Therapist Reports Research Articles

Free to talk about violence: A description of art therapy with a male service user in a low secure unit

A low secure unit is a challenging environment in which to work. This article charts the progress, development and role of art therapy within a low secure ward for male clients within a National Health Service (NHS) setting. Through a case example, it will describe how the image is central to the therapeutic process of treating offending behaviour. I will also explore how art making can build safety and security in different ways through selected examples of art images and accompanying dialogue. The dialogue is selected from a service user report and my own therapist report. Since the 1980s and '90s low secure units have grown around the country. They are subject to continuous public scrutiny, making them tense environments in which to work. I hope that my observations about practice will be of interest to other art therapists working in forensic and related settings. Art therapy approaches in forensic settings vary in their treatment approach to offending behaviour. I will describe the context in detail and explore the practice through a case example.

Obergutachten bei den psychodynamischen Verfahren - ein Beitrag zur Qualitätssicherung in der Richtlinien- Psychotherapie. Ergebnisse aus dem MARS1-Projekt

The study investigates the factors that have a bearing on the development of a chief expert opinion in standardized German psychotherapy (psychodynamic therapies). As part of the MARS project a documentation system was developed to record the sociodemographic, clinical and biographical data of the patients as well as data relating to the therapists and the evaluation of the experts, all of which are contained in the therapist's reports. In a comparison of n = 153 chief expert opinions with n = 291 opinions relating to the control group under the normal process, differences occurred between the two groups with respect to the data on both patients and therapists. Moreover, the system records the frequency with which the individual experts contribute to the initiation of a chief expert opinion over a period of 3 years. Proceedings based on chief expert opinions are initiated with patients who have severe psychopathologies and marginal prognostic prospects. Reservations expressed by the experts refer in particular to the psychodynamics described and the foreseen treatment planning. The qualification and gender of the therapists are certainly an issue for chief expert opinions. The experts themselves contribute with varying degrees to the initiation of an expert opinion. While the role of patients and therapists in the realization of a chief expert opinion comes as no surprise and is in fact testimony to the quality assurance function of the process, considerable differences have emerged in the handling and approach adopted by the experts themselves. Calls for a better coordination process on the part of the experts should not go unheeded.

Physical activity in hospitalised stroke patients.

The aim of this paper was to examine the amount and type of physical activity engaged in by people hospitalised after stroke. Method. We systematically reviewed the literature for observational studies describing the physical activity of stroke patients. Results. Behavioural mapping, video recording and therapist report are used to monitor activity levels in hospitalised stroke patients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6%–69.3%), alone (median 53.7%, IQR 44.2%–60.6%) and in their bedroom (median 56.5%, IQR 45.2%–72.5%). Approximately one hour per day is spent in physiotherapy (median 63.2 minutes, IQR 36.0–79.5) and occupational therapy (median 57.0 minutes, IQR 25.1–58.5). Even in formal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear more common in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels are low in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance our ability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventions to increase physical activity after stroke need to be tested further.

Outpatient psychotherapy practice with adolescents following psychiatric hospitalization for suicide ideation or a suicide attempt

Outpatient treatment is standard care for adolescents discharged following a psychiatric hospitalization. There is little research, however, on the amount and types of psychotherapy these clients receive in the community. We examined therapy attendance and therapist report of outpatient therapy practice with adolescents discharged from psychiatric hospitalization following either a suicide attempt or severe suicidal ideation in the Northeastern USA. Therapists (n = 84) completed a packet of self-report questionnaires regarding treatment of these adolescents in the first six months after discharge from the hospital. Information on number of sessions attended, primary presenting problem, therapist orientation, therapy techniques, and therapeutic relationship was collected. The findings indicated that therapists met their clients in both private and community outpatient settings. The most common modality of treatment was individual therapy, but almost all types of therapeutic techniques were endorsed. Adolescents attended an average of 8.1 therapy sessions (SD = 4.7), with 18% terminating treatment against therapist advice within the first three months. Psychologists, psychiatrists, and social workers used cognitive-behavioral, psychodynamic, and family system techniques about equally. Social workers used humanistic techniques more than their counterparts. The variability in number of therapy sessions attended suggests that many adolescents discharged after a psychiatric hospitalization will not receive adequate care. Short-term therapy protocols designed for community practice emphasizing cognitive techniques may be useful to test in future community-based research trials based on the high percentage of adolescents attending relatively few sessions.

Therapist Personal Agency: A Model for Examining the Training Context

This study reviews the creation and testing of a model of Therapist Personal Agency during MFT training. A model including self-efficacy, trainee developmental level, supervisor working alliance, family of origin relationships, and psychological states was supported by data collected from a national sample of MFT students. The model supported by the data was consistent with much of the previous research regarding the correlates of therapist self-efficacy. Furthermore, the model accounted for 20% of the variance in therapist performance as measured by therapist reports of the working alliance. The results also highlighted the importance of attending to the relationships, interactions, and experiences that take place within the training environment and secondly, the added value that may accrue from focusing on the trainee's extended network of family relationships. A brief case example serves to illustrate the importance of tending to Therapist Personal Agency. In sum, this study provides preliminary support for holistic training methods that focus upon the whole person of the therapist.

Collecting Routine Outcome Data in a Psychotherapy Community Clinic for Young People: Findings from an Ongoing Study.

The paper reports on the collection of routine outcome data from an ongoing audit at a voluntary sector psychotherapy service for young people aged 12 to 21 years in London offering once-weekly psychotherapy. The study uses intake and follow-up data from an ongoing audit of the psychotherapy service that started in 1993; 1608 young people were included in the study. Measures and areas of interest include the Youth Self Report Form, a significant other (SO) version of the Teacher's Report Form, the Young Adult Self Report Form, and the Young Adult Behaviour Check List. Percentage returns at intake were 94% (self), 66% (SO) and 80% (therapist), but became 35%, 21% and 38% at 3-month follow-up, and decreased further at 6- and 12-month follow-up. At all time points, significant other report rates were lower than self or therapist report rates. Young people who did not provide data at intake were more likely to have dropped out of treatment. Over the 15-year period of the audit, intake self-report data rates remained stable (about 94%) whereas SO and especially therapist report rates increased. However, there was a reduction in self, significant other and therapist report rates at 3- and 6-month follow-up. Collecting routine outcome data was compromised by a variety of factors, and systematic efforts, including introducing initiatives for participation are needed to increase follow-up data rates and improve their quality.

A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians.

The goals of this naturalistic, cross-sectional study were to describe the patient, therapist, and therapeutic conditions of an international sample of dissociative disorder (DD) patients treated by community therapists and to determine if community treatment for DD appears to be as effective as treatment for chronic PTSD and conditions comorbid with DD. Analyses found that across both patient (N 280) and therapist (N 292) reports, patients in the later stages of treatment engaged in fewer self-injurious behaviors, had fewer hospitalizations, and showed higher levels of various measures of adaptive functioning (e.g., GAF) than those in the initial stage of treatment. Additionally, patients in the later stages of treatment reported lower symptoms of dissociation, posttraumatic stress disorder, and distress than patients in the initial stage of treatment. The effect sizes for Stage 5 versus Stage 1 differences in DD treatment were comparable to those published for chronic PTSD associated with childhood trauma and depression comorbid with borderline personality disorder. Given the prevalence, severity, chronicity, and high health care costs associated with DD, these results suggest that extended treatment for DD may be beneficial and merits further research.

Physiology-based affect recognition for computer-assisted intervention of children with Autism Spectrum Disorder

Generally, an experienced therapist continuously monitors the affective cues of the children with Autism Spectrum Disorders (ASD) and adjusts the course of the intervention accordingly. In this work, we address the problem of how to make the computer-based ASD intervention tools affect-sensitive by designing therapist-like affective models of the children with ASD based on their physiological responses. Two computer-based cognitive tasks are designed to elicit the affective states of liking, anxiety, and engagement that are considered important in autism intervention. A large set of physiological indices are investigated that may correlate with the above affective states of children with ASD. In order to have reliable reference points to link the physiological data to the affective states, the subjective reports of the affective states from a therapist, a parent, and the child himself/herself were collected and analyzed. A support vector machines (SVM)-based affective model yields reliable prediction with approximately 82.9% success when using the therapist's reports. This is the first time, to our knowledge, that the affective states of children with ASD have been experimentally detected via physiology-based affect recognition technique.

Parents’ involvement in their children's behavioral intervention programs: Parent and therapist perspectives

Although the need for active parent involvement in Intensive Behavioral Intervention (IBI) has been emphasized by professionals in the field, little research has explored this involvement or what it entails. A parent self-report questionnaire and a similar therapist questionnaire were designed for this study, in which parent Involvement and five variables believed to influence Involvement were operationalized and measured. The independent variables included: parents’ Self-efficacy; Knowledge of autism and IBI; Belief in IBI; Perception of Child Progress; and Stress. Forty-eight parents and 34 therapists completed questionnaires about parents’ involvement. Both similarities and discrepancies were noted between parent and therapist report. Parents’ Self-efficacy, Knowledge, and Belief in IBI were significantly correlated with their Involvement. Furthermore, according to parent report, Self-efficacy accounted for almost half of the variance in predicting Involvement, even when controlling for child characteristics. Clinical implications are discussed.

Working Alliance in Adolescent Outpatient Therapy: Youth, Parent and Therapist Reports and Associations with Therapy Outcomes

The perceived quality of the working alliance in psychotherapy has been a consistent predictor of engagement and outcome in adult psychotherapy, yet there is limited research on working alliance in youth psychotherapy, particularly in the context of “usual” community-based services. In this study, we examined working alliance among 78 adolescents referred for community-based psychotherapy, their parents and therapists. We investigated (1) temporal stability of alliance from 1 to 6 months into treatment, (2) consistency among adolescent, parent, and therapist reports of alliances, and (3) associations between alliance and four outcome domains: symptoms, functioning, satisfaction, and environmental impact. We found individual reports of alliance relatively stable from 1 to 6 months into treatment, but consistency among reporters on quality of their alliance was low. We also found adolescent and parent reported alliances with therapists to be positively associated with several outcome indicators.

Little therapy, little physical activity: Rehabilitation within the first 14 days of organized stroke unit care

To examine rehabilitation interventions and resulting physical activity patterns of patients managed in acute stroke units to help inform development of a randomized controlled trial of very early rehabilitation. An open observational study of patient activity and therapist report of patient interventions. A survey of stroke unit resources. Patients less than 14 days post-stroke from 5 metropolitan stroke units were observed over 2 consecutive weekdays at 10-minute intervals between 08.00 h and 17.00 h. Physical activity, location and person(s) present were ascertained at each observation. Therapists completed treatment records. Senior staff completed stroke unit surveys. Patients after stroke (n=58) were with therapists 5.2% of the observed day. Few patients (17.1%) received daily therapy by more than one therapist. When patients received therapy, average session times were 24 minutes of physiotherapy, 23 minutes of occupational therapy and 33 minutes of speech pathology. The more time that family members were present, the longer the treatment time. Four to 11 min of upper-limb therapy was provided. Muscle weakness and left hemiparesis were associated with less upper-limb activity. These acute stroke care units were resourced according to recommended staff-patient ratios. Patients received little therapy and had low levels of physical activity.

Randomized controlled trial of a brief intervention for increasing participation in parent management training.

Evidence-based treatments exist for a range of child and adolescent behavior problems; however, effects are often limited by poor treatment attendance and adherence. The authors developed and evaluated the efficacy of a brief (5 to 45 min) intervention designed to increase treatment attendance and adherence in a sample of 76 parents referred for treatment of their child's oppositional, aggressive, and antisocial behavior. The results of this randomized controlled trial showed that parents who received this brief intervention had greater treatment motivation, attended significantly more treatment sessions, and had greater adherence to treatment according to both parent and therapist report. This study provides researchers and clinicians with a brief and efficacious method of increasing motivation, attendance, and adherence for treatment.

Premature termination as a function of intake data based on ethnicity, gender, socioeconomic status, and income

Although it is acknowledged that premature termination is detrimental to the therapy process, there is limited information on how to utilize client demographic data to indicate which clients have greatest potential to prematurely terminate. The study assessed how client ethnicity interacts with client gender, therapist gender, therapist ethnicity, and client socioeconomic status (education and income) to affect premature termination. The study consisted of 527 cases which received therapy services from the Auburn University Marriage and Family Therapy Center from October 1993 to October 1999. The three definitions of premature termination used were termination after one session, prior to six sessions, and by therapist report. Results indicated that interactions of client income and ethnicity and therapist gender and ethnicity were the most useful demographic data indicators of premature termination.

Toward Effective Quality Assurance in Evidence-Based Practice: Links Between Expert Consultation, Therapist Fidelity, and Child Outcomes

This study validated a measure of expert clinical consultation and examined the association between consultation, therapist adherence, and youth outcomes in community-based settings. Consultant adherence to the multisystemic therapy (MST) consultation protocol was assessed through therapist reports, and therapist adherence to MST principles was assessed through caregiver reports in 2 samples of families (N1 = 178, N2 = 274) and therapists (N1 = 87, N2 = 162). Caregiver reports of youth behavior and functioning were obtained in the second sample pre- and posttreatment. Random effects regression models demonstrated associations between consultant behavior, therapist adherence, and posttreatment youth behavior problems and functioning. Instrumental aspects of consultation supported therapist adherence and improved youth outcomes; supportive aspects of consultation were negatively associated with adherence and outcomes. These findings suggest the availability to clinicians of expert consultation can impact clinician fidelity to a treatment model and child outcomes.

Transporting Efficacious Treatments to Field Settings: The Link Between Supervisory Practices and Therapist Fidelity in MST Programs

Validated a measure of clinical supervision practices, further validated a measure of therapist adherence, and examined the association between supervisory practices and therapist adherence to an evidence-based treatment model (i.e., multisystemic therapy [MST]) in real-world clinical settings. Evidence of linkages between supervisor adherence to the MST supervisory protocol, as assessed through therapist reports, and therapist adherence to MST principles, as assessed through caregiver reports, was obtained from 285 families of youths presenting serious clinical problems, and 74 therapists and 12 supervisors of 16 teams in 9 organizations providing MST across 3 states. The findings provide a valuable step in examining the determinants of therapist fidelity to complex treatments in real-world clinical settings.

Will it hurt? Patients' experience of X-ray examinations: a pilot study

There is a worldwide trend towards involving patients in health care, but little is known about children's expectations of routine radiological procedures. To determine children's perceptions of X-ray examinations. A convenience sample was selected from consecutive patients referred to a children's hospital in Scotland. Children were allocated either to a drawing study ( n=20) or a two-stage interview ( n=25). The investigation was restricted to first-time users of the radiological service aged 7-14 years if accompanied by a parent and consent having been obtained. Children were excluded if pain control was administered in the Accident and Emergency Department. Children's drawings were reported on by an art therapist and a child psychiatrist. All children approached agreed to participate. Seventeen children provided accurate pictures of the X-ray examination room. Concordance existed between the psychiatrist's and art therapist's reports. Children at interview had at least a minimal level of knowledge of X-rays and this was from (1) family, friends and neighbours, (2) the school classroom, and (3) television programmes. Children had anxieties revealed through drawings and interviews. We recommend drawings for establishing children's views of radiology.

Patient Attachment Orientation and the Early Working Alliance-A Study of Patient and Therapist Reports of Alliance Quality and Ruptures

This study investigated the relationship between attachment orientation in adult patients and the early therapeutic alliance. Attachment was measured by self-report following the first session of therapy. The alliance was studied using patient and therapist ratings of its quality and reports of ruptures following early sessions. The sample comprised 30 clinical psychology outpatients treated by 11 experienced therapists. Correlation and multiple regression statistics provided partial support for the hypothesized relationships between attachment orientation and reports of alliance quality and ruptures. In line with predictions, fearful attachment was associated with lower alliance ratings (significantly with patient ratings at sessions 3 and 5 and therapist ratings at session 2) and secure attachment was associated with higher alliance ratings (significantly with therapist ratings at session 5). Preoccupied attachment and dismissing attachment were associated with improvement in alliance ratings over time, although there was some question about the reliability of these findings. Additionally, the frequency of rupture reporting varied with attachment orientation. Preoccupied attachment was associated with more frequent reports of ruptures and dismissing attachment was associated with fewer reports of ruptures. Implications for clinical understanding and future research are discussed.

Temporal interaction of process variables in psychotherapy

A sample of 91 courses of dyadic psychotherapy using different treatment modalities was analyzed in order to study session-by-session dynamics. The process data consisted of therapist and patient session reports and therapy outcome was evaluated by pre-post questionnaires and direct measures of change. After data reduction by principal component analysis, linear time series models of the resulting factors were computed to describe the prototypical dynamical patterns of the sample and of the modality subsamples (cognitive-behavioral, client-centered, schema-theoretical psychotherapy). It was found that the factor of Patient's Sense of Self-Efficacy/Morale governed the observed dynamics of the sample, whereas the therapeutic bond factors did have less impact on the dynamics. The dynamical patterns of client-centered therapies differed from other modalities. The dynamics-outcome findings showed that direct measures of change were associated with a specific process pattern in which the patient's sense of self-efficacy was supported by other process variables.

Outcome and Six Month Follow Up of Patients After Ultra Rapid Opiate Detoxification (URODSM)

Objectives -(1) Evaluate the safety and efficacy of Ultra Rapid Opiate Detoxification (UROD); and (2) evaluate six month outcome data of patients choosing this method. Design -Two center parallel group clinical trial. No grant funding. Setting -Two academic medical centers. Participants -Ninety-three men and 27 women, aged 18 to 55 years, with opiate dependency self selected to undergo detoxification. Interventions -UROD followed by naltrexone maintenance and an aftercare program. UROD and aftercare costs were the responsibility of the patients and/or their significant others. Main Outcomes Measure -(1) Completion of UROD as determined by a non reactive response to a naloxone challenge test under anesthesia and non reactive response to naltrexone administration before discharge. (2) Patient outcome as determined at six month follow up of UROD patients' self reported relapse free status confirmed by urine drug screen, significant other reports, and/or therapist reports. Results -One hundred percent successful detoxification with UROD with low morbidity and no mortality. Relapse data were available for 111/123 procedures performed (90%), with 61/111 patients (55%) with reported relapse free status at the six month follow up interval. Conclusions -For individuals who are addicted to opioids, the Ultra Rapid Opiate Detoxification method appears to be a viable treatment option.

A naturalistic study of psychotherapeutic methods and client in-therapy functioning in a child community setting

Utilized a naturalistic methodology to examine treatment responses associated with major psychotherapeutic methods in 150 youth aged 11 to × 7 years old in a community mental health center. Treatment methods were not experimentally controlled but were measured retrospectively by therapist report. Treatment response was assessed by a composite of 6 measures completed by clients, patients, and therapists. Pretest/posttest comparisons indicated improved functioning in the sample as a whole. Treatment response was not related to the proportion of therapy using individual, family, or group modalities. Therapy response positively associated with extent of use of cognitive therapy. Social skills training, behavior therapy, and family systems therapy were associated with more positive treatment response in soma subgroups of clients. The number of approache4 used in w individual case (technical eclecticism) was positively related to client response. Treatment response was more consistently related to level of client and parent functioning in therapy than to treatment method.