Mechanisms Of Therapeutic Change Research Articles

A Bayesian Longitudinal Network Analysis of Panic-Disorder Symptoms and Respiratory Biomarkers

The network theory of psychopathology is gaining popularity as a conceptualization of psychological disorders that may aid the identification of mechanisms of therapeutic change. However, many existing networks do not consider other relevant variables beyond the symptoms themselves. We present a large-scale ( n = 1,873), longitudinal Bayesian network analysis of panic disorder using the symptom items from the Panic Disorder Severity Scale (PDSS) and two respiratory biomarkers (respiration rate and end-tidal CO2) collected during routine monitoring of a capnometry-guided respiratory intervention (CGRI). Our findings offer support for avoidance and fear of panic as drivers of subsequent panic-disorder symptoms over the 4-week course of treatment. Moreover, respiration rate but not end-tidal CO2 was associated with downstream PDSS symptoms. These findings provide further evidence supporting the role of respiratory biomarkers in the maintenance of panic disorder and some support for normalization of dysfunctional breathing as one therapeutic mechanism governing CGRI.

Using virtual reality to understand mechanisms of therapeutic change

Using virtual reality to understand mechanisms of therapeutic change

On the importance of identifying mechanisms and active ingredients of psychological treatments

This commentary addresses the thought-provoking article by Lorenzo-Luaces (in press). We review areas of both agreement and disagreement with the author's points, noting that readers should not infer that research into active ingredients and mechanisms is pointless. We conclude with a call for more research into the mechanisms of therapeutic change and the active ingredients of therapeutic interventions, with the aim of disseminating treatments that are both effective and efficient.

Exploring putative therapeutic mechanisms of change in a hybrid compassion-focused, ecological momentary intervention: Findings from the EMIcompass trial

Compassion-focused interventions represent a promising transdiagnostic approach, but the mechanisms involved in hybrid delivery combining face-to-face sessions and an ecological momentary intervention remain unexplored. The current study aimed at exploring associations of putative mechanisms with clinical outcomes at post-intervention/follow-up and mediation of outcome at follow-up by preceding pre-to post-intervention changes in putative mechanisms. The compassion-focused EMIcompass intervention was applied in an exploratory randomized controlled trial (treatment as usual (TAU) vs. TAU + EMIcompass) with youth with early mental health problems. Data was collected before randomization, at post-intervention and at four-week follow-up. We recruited N = 92 participants, N = 46 were allocated to the experimental condition. After control for baseline levels of the target outcomes, baseline-to post-intervention improvement in adaptive emotion regulation was associated with lower levels of clinical outcomes (e.g. psychological distress b = −1.15; 95%CI = −1.92 to −0.39) across time points. We could not detect indirect effects, but we observed associations of change in self-compassion and adaptive emotion regulation with outcomes at follow-up in the mediation analysis (e.g., β = −0.35, 95%CI = −0.52 to −0.16). If successfully targeted by interventions, self-compassion and emotion regulation may be promising putative therapeutic mechanisms of change.

Cognitive Behavioral Therapy for the Management of Episodic Migraine.

This article provides an overview of the application of CBT in the management of episodic migraine while also providing context and insight into the underlying neurophysiological mechanisms of therapeutic change. It discusses the theoretical foundations of CBT and highlights key components including education, cognitive restructuring, behavioral interventions, relaxation techniques, and lifestyle changes. Cognitive behavioral therapy (CBT) is an empirically based treatment that is well suited for the management of episodic migraine. Although first-line treatments of migraine are typically pharmacological, a review of empirical literature suggests growing evidence for the use of CBT as a standard non-pharmacological treatment of headache conditions. In summary, this article explores evidence supporting the efficacy of CBT in reducing the frequency, intensity, and duration of migraine attacks as well as improving the quality of life and psychological well-being of those with episodic migraine.

Mediators of change in cognitive-behavioral couple therapy for genito-pelvic pain: Results of a randomized clinical trial.

A novel cognitive-behavioral couple therapy (CBCT) has shown efficacy for treating provoked vestibulodynia (PVD), the most common type of genito-pelvic pain, in comparison to topical lidocaine. However, mechanisms of therapeutic change have not been determined. We examined women's and partners' pain self-efficacy and pain catastrophizing as mediators of change in CBCT, using topical lidocaine as a control group. 108 couples coping with PVD were randomized to 12-week CBCT or topical lidocaine and assessed at pre-treatment, post-treatment, and six-month follow-up. Dyadic mediation analyses were conducted. CBCT was not more effective in increasing pain self-efficacy than topical lidocaine, so this mediator was discarded. In women, decreases in pain catastrophizing at post-treatment mediated improvement in pain intensity, sexual distress, and sexual function. In partners, decreases in pain catastrophizing at post-treatment mediated improvement in sexual function. Partners' decreases in pain catastrophizing also mediated reductions in women's sexual distress. Pain catastrophizing may be a mediator specific to CBCT for PVD, explaining improvements in pain and sexuality. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Enhancing Internet-based psychotherapy for adults with emotional disorders using ecological momentary assessments and interventions: Study protocol of a feasibility trial with “My EMI, Emotional Well-being” app

IntroductionEmotional disorders are the most frequent mental health problems globally. To ensure the dissemination of psychological treatments for these conditions, novel forms of delivery (e.g., Internet or mobile apps) and more scalable forms of psychotherapy (e.g., transdiagnostic interventions) have become increasingly popular. Research, however, shows that a significant number of patients, around 40 % according to some studies, do not respond to the interventions as expected (i.e., not-on-track patients). Ecological momentary assessments (EMAs) and ecological momentary interventions (EMIs) could simplify tailoring treatments to the patients' progress and rapidly respond to undesired outcomes during psychotherapy. Therefore, these would facilitate measurement-based care with little therapist involvement. This study aims to explore the feasibility of an app-based system called My EMI, Emotional Well-being for people with emotional disorders. According to daily EMAs, the app will provide personalized EMIs while participants receive a self-applied online transdiagnostic treatment. The app will be used as an add-tool to the online intervention to address emotion dysregulation, foster adherence, and reinforce contents. The current study describes the study protocol for this trial. Method and analysisA single-group, open trial design will be used. Participants will be 30 adults suffering from emotional disorders. Primary outcomes will be app usability, acceptability, and response rates. Secondary outcomes will be either evaluated in Qualtrics at pre-treatment, post-treatment, and 3-month follow-up (depression and anxiety severity, and transdiagnostic dimensions of emotional disorders) or daily throughout the study with the app (EMAs of mood and five transdiagnostic mechanisms of therapeutic change). EMIs will consist of brief, evidence-based transdiagnostic CBT digital content (images, infographics, or videos) delivered just-in-time. Only if problems persist, short phone calls or episodic videocalls will be conducted. The Ethics Committee of the Jaume I University approved the study and all its procedures (CD/111/2021) in December 2021. DiscussionIdentifying personalized and scalable interventions is paramount to improve mental health care, especially its accessibility, and to reduce the psychological distress of people with mental health problems. Feasibility data of the app (EMA and EMI system) supported by a self-applied online transdiagnostic intervention will be important to explore whether this modern approach is a real option to move forward personalized psychological interventions for persons with emotional disorders. Trial registrationClinicalTrials.gov Identifier: NCT05109780. Registered 05 November 2021, https://clinicaltrials.gov/ct2/show/NCT05109780.

The Role of Social Support in Coping with Psychological Trauma: An Integrated Biopsychosocial Model for Posttraumatic Stress Recovery.

This theoretical review proposes an integrated biopsychosocial model for stress recovery, highlighting the interconnectedness of intra- and interpersonal coping processes. The proposed model is conceptually derived from prior research examining interpersonal dynamics in the context of stressor-related disorders, and it highlights interconnections between relational partner dynamics, perceived self-efficacy, self-discovery, and biological stress responsivity during posttraumatic recovery. Intra- and interpersonal processes are discussed in the context of pre-, peri-, and post-trauma stress vulnerability as ongoing transactions occurring within the individual and between the individual and their environment. The importance of adopting an integrated model for future traumatic stress research is discussed. Potential applications of the model to behavioral interventions are also reviewed, noting the need for more detailed assessments of relational dynamics and therapeutic change mechanisms to determine how relational partners can most effectively contribute to stress recovery.

Introduction to the Section: Widening the Scope of Psychodynamic Child and Adolescent Psychotherapy Research: Recent Applications and New Directions

ABSTRACT Recent developments in psychodynamic work with children and adolescents have made empirical research a higher priority in the field. In order to support the evidence-base of psychodynamic child and adolescent psychotherapy, more research is needed to identify the underlying therapeutic processes that make psychodynamic psychotherapy effective for different kinds of children and adolescents and contribute to the literature on therapeutic mechanisms of change. Drawing on the expertise of a range of contributors, this special section describes recent child and adolescent psychodynamic psychotherapy research illustrating a range of quantitative and qualitative methodologies that have been developed to investigate different clinical phenomena, processes of psychotherapy and outcome. These papers will serve as a vital resource helping researchers and clinicians develop clinically relevant research agendas to improve clinical practice and care with children and adolescents.

Acceptability and mechanisms of change associated with group cognitive behavioural therapy using the Recovering from Childhood Abuse Programme among women with CPTSD: a qualitative analysis

AbstractSurvivors of childhood trauma are at increased risk of complex post-traumatic stress disorder (CPTSD). The Recovering from Child Abuse Programme (RCAP) is a cognitive behavioural therapy (CBT) group promoting adaptive coping strategies which may help overcome CPTSD symptoms in adult survivors of childhood trauma. We sought to explore patient experiences of factors influencing treatment acceptability and potential mechanisms of therapeutic change in a sample of participants in the RCAP programme. As the group was delivered during the COVID-19 pandemic, necessitating a transition to remote therapy, we further aimed to capture experiences of the transition to telehealth delivery of the programme. A naturalistic sample of 10 women with CPTSD attending a specialist out-patient psychological trauma service participated in the study. Therapy sessions were recorded, transcribed verbatim and group members completed written feedback forms following each session. Reflexive thematic analysis was used to analyse the written feedback and transcripts. The RCAP was acceptable to group members and several themes were identified related to the experience of change in the group. Key themes centred on group solidarity; safety in the psychotherapeutic process; schema changes related to the self, others and future catalysed by the shifting of self-blame; increased emotional regulation to feel safer in the present; and increased future optimism. Therapeutic progress continued following the transition to telehealth, although face-to-face delivery was generally preferred. The programme was acceptable and led to cognitive change, enabling increased emotional regulation in the present and improved self-concept, thereby addressing key symptoms of CPTSD.Key learning aims(1)To identify potential mechanisms of therapeutic change related to participation in the Recovery from Childhood Abuse group CBT intervention.(2)To understand factors influencing acceptability of the group intervention among women with CPTSD to childhood sexual abuse.

ENhancing Assessment of Common Therapeutic factors (ENACT) tool: adaptation and psychometric properties in South Africa.

The ENhancing Assessment of Common Therapeutic factors (ENACT) tool measures a set of therapeutic competencies required for the effective psychological intervention, including delivery by non-specialists. This paper describes the systematic adaptation of the ENACT for the South African (SA) context and presents the tool's initial psychometric properties. We employed a four-step process: (1) Item generation: 204 therapeutic factors were generated by SA psychologists and drawn from the original ENACT as potential items; (2) Item relevance: SA therapists identified 96 items that were thematically coded according to their relationship to one another and were assigned to six domains; (3) Item utility: The ENACT-SA scale was piloted by rating recordings of psychological therapy sessions and stakeholder input; and (4) Psychometric properties: Internal consistency and inter-rater reliability of the final 12-item ENACT-SA were explored using Cronbach's alpha and intraclass correlation co-efficient (ICC) for both clinical psychologists and registered counsellors. Although the original ENACT provided a framework for developing a tool for use in SA, several modifications were made to improve the applicability of the tool for the SA context, and optimise its adaptability other contexts. The adapted 12-item tool's internal consistency was good, while the inter-rater reliability was acceptable for both clinical psychologists and registered counsellors. The ENACT-SA is a reliable tool to assess common factors in psychological treatments. It is recommended that the tool be used in conjunction with assessment protocols and treatment-specific competency measures to fully assess implementation fidelity and potential mechanisms of therapeutic change.

The active ingredients in a treatment for justice-involved persons with mental illness: The importance of addressing mental illness and criminal risk.

[Correction Notice: An Erratum for this article was reported online in Psychological Services on Oct 8 2020 (see record 2020-75253-001). In the article, the authors listed the wrong version of a measure in the Method section of Study 2. The article should have listed PICTS-Layperson-Short Form (PICTS-L-SF) instead of the PICTS-Short Form (PICTS-SF) as the measure used. The correct citation for the measure appears in the erratum.] Corrections research literature is replete with treatment and intervention outcome studies but lacking empirical examinations of the process of change in justice-involved populations. The current studies expand upon previous outcome evaluations of Changing Lives and Changing Outcomes (CLCO), a treatment program for justice-involved persons with mental illness, by using process research designs to examine therapeutic mechanisms of change. Study 1 used CLCO participants' (n = 264) pre and post module quizzes to examine differences in content retention between Mental Illness, Criminalness, and Both mental illness and criminalness domains to determine if participants differentially learn treatment content. In Study 2, 1 CLCO module was administered to 9 groups of adult men on probation in a residential treatment facility (n = 4 to 8 per group) in 3 iterations: (a) Mental Illness-only content (n = 16), (b) Criminalness-only content (n = 20), (c) Full module (mental illness and criminalness content; n = 22). Results for both studies indicated significant treatment gains across outcome measures of interest (namely content retention and symptomology). Contrary to expectations in Study 1, effect sizes of Mental Illness and Criminalness content retention were similar, suggesting there are not differential effects in the magnitude of content retained between the 2 domains. In Study 2, the integration of mental illness and criminalness content produced greater global improvement than focusing on mental illness or criminalness alone. These results underscore the necessity and effectiveness of integrating mental illness and criminalness in the treatment of justice-involved persons with mental illness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

"The active ingredients in a treatment for justice-involved persons with mental illness: The importance of addressing mental illness and criminal risk": Correction to Scanlon and Morgan (2020).

Reports an error in "The active ingredients in a treatment for justice-involved persons with mental illness: The importance of addressing mental illness and criminal risk" by Faith Scanlon and Robert D. Morgan (Psychological Services, Advanced Online Publication, Jan 16, 2020, np). In the article, the authors listed the wrong version of a measure in the Method section of Study 2. The article should have listed PICTS-Layperson-Short Form (PICTS-L-SF) instead of the PICTS-Short Form (PICTS-SF) as the measure used. The correct citation for the measure appears below. (The following abstract of the original article appeared in record 2020-03338-001.) Corrections research literature is replete with treatment and intervention outcome studies but lacking empirical examinations of the process of change in justice-involved populations. The current studies expand upon previous outcome evaluations of Changing Lives and Changing Outcomes (CLCO), a treatment program for justice-involved persons with mental illness, by using process research designs to examine therapeutic mechanisms of change. Study 1 used CLCO participants' (n = 264) pre and post module quizzes to examine differences in content retention between Mental Illness, Criminalness, and Both mental illness and criminalness domains to determine if participants differentially learn treatment content. In Study 2, 1 CLCO module was administered to 9 groups of adult men on probation in a residential treatment facility (n = 4 to 8 per group) in 3 iterations: (a) Mental Illness-only content (n = 16), (b) Criminalness-only content (n = 20), (c) Full module (mental illness and criminalness content; n = 22). Results for both studies indicated significant treatment gains across outcome measures of interest (namely content retention and symptomology). Contrary to expectations in Study 1, effect sizes of Mental Illness and Criminalness content retention were similar, suggesting there are not differential effects in the magnitude of content retained between the 2 domains. In Study 2, the integration of mental illness and criminalness content produced greater global improvement than focusing on mental illness or criminalness alone. These results underscore the necessity and effectiveness of integrating mental illness and criminalness in the treatment of justice-involved persons with mental illness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Processing of Positive Memories Technique among Clients Reporting Traumatic Experiences: A Case Series

Many current treatments for posttraumatic stress disorder (PTSD) emphasize processing and engaging with trauma memories as the key mechanism of therapeutic change. However, promising emerging research indicates links between PTSD symptoms and positive memories. Processing positive memories, to therapeutically impact health outcomes for trauma-exposed individuals, may have several benefits, including (a) increasing access to positive coping mechanisms via activating positive affect and thoughts; (b) addressing avoidance of positive affect and thoughts; and (c) honing skills that will aid in the eventual processing of trauma memories. The present article demonstrates the utility and effects of a novel Processing of Positive Memories Technique (PPMT) with three clients who reported a history of traumatic experiences. We outline the procedures of a 5-session PPMT, that incorporates symptom assessment, detailed imaginal experiencing of positive memories, and processing of associated positive values, affect, strengths, and thoughts. We utilize longitudinal assessment data to demonstrate the clinical benefits of PPMT, such as less PTSD severity, improved mood (e.g., less negative affect), and greater self-esteem. Finally, we discuss treatment considerations based on unique client factors and treatment modalities (i.e., in-person vs. video telehealth).

Emotion-focused prayer with an emotion friendly God –My exploration of prayer with EFT techniques as a Chinese Christian counsellor

ABSTRACT This research is a self-as-subject heuristic inquiry, designed to provide in-depth qualitative data on the incorporation of a spiritual dimension into an experiential counseling approach. Training in the UK exposed my emotional block to anger, once hidden in a home culture and a Chinese Christian community. I was stuck in a position where I needed the relational capacity to form a trusting therapeutic relationship for therapy to work and yet did not have that very capacity to trust any therapist. Both Emotion-focused therapy (EFT) procedures and Christian prayer healing contributed to a breakthrough on my work with the emotional block, which fascinated and motivated me to explore the integration of the two. My personal interest in searching for therapeutic change mechanisms led me to find God as an emotion friendly Person who was helping me to become such a person. This paper aims to lend perspectives to therapists who work with clients who have a personal relationship with their God, even if the therapist has a different belief system.

Θεραπευτική σχέση και μακρόχρονη ομαδική συστημική ψυχοθεραπεία: μια ποιοτική προσέγγιση

The therapeutic relationship has been highlighted as a major mechanism of therapeutic change in current literature. Existing research has focused on certain qualities of the therapist, such as empathy, acceptance and authenticity, as well as of the client, such as the quality of their interpersonal relationships and their expectations, which enhance the therapeutic alliance. Less is known about the importance of the therapeutic relationship in long-term systemic group therapy. Ten semi-structured interviews were conducted with clients who had completed long-term group therapy following an enriched systemic approach SANE - System Attachment Narrative Encephalon®. Participants were invited to talk about their personal experience of group therapy 2-8 years after its completion. Three higher order themes and six subthemes emerged related to the therapeutic relationship. The higher order themes are: (1) the role of the therapist; (2) the function of the therapist; (3) the qualities of the therapist. The subthemes are: 1.a) the therapist as a source of safety; 1.b) the therapist as a parental role model; 2.a) the expression of the therapist’s feelings; 2.b) the client’s transition from dependency to autonomy; 3.a) the therapist’s personality traits; 3.b) the therapist’s professional role fulfillment. The study aims to contribute to the bibliography of process research of long term group therapy from the clients’ perspective, in order to clarify the parameters of the therapeutic relationship the clients consider more important and helpful.

Altered resting-state functional connectivity of the default mode and central executive networks following cognitive processing therapy for PTSD

Psychotherapy research is increasingly targeting both psychological and neurobiological mechanisms of therapeutic change. This trend is evident in and applicable to post-traumatic stress disorder (PTSD) treatment research given the high nonresponse rate of individuals with PTSD who undergo cognitive-behavioral therapy (CBT). Functional connectivity analyses investigating disrupted brain networks across mental disorders have been employed to understand both mental disorder symptoms and therapeutic mechanisms. However, few studies have examined pre-post CBT brain changes in PTSD using functional connectivity analyses. The current study investigated a) whether brain networks commonly implicated in psychopathology (e.g., default mode network [DMN], central executive network [CEN], and salience network [SN]) changed following Cognitive Processing Therapy (CPT) for PTSD and b) whether change in these networks was associated with PTSD and/or transdiagnostic symptom change. Independent components analysis was implemented to investigate resting-state functional connectivity in DMN, CEN, and SN in 42 women with PTSD and 18 trauma-exposed controls (TEC). Results indicated decreased CEN-cerebellum connectivity in PTSD participants versus TEC prior to CPT and decreased DMN connectivity in PTSD participants after CPT. Additionally, DMN and SN connectivity was related to change in positive and negative affectivity, while exploratory analyses at a cluster threshold of pFDR < .10 indicated DMN and SN connectivity was also related to change in PTSD symptoms and rumination. These findings provide evidence for normalization of CEN connectivity with treatment and implicate the DMN and SN in clinical symptom change following CPT.

A pilot feasibility study of an unguided, internet-delivered cognitive behavioral therapy program for irritable bowel syndrome.

Irritable bowel syndrome (IBS) is linked with lower health-related quality of life. Cognitive behavioral therapy (CBT) designed for IBS management can improve outcomes but further research of more accessible implementations of this treatment approach for IBS is needed. This study assessed the feasibility of a web-delivered CBT program among adults with IBS to apply to a future clinical trial. Twenty-five participants were randomized to receive an unguided web-based, CBT program for IBS. The primary outcome was changes in IBS symptom severity (IBS Symptom Severity Scale [IBS-SSS]). Secondary outcomes included IBS-specific CBT therapeutic mechanisms of change (GI-specific anxiety, unhelpful IBS behaviors, and GI-focused cognitions) and changes in depressive (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder-7 scale [GAD-7]) symptom severity. Among participants randomized to receive web-based CBT, the average baseline IBS-SSS score was 296.3 (SD=100.9). IBS symptom severity significantly improved at 2-month (p<0.001) and 3-month follow-up (p<0.0001); the within-group effect size between baseline and 3-month follow-up IBS-SSS scores was large (d=1.14) and 63.6% experienced a clinically meaningful improvement (ie, ≥50-point IBS-SSS score reduction). GI-specific anxiety symptoms and cognitions significantly improved at 2-month follow-up, as did unhelpful IBS safety behaviors. Additionally, clinically meaningful improvement was observed in depressive and anxiety symptoms at 3-month follow-up among participants with symptoms above the clinical threshold (ie, PHQ-9≥10 and GAD-7≥10, respectively) at baseline. These preliminary findings warrant a larger trial to investigate an unguided, web-based CBT for IBS symptom management that is powered to detect between-group treatment effects.

An exploration of the relationships between patient application of CBT skills and therapeutic outcomes during a two-week CBT treatment

ABSTRACT The application of Cognitive Behavioural Therapy (CBT) skills are believed to be a mechanism of therapeutic change in treatment. Research has shown that the application of CBT skills affects outcomes, however, the way these relationships may change during treatment has not been explored. In this study, a naturalistic observational approach is used to examine the relationships between patients’ wellbeing, symptoms, and the application of CBT skills throughout treatment. It is hypothesized that the application of CBT skills would lead to an increase in patients reported wellbeing, and a decrease in symptoms. Additionally, it was hypothesized that the application of CBT skills affects wellbeing and symptoms at different points in therapy. A sample of 584 patients in a two-week CBT treatment completed session-to-session measures of wellbeing, symptoms, and their application of CBT skills. Results of an autoregressive cross-lagged path analysis indicated that in the early stages of treatment the application of CBT skills predicted patient wellbeing but not symptoms. At the later stages of therapy, the application of CBT skills predicted both patient wellbeing and symptoms. At no point in treatment did patient wellbeing or symptoms predict the later application of CBT skills. Implications and future directions for research are discussed.

The Building of Epistemic Trust: An Adoptive Family’s Experience of Mentalization-Based Therapy

ABSTRACT Recently, theorists have posited the development of epistemic trust – the trust in others as reliable sources of information – as an essential aspect of the therapeutic relationship and a mechanism of therapeutic change. Epistemic trust is likely to be disrupted in adoptive children and families and Mentalization Based Treatment (MBT) aims to explicitly promote its development. Therefore, this study aims to investigate how epistemic mistrust is addressed and how epistemic trust is established within the MBT framework. This single-case, exploratory study reports data from in-depth interviews with one adoptive family, which were analyzed qualitatively using Interpretative Phenomenological Analysis. Two superordinate themes are reported: pre-therapy factors contributing to epistemic mistrust and factors contributing to the development of epistemic trust. The findings highlight two critical elements in establishing epistemic trust: the use of certain clinical skills that help build a secure base within therapy and the possibility of trust being transferred from and to other professionals/systems beyond therapy. Hence, this study informs a deeper understanding of how epistemic trust may be built in therapeutic work with adopted children and identifies possible clinical approaches that may be used by clinicians working with this client group.