFENSE
• 20 states allow Guilty But Mentally Ill (GBMI)
• Verdict only available for defendants who plead NGRI
• Juries usually render GBMI verdicts when defendants may not
have been sane enough to be held legally responsible for
actions but were culpable enough to warrant punishment.
• Usually sentenced to same period of confinement as any other
defendant but supposed to get mental health treatment in
correctional facility – rarely get adequate treatment.
21
CHILD CUSTODY EVALUATIONS
• Among most ethically challenging and clinically difficult forensic cases
• Best interest of the child must be highest priority
• Evaluations can involve child and parents, as well as third parties who
know the family
• Common methods include interviews, observation of interaction, IQ
tests, personality tests, medical records review, and specialized
instruments
• Multimethod approach is expected
22
11
11/21/24
COMPETENCY TO STAND TRIAL
• Person accused of crime can only be tried in court if that person is mentally
fit to undergo the trial. Must be able to understand the criminal process and
function within it
• Goal is to determine “whether [defendant] has sufficient present ability to
consult with his lawyer with a reasonable degree of rational understanding,
and whether he has a rational as well as factual understanding of
proceedings against him”. [Dusky v US, 1960]
• Usually assessed using specialized structured clinical interviews to evaluate
understanding of the legal system
23
COMPETENCY TO STAND TRIAL
• 70-90% of defendants evaluated found to be competent
• Those found incompetent usually have serious mental illnesses (e.g.
schizophrenia)
• If found incompetent:
• Minor charges might be dropped
• If charges are serious, defendant may be sent to institution for
treatment to restore competence (can last up to 4-6 months)
• Most defendants become competent after psychotropic meds
and they return to jail to await trial
• If still not competent, defendant may be evaluated for civil
commitment
24
12
11/21/24
TREATMENT OF FORENSIC CLIENTS
• Therapy with individuals hospitalized after being found not
guilty by reason of insanity
• Increasing competence of individuals found incompetent
to stand trial
• Treatment of mental disorders of incarcerated individuals
• Address emotional and behavioral problems that
contribute to unlawful behavior, e.g., sex offender
programs
• Cultural competence essential in jails and prisons
25
EXPERT TESTIMONY
• Provide expertise regarding mental health issues to the court
• Must not testify to support one side of a case, but to present
truthful and complete expert knowledge of subject matter
• Voir dire is the process by which an expert witness is approved
for the court
• Testimony must be reliable and valid to be admissible
26
13
11/21/24
EXPERT TESTIMONY
• Used in about 8% of civil trials in federal courts
• Expert testimony has been criticized as lacking in reliability,
validity, propriety, and usefulness.
• Expert witnesses may be attacked by opposing attorney
• Opposing expert witnesses can be confusing to juries and both
experts will be discounted.
27
CONSULTATIONS WITH LAW
ENFORCEMENT
• Preemployment evaluations with candidates for law
enforcement jobs
• Fitness-for-duty evaluations for current officers
• Therapeutic interventions, especially after stress or
trauma encountered on the job
28
14
11/21/24
UCI FACULTY & PROGRAMS
• UCI Center for Psych and Law
• https://psychlaw.soceco.uci.edu/
• https://psychlaw.soceco.uci.edu/faculty2019/
• UCI Master of Legal and Forensic Psych (MLFP) program
• https://mlfp.soceco.uci.edu/
• https://mlfp.soceco.uci.edu/page/potential-career-paths
• https://mlfp.soceco.uci.edu/faculty
29
15
11/25/24
CONDUCTING
RESEARCH
1
TYPES OF RESEARCH
• Treatment outcome
• Assessment methods
• Diagnostic issues
• Causes and consequences of mental health issues
• Professional issues
• Teaching and training issues
2
1
11/25/24
LEVELS OF EVIDENCE
3
4
2
11/25/24
THE EXPERIMENTAL METHOD
• Most powerful way to determine cause-effect relationship
is a controlled experiment
• Independent Variables: Variables manipulated by the
experimenter
• Usually type of treatment
• Dependent Variables: Factors in which changes are to
be observed
• Usually symptoms of psychological disorders
5
RANDOMIZED CONTROLLED TRIAL
•
Gold standard for outcome research
•
Require
• Large, relatively homogenous samples
• Random assignment to conditions
• Carefully monitored treatment regimens
• Multiple evidence-based measures of dependent variables (e.g.,
symptoms
6
3
11/25/24
WHY RANDOMIZE?
• Ensures balance between the groups on factors that
may affect the response
• Prevents bias
• Selection bias: Assignment of one type of participant to
one group
7
CONTROL GROUPS
•
Assessment only / Waitlist control: Goal is to see if the treatment is
better than no treatment
•
Treatment as usual: Goal is to see if the treatment is better than what
is typically given to patients
•
Active control: Goal is to see if your treatment does better than a
placebo treatment, matching for time and attention
•
Other gold standard treatment: Goal is to see if the treatment you’re
testing is as good as what we already have
8
4
11/25/24
DISMANTLING RESEARCH
• Examines which component of treatment protocol is
active component
• Leads to more streamlined treatments
9
EMDR
• Eye Movement Desensitization and Reprocessing
(EMDR) is a psychotherapy treatment originally designed
to alleviate the distress associated with traumatic memories
• Shapiro (1995, 2001) hypothesizes that EMDR facilitates
the accessing of the traumatic memory network, so that
information processing is enhanced, with new associations
forged between the traumatic memory and more adaptive
memories or information
10
5
11/25/24
DOES EMDR WORK?
• It works better than no treatment for relieving PTSD
symptoms.
• It probably works better than supportive listening (no
intervention from therapist)
• It does not work better or faster than behavioral or CBT
interventions (e.g. exposure)
11
• The eye movements do not improve effectiveness.
11
FIDELITY
•
How do you make sure that everyone gets the same thing?
•
Key issues:
• Therapist effects: Are all study therapists delivering the treatment in
the same way?
• Contamination: Are participants in treatment A getting things from
treatment B?
•
Strategies for maintaining fidelity
• Training
• Continued supervision
• Observation and feedback (e.g., audio, video, live)
12
6
11/25/24
MAJOR CHALLENGES IN CLINICAL
TRIALS
Blinding
Adherence
Dropout
If everyone comes back…
If only people who get better
come back...
20
20
15
15
10
10
5
5
0
0
-5
-5
-10
-10
-15
-15
-20
-20
-25
-25
-30
-30
?
13
CLINICAL TRIALS
• Clinical trials can be designed to answer many different
questions relevant to treatment outcomes
• Is this treatment feasible and acceptable to particular clients?
• Any side effects?
• Is this treatment effective compared to a placebo?
• What is the relative effectiveness of two different treatments?
• Which treatment is best for a given individual?
• What is the best / most efficient dose of treatment?
14
7
11/25/24
CLINICAL TRIALS
•
How long do treatment effects last?
•
What components of the treatment lead to changes?
•
Which delivery mode is associated with the best effects?
•
Can alternate delivery modes improve access while maintaining
efficacy?
•
Are interventions cost effective?
15
MEDIATORS: HOW DOES THE
TREATMENT WORK?
Mediator
Variable
Independent
Variable
Dependent
Variable
+
Behavioral
Activation
Engagement
in activities
Depression
16
8
11/25/24
MODERATORS: WHO DOES THE
TREATMENT WORK FOR?
Moderator
Variable
Independent
Variable
Moderators change the
strength of the relationship
between the IV and DV
Dependent
Variable
Cultural
background
Treatment
Depression
17
18
9
11/25/24
WITHIN-GROUP DESIGN
A. When you assign all individuals to a single
condition and measure them at various points in time
For example, you give an 8-week exercise regimen
and see how depression levels change from week to
week.
19
QUASI-EXPERIMENTAL DESIGN
C. When you assign groups (e.g., classroom) rather
than people to conditions
These designs occur when you aren’t able to
randomly assign people to certain conditions.
20
10
11/25/24
META-ANALYSIS
• Statistical method of combining results of separate studies into
a single summary finding
• Requires a systematic review of the whole literature
• Study findings are translated into effect sizes
• In clinical trials, effect size is often the magnitude or size of the
difference between the two groups
• Can look for moderators, i.e., variables that help to explain why
different studies may have different effect sizes
21
EXAMPLE – META-ANALYSIS
• Meta-analysis examining the relationship between social
support and PTSD symptoms
• 139 studies with 145 cross-sectional effect sizes
• Overall effect size: r = -.27
Moderator
Neffects
r
95% CI
Sample type
Q (df)
8.07(1)**
Civilian
98
-.23
-.26, -.20
Veteran
44
-.32
-.37, -.27
22
11