Target Complaint Research Articles

How therapists' emotion recognition relates to therapy process and outcome.

Empathy is an essential characteristic for therapists that explained 9% of the variance in treatment outcomes. Many measures of empathy are based on self-report questionnaires. Therefore, they reflect how a person perceives his empathic abilities, which can be biased from his true abilities. The ability to recognize emotions has been found to be related to empathy and serves as a measure for the use of empathic abilities. In this study, we examined therapists' empathic abilities, using a novel task for recognizing emotions, and looked at how they related to the therapy process and outcomes. The study included 33 patient-therapist dyads. Therapist empathy was assessed with an emotion detection task, the JeFEE. Clients filled questionnaires after each session regarding therapy progress and their symptoms. We found that emotion recognition moderated the change in (a) client secure attachment to therapist, (b) client avoidant attachment to therapist, (c) client working alliance, (d) client rate of tense or upset they felt during the session, (e) client lack of emotional clarity of emotions, (f) client non-acceptance of emotional responses, (g) client overall emotion regulation and (h) client main target complaint. Implication for therapy and therapists' selection and training are discussed.

Negotiating therapeutic alliances with a family at impasse.

To bridge the science-practice gap, the APA Presidential Task Force endorsed the publication of evidence-based case studies, but to date, there have been few such investigations of conjoint family therapy. To fill this gap, we studied a successful case of treatment-as-usual in a community agency. Owing to the complexity of the working alliance in conjoint therapy, we examined how an experienced family therapist managed to develop and sustain multiple alliances over time with an estranged couple in crisis. The outcome data showed clinically meaningful changes as well as high satisfaction levels and notable declines in the target complaint discomfort levels of all family members. Alliance indicators showed that the therapist worked diligently over time to connect emotionally with each family member and to foster and maintain safety. Session impact scores showed consistently deep sessions but more variability in smoothness. By working toward the only shared treatment goal-to repair each parent's individual relationship with their very angry daughter-the therapist was able to reduce the effect of the marital estrangement on the child. At the end of the 10 contracted family sessions, the parents agreed to begin working on their relationship in couples therapy, which led shortly thereafter to a reconciliation.

Treatment of Paranoid Personality Disorder with Cognitive Analytic Therapy: A Mixed Methods Single Case Experimental Design

Paranoid personality disorder (PPD) presents as chronic and widespread interpersonal distrust, whereby the actions of others are interpreted as malevolent and malicious. This research details the assessment, formulation and treatment of a case of PPD within a 24-session contract of cognitive analytic therapy (CAT). The outcome methodology was an A/B with extended follow-up single case experimental design (SCED). The SCED was supplemented with qualitative patient interviewing via the Change Interview regarding their experience of CAT, whether change had taken place and detailing of any identified change mechanisms. Quantitative results show that five out of the six daily rated paranoia target complaint measures were extinguished during the treatment phase. Qualitatively, the patient attributed change to the therapy conducted. The results suggest that CAT was an effective intervention in this case of PPD and are discussed in terms of identified methodological shortcomings, treatment implications and the potential for generating a convincing evidence base for the psychotherapy of PPD. Narrative reformulation using a CAT model offers a key opportunity for the patient to achieve a new understanding of their paranoia. Psychotherapy for PPD requires a cognitive component, within a boundaried and relational therapy, that is able to reflect on paranoid enactments and ruptures within the therapeutic relationship.There is a large role for clinician-researchers in developing a PPD outcome evidence base.

Persekütuar Tip Sanrısal Bozuklukta Bütünleyici Psikoterapi Yaklaşımı: Bir Olgu Sunumu / Integrative Psychotherapy for a Patient with Delusional Disorder Persecutory Type: A Case Study

In this case report integrative psychotherapy with cognitive-behavioral, psychodynamic, and supportive psychotherapy techniques were used to provide treatment to the patient with delusional disorder, persecutory type. The patient was stable on antipsychotics and antidepressants during the psychotherapy process. The patient’s main delusion was being followed and called ‘loser’ by others. He believed people on the street knew he had not worked and devalued him for not having worked. In the beginning of the therapy, the patient was able to finish his exercise, i.e. walking, 40% of the time, only with great anxiety. During the therapy, the patient’s thoughts, feelings, and behaviors were followed using cognitive-behavioral forms. Several forms including tracking degree of thought, using the vertical descent, cost-benefit analysis, point and counter-point, examining the evidence were used to track the patient’s progress. In addition, the patient’s problematic relationships with his family were discussed from a psychodynamic perspective in order to provide meaning and insight into the source of his difficulties. When the therapy ended, the patient was able to complete his exercise 90% of the time he attempted walking in the park, which suggested an improvement in his target complaint.

The Effect of Working Alliance on Adherence and Outcome in Cognitive Remediation Therapy

Cognitive remediation therapy (CRT) for schizophrenia has been effective in improving cognitive and global functioning outcomes. It is now important to determine what factors maximize benefit. The quality of relationship--or working alliance--between clients and therapists may be one such factor that improves outcome. To investigate this, 49 individuals with schizophrenia were recruited into a naturalistic study of the impact of CRT on work and structured activity outcomes. Participant's cognitive skills, severity of symptoms, and social skills were assessed at baseline. Both client and therapist working alliance ratings were gathered early in therapy. After controlling for depression, clients who rated the alliance more favorably stayed in therapy longer and were more likely to improve on their main target complaint but notably not on working memory performance or self-esteem. Therapist's ratings of the alliance were not associated with memory outcome. These findings indicate that working alliance is important for client satisfaction with therapy.

Development of working alliance over the course of psychotherapy

The goal was to investigate patients' rating of working alliance in longer-term individual psychotherapy (N=201), in order to determine different patterns of development and predictors of positive versus negative development. The study explored patient factors that might be associated with positive versus negative development of the alliance, from early in treatment until the end. Subgroups of patients with different alliance development were compared, in order to identify predictors of these groups. The data analyses identified patients who demonstrated significant change in the perceived quality of alliance using the reliable change index. Most patients were expected to have a stable alliance, and fewer were expected to have improving or deteriorating alliance. We found three patterns: stable alliance, improving alliance, and deteriorating alliance. Seventy per cent of the therapies had a stable alliance, which was maintained throughout the treatment, supporting the assumption that the quality of the early alliance is important for the therapy process. We observed different pre-treatment scores of Target Complaint and Expectation of Change in Target Complaint between the subgroups with different development of the working alliance. Higher Expectation of Change was associated with improving alliance, whereas the combination of higher Target Complaint scores and lower Expectation of Change was associated with deteriorating alliance. Also, lower score on Global Assessment Scale (<50) was associated with deteriorating alliance. Clinical case vignettes illustrate the developments of improving and deteriorating alliance. Several pre-treatment patient characteristics were associated with development of alliance in positive versus negative directions. Clinical implications are discussed.

Emotion‐Focused Couples Therapy and the Facilitation of Forgiveness

The goal of this study was to evaluate the effectiveness of an emotion-focused couple therapy intervention for resolving emotional injuries. Twenty couples acting as their own waitlist controls were offered a 10-12-session treatment to help resolve unresolved anger and hurt from a betrayal, an abandonment, or an identity insult that they had been unable to resolve for at least 2 years. Treated couples fared significantly better on all outcome measures over the treatment period compared to the waitlist period. They showed a significant improvement in dyadic satisfaction, trust, and forgiveness as well as improvement on symptom and target complaint measures. Changes were maintained on all of the measures at 3-month follow-up except trust, on which the injured partners deteriorated. At the end of treatment, 11 couples were identified as having completely forgiven their partners and six had made progress toward forgiveness compared with only three having made progress toward forgiveness over the waitlist period. The results suggest that EFT is effective in alleviating marital distress and promoting forgiveness in a brief period of time but that additional sessions may be needed to enhance enduring change.

An Exploratory Outcome Comparison between an Ericksonian Approach to Therapy and Brief Dynamic Therapy

The purpose of this study was to determine whether an Ericksonian approach to therapy using hypnosis (ET) was as effective as brief dynamic therapy (BDT), a long-standing and well-researched form of psychotherapy. The study used a comparative pretest/posttest design with four paper and pencil tests [Clark Personal and Social Adjustment Scale (CPSAS), Hopkins Symptom Checklist (HSCL), Target Complaint (TC), and Global Improvement (GI)] and six therapy sessions. The investigators attempted to choose design features that would not interfere with the unique qualities of ET while maintaining empirical regularity. No statistically significant difference was found except on HSCL where ET was superior. An interesting finding was that without direct discussion of the target complaint, ET brought about the same improvement on targeted problems as BDT. ET subjects reported gaining understanding of their problems as much as BDT subjects, but from a different source. The results of this study are a step toward empirical confirmation of ET as an evidence-based treatment alternative for psychotherapy.

Client–therapist agreement on target problems, working alliance, and counseling outcome

It is widely asserted that clients and therapists should agree on which client problems are to be the focus of treatment. According to working alliance theory, client–therapist agreement on therapy objectives contributes to treatment success. However, few empirical studies exist of the relevance of target problem agreement to therapy outcome. We examined the relationships among actual client–therapist agreement on target problems, working alliance (perceived agreement), and therapy outcome. Client–counselor dyads completed target complaint lists and symptom ratings at 3 points during therapy. Improvement and working alliance ratings were also completed after the 4th session and at a final ratings point. Fourth-session target complaint agreement and working alliance contributed to the prediction of therapy outcome. However, actual target complaint agreement was unrelated to working alliance (perceived agreement) ratings. Implications for working alliance theory are discussed.

Insight and symptom reduction in time-limited psychoanalytic counseling.

The contention that client insight causes symptom reduction was examined for 12 clients who completed 20 sessions of psychotherapy. Clients rated target complaints before each counseling session and completed the Important Events Questionnaire (IEQ; A. L. Cummings, J. Martin, E. T. Hallberg, & A. G. Slemon, 1992) after each counseling session. Counselors rated target complaints for their clients after each session. Three judges rated the IEQs using the Insight Rating Scale (IRS; R. W. Morgan, L. Luborsky, P. Crits-Christoph, H. Curtis, & J. Solomon, 1982). Validity of the IRS was established by examining the relationship between IRS ratings, counselor-judged insight, and counts of client insight statements. Regression analyses showed that clients had significant linear increases in insight and significant linear decreases in target complaint distress across the 20 counseling sessions. Time-series analyses showed that increases in insight led reductions in target complaints. These results support the importance of insight for symptom reduction.

EFFECTS OF A COMMUNICATION TRAINING COMPONENT ADDED TO AN EMOTIONALLY FOCUSED COUPLES THERAPY

In this study a 4‐session communication skills training component was added to an 8‐session Emotionally Focused couples therapy package. This treatment (EFT + CT) was compared to 12 sessions of Emotionally Focused therapy (EFT) to investigate whether the communication training component enhanced the effectiveness of EFT, and both treatments were compared to a wait‐list control. Both treatments achieved superior gains at posttest compared to the control group on measures of marital adjustment and target complaint improvement (but not on intimacy and passionate love), with EFT + CT being superior on communication. The only differential treatment effect was EFT's superiority on target complaints at follow‐up.

EMOTIONALLY FOCUSED COUPLES THERAPY: AN OUTCOME STUDY*

In a within‐subjects design in which couples acted as their own controls, assessment was completed at four times: at the time of intial contact, after an eight‐week waiting period, after eight sessions of Emotionally Focused Marital Therapy, and at an eight‐week follow‐up. Couples reported no significant changes on measures of dyadic adjustment, intimacy, target complaint reduction and goal attainment after the waiting period, but significant changes were found after treatment.

Differential effects of experiential and problem-solving interventions in resolving marital conflict.

The present study compared the relative effectiveness of two interventions in the treatment of marital discord: a cognitive-behavioral intervention, teaching problemsolving skills, and an experiential intervention, focusing on emotional experiences underlying interaction patterns. Forty-five couples seeking therapy were randomly assigned to one of these treatments or to a wait-list control group. Each treatment was administered in eight sessions by six experienced therapists whose interventions were monitored and rated to ensure treatment fidelity. Results indicated that the perceived strength of the working alliance between couples and therapists and general therapist effectiveness were equivalent across treatment groups and that both treatment groups made significant gains over untreated controls on measures of goal attainment, marital adjustment, intimacy levels, and target complaint reduction. Furthermore, the effects of the emotionally focused treatment were superior to those of the problem-solving treatment on marital adjustment, intimacy, and target complaint level. At follow-up, marital adjustment scores in the emotionally focused group were still significantly higher than those in the problem-solving group.

Two helping alliance methods for predicting outcomes of psychotherapy. A counting signs vs. a global rating method.

This paper reports on the development of measures of helping alliances in psychotherapy, i.e., the patient's experience of the treatment or relationship with the therapist as helpful, or potentially helpful. The helping alliance counting signs measure, which is the special focus of this paper, entails the counting of certain types of patient statements (signs) which are identified in a manual. The main findings were: a) these types of statements were found to be "scorable" with moderate interjudge agreement; b) scores based on the manual showed moderate agreement with a similar helping alliance manual based upon global ratings; c) scores were fairly to moderately consistent from early to late in treatment; d) scores predicted outcome significantly, e.g., early positive signs of helping alliance correlated .57 (p less than .01) with rated benefits, and .59 (p less than .01) with change in the first target complaint (Battle, C., Imber, S., Hoehn-Saric, R., et al. Target complaints as criteria of improvement. Am. J. Psychother., 20: 184-192, 1966); and e) basic background similarities between patient and therapist, such as in age and religious activity, attained highest correlations with the helping alliance measure, e.g., the sum of 10 similarities correlated .60 (p less than .01) with early positive helping alliance counting signs.

Addition of time-limited psychotherapy to medical treatment in a general medical clinic. Results at one-year follow-up.

This study compares 72 patients screened for significant emotional problems and treated only by internists of a general medical clinic with 62 patients also treated by internists but completing in addition 10 weekly psychotherapeutic visits. Forty-one patients did not keep their initial appointments and 69 patients dropped out of treatment but are not considered in this report. These patients, from inner-city Baltimore, were socially and economically a highly disadvantaged group. At intake, the 62 patients who completed psychotherapy and the 72 patients treated only by internists were equal demographically and in diagnosed physical illnesses. The two groups were approximately equal in the extent of emotional disturbance. All patients were followed up at 4 months and 1 year after intake. Methods of evaluation included a 7-point self-report of global improvement, the 58-item Hopkins Symptom Checklist, the primary target complaint, scaled clinical estimates of psychosocial adjustment, and scaled data from systematic review of medical charts. Significantly more patients undergoing the psychotherapy remained improved at 1-year follow-up, independent of age, sex, degree of disability, diagnosed medical illnesses, level of emotional disturbance, and employment status. While there was evidence of a common denominator to therapeutic results in both groups, the data strongly suggests specific effects of psychotherapy.

A multiple baseline study of systematic desensitization in a patient with multiple phobias

This study investigated the effectiveness of desensitization in a multiple baseline design. A patient with multiple phobias was assessed for the intensity of each fear using a target complaint scale. Separate baselines were established for each phobia and then contact and imagery-based desensitization were sequentially applied to each phobia in turn. The therapist was a mental health technician in a community mental health center. Each fear showed significant and reliable decreases as a function of the application of desensitization. Behavioral observations confirmed the successful outcomes as reflected in the self-report data. Followup at two months after termination indicated maintenance of the therapeutic effects.