Psychotherapy Outcome Studies Research Articles

A major dilemma in psychotherapy outcome research: Disentangling therapists from therapies.

In interpreting results of psychotherapy outcome studies, particularly those of comparative studies, it is often difficult to disentangle the effects due to the treatments per se from those that may be due to differential competence and other characteristics of the therapists carrying out the treatments. This article attempts to address this general dilemma in psychotherapy outcome research, drawing on the experience and findings of the NIMH Treatment of Depression Collaborative Research Program. Issues discussed include the nature of the overall therapist sample, variability in therapist efficacy, therapist characteristics, training and supervision of therapists, and adherence and competence in carrying out a treatment. Implications discussed include the need to provide, both in presentations of the results of individual outcome studies and in dissemination of information regarding “empirically validated treatments,” critical information about the therapists carrying out the treatment.

Predictors of dropout from psychosocial treatment of cocaine dependence

The current study assessed demographic, drug and psychiatric predictors of dropout in the pilot/training phase of a large, multi-site psychotherapy outcome study for patients with cocaine dependence. The different predictors of dropout were assessed throughout the phases of the study: screening, intake, stabilization and assessment phase, and following randomization to treatment. Results showed that (1) younger patients were less likely to keep their intake appointment. (2) Of the patients who had an intake visit, those who did not complete high school and with more days of cocaine use in the previous month were less likely to complete an initial stabilization and assessment phase requiring 1 week of abstinence from all drugs. A survival analysis was used to examine time to dropout for the 286 patients randomized to individual treatment. (3) Again, younger age was associated with dropout after randomization. (4) Drug use variables did not predict time to dropout. (5) Presence of any current Axis I disorder was associated with later dropout from treatment. Minority treatment information seekers and treatment initiators were less likely to go on to complete the full treatment program.

A Meta-Analysis of School-Based Studies of Counseling and Psychotherapy: An Update

The effectiveness of psychological interventions has long been discussed and studied in the behavioral sciences. In recent years, the quantitative review technique of meta-analysis has been utilized to evaluate effectiveness across a wide variety of therapeutic interventions. The purpose of this study was to apply this technique to school-based outcome studies of counseling and psychotherapy published in a recent 10-year period. In particular, this study updates and extends an earlier meta-analysis focusing on the same question (Prout & DeMartino, 1986). Seventeen studies were identified that met criteria acceptable for use in a meta-analysis and were either conducted in school settings or dealt with relevant school issues or problems. The analysis found an overall effect size of nearly one standard deviation across all studies and outcome variables. These findings support the effectiveness of school-based therapeutic interventions, although this conclusion is offered with some cautions and limitations. These findings apply almost exclusively to group interventions. Further, the greatest impact was on self-report variables and variables reflective of more internal states. Cognitive-behavioral interventions appeared to have the stronger effects, with interventions with elementary students also showing greater impact. Implications for practice and directions for future research are discussed.

The Protocol Deviation Patient: Characterization and Implications for Clinical Trials Research

This paper addresses those patients who neither complete treatment nor drop out from clinical trials but who deviate from the protocol treatment by seeking or receiving additional treatment. Psychotherapy researchers may be missing important information by withdrawing these patients from analyses or combining them with dropouts from treatment. In a multisite psychotherapy outcome study for patients with cocaine dependence, patients who deviated from protocol could be distinguished from completers and dropouts on pretreatment patient characteristics. Patients who deviated from protocol were more likely to be African American, to have higher psychiatric severity, and to have had more previous drug treatment attempts. Data indicate that there is a value in obtaining follow-up assessment after the protocol deviation and including these patients in data analysis to avoid bias in findings. Differential outcome for protocol deviation patients compared to dropouts and completers is discussed. In diesem Beitrag werden Patienten beschrieben, die in klinischen Studien weder die behandlung beenden noch abbrechen, die aber deren Einschlusskriterien nicht erfüllen, weil sie zusätzliche Behandlung erhalten oder suchen. Psychotherapieforschern gehen wichtige Informationen verloren, wenn sie diese Patienten nicht in ihre Analysen mit einbeziehen bzw. wenn sie sie als dropouts behandeln. In einer multizentrischen Untersuchung zum Psychotherapieergebnis bei kokainabhängigen Patienten konnten jene Patienten, die die Kriterien nicht erfüllten, deutlich von den anderen Gruppen im Hinblick auf Mermale vor Behandlungsbeginn differenziert werden. So waren bspw. unter den Patienten, die die Kriterien nicht erfüllten, häufiger Afro-Amerikaner; sie waren psychiatrisch auffälliger und waren im Vorfed häufiger medikamentös behandelt worden. Die Daten zeigen, dass es u. U. sinnvoll ist, diese Patienten katamnestisch mit zu untersuchen und sie ggf. in die Datenanalyse mit einzubeziehen, um Fehler zu vermeiden. Differentielle Therapieergebnisse für die Gruppe von Patienten, die die Kriterien nicht erfüllten, werden im Vergleich zu den dropouts und den Patienten, die die Therapie regulär beendeten, diskutiert. Cet article vise les patients qui ne terminent pas le traitement sans l'abndonner, mais qui dévient du protocole du traitement en cherchant ou en recevant une thérapie additionnelle. Les chercheurs en psychothérapie risquent de rater des informations importantes en retirant ces patients de l'analyse ou en les mêlant aux abandons du traitement. Dans une étude multicentrée au sujet des résultats de psychothérapies pour des patients dépendants à la cocaine, les patients déviant du protocole ont pu être différenciés des patients terminants et des abandons sur la base de caractéristiques relevés avant le traitement. Les patients déviant du protocole avaient plus de chances d'être Afro-Américains, d'être atteints plus gravement sur le plan psychiatrique, et d'avoir traversé déjà plusieurs cures précédentes. Les données indiquent qu'il est valable d'obtenir une évaluation suivie après la déviation du protocole et d'inclure ces patients dans l'analyse des données pour éviter un biais dans les résultats. Les résultats différentiels des des patients déviants du protocole par rapport à ceux qui terminent et aux abandons sont discutées. Este trabjo se refiere a pacientes que no completaron el tratamiento ni abandonaron los intentos clínicos pero que se desviaron del protocolo del tratamiento por buscar o recibir tratamiento adicional. os investigdores en psicoterapia pueden perder importante informatión si retiran a estos pacientes del anélisis o los mezclan con los que abandonaron el tratamienot. En un estudio multicéntrico sobre resultados de la psicoterapia en pacientes con dependencia cocaínca, se pudo diferenciar los que se desviaron del protocolo de los que completaron el tratamiento y de los que lo abandondaron, por medio del use de uso de características obtenidas ante del al tratamiento. Los que se desviaron del protocolo pertenecían en mayor grado al grupo afro-americano; padecín mayor severidad psiquiétrica y habían intentado previamente més tratamientos por drogas. Los datos indican que, para evitar sesgos en los resultados, sn útiles tanto los seguimientos posteriores a la desviación del protocolo como la inclusión de estos pacientes en los anélisis de datos. Se comparan los resultados de los pacientes que se desviaron del protocolo con los que lo abandonaron y los que lo completaron.

Engaging with Clients Cross-Culturally

ABSTRACT Social workers recognize that they must be knowledgeable and competent cross-cultural practitioners to be relevant and effective. While there is an extensive ideological, theoretical, and clinical literature about race and ethnicity, there is little empirical work to provide practitioners with specific and effective principles and/or procedures for use in actual practice. Outcome studies in social work, counseling psychology, and psychotherapy consistently demonstrate that a positive working relationship is associated with positive outcomes across models and that engagement in the initial phase of contact is of central significance. Using existing practice and research knowledge, an approach to cross-cultural engagement is presented. Two key processes in engagement are identified: negotiating compatibility and establishing trust. The role of these processes can be examined through systematic outcome and process research and contribute towards the development of a research based cross-cultural cli...

Psychoanalytic psychotherapy with men with intellectual disabilities: a preliminary outcome study.

Psychotherapy has been demonstrated to be an effective form of treatment for people with psychological problems. However, there is considerable resistance to attempts to generalize these findings to people with intellectual disabilities. Such therapeutic disdain has a long history without any empirical foundation. Recently it has been argued on philosophical grounds that people with intellectual disabilities should have access to the same services as everyone else. Furthermore, that people with intellectual disabilities should be actively targeted as they are more likely to have psychological difficulties than non-handicapped people. The therapeutic literature concerning people with intellectual disabilities is overwhelmingly behavioural. More recently various psychotherapeutic approaches have been explored as alternatives to behavioural interventions. Publication of several case studies in the late 1980s and early 1990s has provided some evidence for the benefit of various psychotherapeutic approaches with people with intellectual disabilities. However, there are no outcome studies. This paper reports an outcome study of individual psychoanalytic psychotherapy provided in normal clinical practice for 25 men with intellectual disabilities who were referred for behaviour problems. Of the 25 participants in the study, 20 completed treatment. In most cases the problem behaviour was eliminated and this was maintained at six months follow-up.

What meta-analyses have and have not taught us about psychotherapy effects: A review and future directions

Sixty-three meta-analyses of psychotherapeutic interventions are reviewed to examine what we have learned from them about the causal nature, magnitude, and generalizability of psychotherapy effects. Despite the large number of meta-analyses demonstrating specific and nonspecific causal effects of psychotherapeutic interventions, limitations in outcome studies and in meta-analytic reviews currently prevent us from drawing strong generalized inferences about the magnitude of effects, conditions that moderate their size, and variables that mediate therapy effects. There is mounting evidence suggesting that biases associated with individual studies do not cancel each other out when studies are combined meta-analytically, leading to inflated mean effect estimates for some interventions, diagnoses, and outcomes, and deflated estimates for others. There is currently little agreement in the reviewed meta-analyses concerning the limits of the apparent robustness of intervention effects, and variables considered as potential moderators of psychotherapy effects are frequently confounded with other study characteristics. Moreover, generalizability of psychotherapy effects to major target universes (e.g., clinical practice settings, African-American and Latino populations) is compromised by the predominance of efficacy studies conducted in controlled research settings on Anglo populations. Future directions for meta-analyses of psychotherapy outcome studies are discussed.

Calibration of measures for psychotherapy outcome studies.

Calibration of measures for psychotherapy outcome studies.

‘Audit-mindedness’ in counselling: Some underlying dynamics

Abstract Some key ideological beliefs that typically inform and underlie ‘audit-mindedness’ in counselling are critically examined. Specifically, and drawing upon the radical and neglected ideas of psycho-social analyst Wasdell, it is argued that the preoccupation with ‘quantity’ and measur-ability that typifies ‘objective’ counselling outcome studies reflects, at least in part, the disintegrative splitting process that pervades technocratic culture; and that this is in turn rooted in the pathological aspects of early developmental experience. Positivist conceptions of the scientific method are seen to be not only fundamentally ideological and pathology-driven, but a singularly inappropriate means of evaluating the efficacy of counselling and psychotherapy. The article then considers the possibility of transforming the ideological belief system that underlies the positivist conception of science which drives the demand for ‘objective’ outcome studies in counselling and psychotherapy. It concludes by consi...

PSYCHOTHERAPY FOR DYSTHYMIC DISORDER

The psychotherapy of dysthymic disorder has received too little serious attention and funding. Impressive advances in the pharmacotherapy of dysthymic disorder should not obscure the need for psychosocial treatment for the high proportion of patients who do not respond to medication. Despite the dearth of psychotherapy outcome studies in this area, such data that do exist suggest that relatively brief, focal, antidepressant psychotherapies may successfully treat many patients with lifelong mood disorders. Maintenance therapy probably is indicated to ensure the persistence of treatment gains.

Validated forms of psychotherapy may lead to better-validated psychotherapy.

The members of Division 12's Task Force on Promotion and Dissemination of Psychological Procedures have recently compiled a list of 22 “well-established treatments” and seven “probably efficacious treatments.” The lists were created after the Task Force had searched for and selected positive psychotherapy outcome studies that met a categorical set of criteria attesting to the methodological adequacy of the studies. Reacting to the Task Force report, Sol Carfield expresses the conviction that we are not yet at the point where we should attempt to draw valid efficacy distinctions among psychological treatments. This commentary describes and analyzes Carfield's concerns, then proposes an alternative effort, designed, like the Task Force endeavor, to move psychotherapy research toward a sustained practical outcome. In contrast to the Task Force approach, the proposed undertaking would draw efficacy distinctions among psychological and pharmacological treatments for a broader range of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) disorders; moreover, it would utilize a dimensional rather than categorical system for judging the methodological adequacy of outcome studies. By comparing the resultant contrasting lists of effective treatments, we should be able to evaluate the differential worth of dimensional and categorical views of methodological adequacy; in so doing, we might be find ourselves in a position to develop even more thoroughly grounded descriptions of effective psychological treatments.

Calibration of measures for psychotherapy outcome studies.

Many findings in psychology, including those in psychotherapy, lack interpretability because measures are not in any meaningful metric. Measures need to be calibrated so as to endow them with inherent meaning. In particular, it is important to calibrate measures against behaviors and real events in people's lives. Approaches to calibrating measures include calibration against direct personal experience, against cross-experiential equivalents, and against cross-modal equivalents, to reflect empirically established behavioral implications as well as just noticeable differences in behavior or between people. Psychological measures may never be as closely calibrated as those for physical properties, but wider reporting of unstandardized regression equations would be of great help. Psychological measures also need to be calibrated against each other so as to permit easy transformations of values or substitutions of measures. Finally, greater standardization of measures is recommended so as to produce better bases for calibration.

What Works in Psychotherapy When It Does Work

Psychotherapeutic methods are proliferating, and a professional eclecticism which incorporates them is also on the rise. In an attempt to filter out the active ingredients in psychotherapy from its inert stylistic embellishments, professionals in the field have been examining the ways psychotherapy is conducted and the results it produces. The consensus of what the latest methods of process research has revealed belies the postulates of most traditional training in psychotherapy. It is the feeling of alliance between the therapist and the patient, as perceived by the patient, not the therapist, that is nwst predictive of good therapeutic outcome (Horvath and Greenberg, 1993; Luborsky, 1994). Disregarding the important variable of individual therapist differences, this single factor is more important than the therapist's theoretical orientation, his or her training, personal analysis, or the length of time that the patient attends therapy. Is there some sense of alliance perceived by those who comprise the placebo groups often used in psychotherapy outcome studies? Might this account for the significant benefits attributed to the placebo effect? What is revealed if we observe the therapeutic alliance outside of the confines of therapy? Healing alliance is naturally sought after by distressed individuals. Dr Frank Reissman, Director of the National Self­ help Clearing House in New York, has pointed out that the benefit accrued to an individual through being understood is a powerful dimension of self-help mutual aid, because of the potential for experiential understanding. Many people benefit from self-help groups or other kindred spirits who rise to the occasion of their needs. learning from the time-honoured placebo

Social phobia with and without avoidant personality disorder: Preliminary behavior therapy outcome findings

The present study is the first psychotherapy outcome study comparing social phobia with and without avoidant personality disorder (APD). Eight social phobic subjects with APD and eight phobic subjects without APD received 8 sessions of behaviorally oriented group therapy for their public speaking anxiety. Before and after treatment, severity measures were taken and subjects were asked to give a talk in front of a small audience. Treatment resulted in the same degree of improved social anxiety and fear of public speaking for both groups. These results add to the literature that questions the validity of distinguishing between avoidant personality disorder and social phobia.

A randomized controlled outcome and follow-up study of Mann's time-limited psychotherapy.

A randomized controlled outcome and follow-up study of Mann's time-limited psychotherapy.

HIV counseling research needs suggested by psychotherapy process and outcome studies.

HIV counseling research needs suggested by psychotherapy process and outcome studies.

HIV counseling research needs suggested by psychotherapy process and outcome studies.

HIV counseling research needs suggested by psychotherapy process and outcome studies.

The Diagnosis and Treatment of Anger in a Cross-Cultural Context

This article proposes that while violent behavior has received much attention, the emotion of anger that may underlay violence, has relatively been ignored in the psychological literature. The status of anger in the psychological and medical literatures is reviewed. A criteria for a proposal of anger disorder for inclusion in DSM are presented. Psychotherapy outcome studies of anger are briefly reviewed. It is proposed that the primary problem in psychotherapy of anger is a failure to reach a therapeutic alliance with clients in order to change their anger. Suggestions for reaching a therapeutic alliance with angry clients and attaining agreement on the explicit goal of changing their anger are presented. Script theories of emotions are presented as an important tool for understanding the therapeutic alliance in different cultural groups. The creation of new scripts that are acceptable to the patients cultural group is presented as one strategy to formulate the therapeutic alliance.

A report of 497 women hospitalized for treatment of bulimia nervosa

Abstract The majority of psychotherapy outcome studies of bulimia nervosa have used outpatient samples. Less is known about the bulimia nervosa patient who requires inpatient treatment. We present data on 497 women treated at an inpatient facility for women with eating disorders along with preliminary 1–3-year follow-up on a subset of the women. Psychometric data suggest that, prior to treatment, the women were of above-average severity in terms of eating disorder and psychiatric symptomatology. Clinically and statistically significant changes in these symptoms were observed during treatment. At follow-up approximately 61% of the women appeared no longer to meet the diagnostic criteria for bulimia nervosa. There was no worsening or further improvement following the first year of follow-up. Results are compared with previous reports of inpatient bulimia nervosa patients.

Comparing Classes of Psychotherapeutic Interventions

This article explores how substantive and methodological differences between English- and German-language psychotherapy outcome studies may have contributed to observed differences in their effectiveness. Data from the meta-analyses by Smith, Glass, and Miller and Wittmann and Matt were reanalyzed to examine the extent to which substantive and methodological differences can account for the difference in the overall effect size of psychotherapy published in English- and German-language sources. The findings indicate that differences in the study of simple phobias, the use of trait inventories as outcome measures, and the selection of effect sizes within studies are likely to have led Smith et al. to overestimate, or conversely, Wittmann and Matt to underestimate the benefits of psychotherapy. Such results suggest that average effect estimates derived for English- and German-language psychotherapy outcomes studies depend on, and have to be interpreted in, the cultural context in which the research is being conducted and reviewed. The comparison between different classes of interventions has to take into account how this context shapes the effect derived for such classes.