Alina

PSY 356

Professor Pole
December 22, 2016
Final Paper: Evidence Based Practice

Im writing as a psychotherapy educational consultant for your clinic. Ive been given
Davids case as representative of your clients and will give advice on the therapy that would be
most suitable for them. Its important to stress my advice is based on scientific literature, which
has its advantages and drawbacks. An advantage is empiricism can provide a certainty beyond
personal opinion that a therapy is effective, under some conditions. A drawback is not all
theoretical orientations and techniques are empirically evaluated in equal fairness. Some are
more easily quantifiable (e.g. SUDs in behavioral therapies), while others are based on nonquantifiable elements (e.g. empathy in humanistic therapies). The quantifiable therapies receive
more empirical attention and accumulate a larger body of scientific literature, which may give
them the appearance of greater legitimacy. Also, empirical findings are more likely to be flawed
if theyre about something that, by nature, is less easily quantifiable. The same empirical method
will yield findings of differing degrees of accuracy, depending on the kind of therapy at hand.
With these caveats in place, Ill proceed to present each significant factor in Davids case, the
influence this factor will have on treatment plans and their effectiveness, and the particular
treatment plans we should aim for as supported by the scientific literature.
To begin with more salient factors, David is Puerto Rican and has a low socioeconomic
status. His cultural and socioeconomic background needs to be taken into account by a therapist
if there is to be effective communication and problem solving. For this reason, I recommend that
multicultural therapy (MCT) be the general theoretical orientation. According to MCT a therapist
who doesnt consider a clients unique cultural norms, and instead assumes the client comes from
the same mainstream norms that she does, will inevitably misinterpret the client. Shell miss the
true significance of the clients concerns and behaviors. The scientific literature on MCT is
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limited, but there are clear conclusions. Meta-analyses show although clients prefer clinicians of
similar ethnic backgrounds, clients doesnt improve any more in a matched than in an unmatched
situation (Cabral & Smith, 2011). Its possible the ethnicity of a clinician is less important than
the understanding a clinician has about a clients ethnicity, and this possibility is backed up by
another meta-analysis (Benish et al., 2011). Clients benefitted substantially more from culturally
adapted therapiestraditional therapies adapted to take the clients ethnic background as the
basis from which to evaluate problems and goalsthan from mainstream therapies.
Another study (La Roche et al., 2011) supports the Benish et al. meta-analysis. The
mental imagery content of a relaxation method was originally based on individualism and was
adapted to be based on familialism. This adaptation made the technique significantly more
effective. This finding supports the cultural match theory, which states that the more closely
fitted methods are to a clients unique cultural background, the more effective the therapy will be
for that client. Furthermore this study found that this anxiety-targeted method decreased anxiety
and not depressive symptoms. It supports yet another hypothesis, the specific therapy ingredient
model, which holds that some techniques are more effective for specific disorders and dont work
equally across the board. Various empirical studies all support that anxiety disorder, in particular,
is more effectively treated by certain techniques than others (Chambless & Ollendick, 2001).
Although the La Roche et al. study is limited from having 44 participants and no control
group, I think its findings still have weight for your clinical decisions. Factors in this study have
striking similarity to your clinics circumstances. Not only is the study concerned with Hispanic
culture and anxiety disorders, half of the participants were specifically of Puerto Rican descent.
Also, the study was conducted at a community health center serving low income clients. These
similarities gives this study high internal validity for your clinic. I advise your clinic to take note

of the subtle cultural content inherent in a technique. When possible, alter this content to suit the
clients cultural background. Also I advise that your clinic use techniques that are intended for
the clients particular disorder.
David has generalized anxiety disorder (GAD), characterized by global, cognitive-based
worrying over everyday things, rather than local, physiologically-based fear over special things.
Due to this cognitive basis, I recommend that we draw techniques from cognitive behavioral
therapy (CBT), while taking MCT as our theoretical orientation. In particular, CBT holds that
maladaptive schemas and irrational beliefs give rise to a clients problems. To address these
problems, a therapist helps a client recognize her faulty thinking, identify the facts of reality, and
change her thinking to more closely resemble reality. For example, Davids suspicion against his
caseworker may be explained by his underlying schema that the world is out to get him, which
prevents him from seeing how people try to support him. Another reason to consider CBT is it
has over 1,000 studies, more than any other therapy, that support its effectiveness (Prochaska &
Norcross, 2014). Meta-analyses on specifically adults with GAD show that CBT, compared to
drug treatments, has a greater effect size, lower dropout rates, and more enduring benefits
(Prochaska & Norcross, 2014). Furthermore, CBT is more economical than most other therapies.
The heft of empirical support for and affordability of CBT make it a strong candidate.
Beyond the impersonal level of his diagnosis and ethnic and economic background, its
also important to consider Davids own history. He experienced physical and emotional abuse in
early childhood, a continuous lack of secure attachments, and gang violence into early adulthood.
Given these chronic experiences, its only natural that David has developed schemas that are
maladaptive for his current parenthood situation and give rise to his anxiety, suspiciousness, and
anger problems. Its possible that his past has been so turbulent, and his schemas are so deeply

rooted, that CBT techniques should be supplemented with acceptance and commitment therapy
(ACT) techniques. ACT holds that continuously trying to change a problem or behavior can lead
to greater frustration or anxiety, and exacerbate a clients problems. I think this effect explains
Davids extreme anxiety that results from the pressure to change with losing his children at stake.
It might also explain the intense physiological fear that accompanies his attempts to control his
hostility towards his caseworker. ACT techniques would help David accept his circumstances,
become aware of his emotions, and regulate them. ACT would also help David foreground his
core values, such as his commitment to his children, and use them to motivate his behavioral
work, such as maintaining sobriety. Furthermore, ACT is empirically supported. Meta-analyses
consistently demonstrate that ACT is more effective than no-treatment and similarly effective as
other therapies (Prochaska & Norcross, 2014). Specifically for anxiety disorders, meta-analyses
show ACT has a large effect size greater than both no-treatment and alternative treatments
(Prochaska & Norcross, 2014).
In particular, an influential process-outcome research study shows how CBT and ACT
techniques elegantly complement each other (Hofmann & Asmundson, 2008). CBT aims to alter
the cognitive processes that precede emotional problems, whereas ACT targets those that follow
these problems. Intervening at both points in time, rather than exclusively one, is more balanced
and comprehensive, and would seem to yield a more robust, stable change. Furthermore, while
the goals in CBT are set on changing thought processes, the goals in ACT are more focused on
developing emotional regulation methods. Cognitive styles and emotional habits feed into each
other, so emphasizing the importance of and working on both seems more effective than leaning
more heavily on one or the other. Although this study is not quantitative and asked researchers to

empirically test the ideas, its theoretically sound and cited in over 200 research articles, so I
believe its ideas are reasonable, rigorous, and worthy of your consideration.
I advise that clients like David receive multicultural therapy, by which the therapist
understands Hispanic culture and prioritizes the clients cultural and socioeconomic background
when making treatment choices. The therapist should integrate CBT and ACT techniques and
especially take into consideration techniques intended to address anxiety issues. The therapist
should look carefully at these techniques, find the aspects where mainstream cultural norms
manifest themselves, and adjust these aspects to the clients own cultural norms. I believe this
advice will lead to the most effective and economical treatment for your clients.

References
Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy
and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling
Psychology, 58(3), 279289. https://doi.org/10.1037/a0023626
Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in
mental health services: A meta-analytic review of preferences, perceptions, and outcomes.
Journal of Counseling Psychology, 58(4), 537554. https://doi.org/10.1037/a0025266
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological
interventions: controversies and evidence. Annual Review of Psychology, 52, 685716.
Hofmann, S. G., & Asmundson, G. J. G. (2008). Acceptance and mindfulness-based
therapy: New wave or old hat? Clinical Psychology Review, 28(1), 116.
https://doi.org/10.1016/j.cpr.2007.09.003

La Roche, M. J., Batista, C., & DAngelo, E. (2011). A culturally competent relaxation
intervention for Latino/as: Assessing a culturally specific match model. American Journal of
Orthopsychiatry, 81(4), 535542. https://doi.org/10.1111/j.1939-0025.2011.01124.x
Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical
analysis (Eighth ed.). Stamford, CT: Cengage Learning.