Therapist responsiveness is defined as therapist behavior being influenced by emerging context. Responsiveness is ubiquitous and creates serious problems for a ballistic, cause–effect understanding ...of how psychotherapy works. This conceptual literature review examines ways psychotherapy researchers have constructively engaged the responsiveness problem. We note classical approaches to the responsiveness problem and review all available citations of the formulation of the problem by Stiles, Honos‐Webb, and Surko (1998, p. 439), focusing on proposed solutions. We identified N = 58 studies that cited the 1998 article and engaged with the responsiveness problem. These along with additional engagements with the responsiveness problem identified by us and by colleagues were reviewed. We distinguished six categories of ways researchers have addressed the responsiveness problem: (a) demonstrating effects of responsiveness, (b) measuring responsiveness quantitatively, (c) describing responsiveness qualitatively, (d) using evaluative measures, (e) developing responsive clinical interventions, and (f) extending responsiveness concepts to related domains. There are ways to engage the responsiveness problem that are scientifically productive. However, appropriately engaging the problem may require some psychotherapy researchers to ask different questions than they have previously asked.
Previous studies have reported similar recovery and improvement rates regardless of treatment duration among patients receiving National Health Service (NHS) primary care mental health psychological ...therapy.
To investigate whether this pattern would replicate and extend to other service sectors, including secondary care, university counselling, voluntary sector and workplace counselling.
We compared treatment duration with degree of improvement measured by the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) for 26 430 adult patients who scored above the clinical cut-off point at the start of treatment, attended 40 or fewer sessions and had planned endings.
Mean CORE-OM scores improved substantially (pre-post effect size 1.89); 60% of patients achieved reliable and clinically significant improvement (RCSI). Rates of RCSI and reliable improvement and mean pre- and post-treatment changes were similar at all tested treatment durations. Patients seen in different service sectors showed modest variations around this pattern.
Results were consistent with the responsive regulation model, which suggests that in routine care participants tend to end therapy when gains reach a good-enough level.
Not only do treatment, therapist, client, and contextual variables depend partly on each other—confounding effects supposedly assessed in randomized clinical trials (RCTs) of psychotherapy, as Krause ...and Lutz (2009) explained—but the independent variables depend partly on the dependent variables. Therapists and clients can use emerging information about outcome to modify their activity in therapy and so optimize outcome, a phenomenon described as appropriate responsiveness. As a result of appropriate responsiveness, not only are RCTs uninterpretable in terms of experimental effects, but also the hypothesized effects (i.e., differential effectiveness of treatments) tend to be specifically defeated, yielding frequent findings of equivalent effectiveness for theoretically and technically diverse treatments.
In this journal's first article,
Strupp (1963)
pointed to problems specifying independent and dependent variables as a source of slow progress in psychotherapy outcome research. This commentary ...agrees, shows how the concept of variable loses its meaning in psychotherapy research because of participants' responsiveness, and notes an alternative research strategy that does not depend on variables.
Objective: The study aimed to (a) investigate the effect of treatment location on clinical outcomes for patients receiving psychological therapy (a clinic effect, akin to the concept of a therapist ...effect) and (b) assess the impact of explanatory individual and aggregate demographic and process variables on the clinic and therapist effects. Method: The sample comprised 26,888 patients, seen by 462 therapists, across 30 clinics. Mean patient age was 38 years (69% female, 90% White, 92% planned ending). The dependent variable was patients' posttherapy score on the Clinical Outcomes in Routine Evaluation-Outcome Measure. An incremental 3-level multilevel model was constructed. Markov Chain Monte Carlo estimation created 95% probability intervals for the clinic and therapist effects. Results: A 3-level model with no explanatory variables detected a clinic effect of 8.2%, significantly larger than the therapist effect of 3.2%. Adding explanatory variables significantly reduced the clinic effect to 1.9% but did not significantly alter the therapist effect (3.4%). Patient-level symptom severity and employment status, and clinic-level percentage of White patients and health care sector, explained the most clinic outcome variance and overall outcome variance. Conclusions: Substantial variability in clinical outcomes was found between clinics providing psychological therapy. Socioeconomic mix of patients explained significant proportions of variability at the clinic level but not the therapist level. Clinical implications include the need to go beyond the therapist-patient interaction to deliver effective psychological therapy. Future research is also needed to identify the mechanisms by which clinic and/or area-level factors impact on clinical outcomes.
What is the public health significance of this article?
This study demonstrates that typical outcomes for people receiving psychological therapy vary systematically across clinics in the United Kingdom. Levels of (un)employment and ethnic-racial composition may help to explain between-clinics differences in effectiveness. It is important to consider the broader socioeconomic and geographic context in which therapy is offered to improve the effectiveness of psychological interventions.
Coming to terms Stiles, William B.
Psychotherapy research,
07/2011, Letnik:
21, Številka:
4
Journal Article
Recenzirano
The assimilation model is a theory of psychological change that depicts the self as a community of internal voices, composed of traces of the person's experiences. The model suggests that ...disconnection of certain voices from the community underlies many forms of psychopathology and psychological distress. Such problematic voices may be assimilated through psychotherapeutic dialogue by building meaning bridges. Meaning bridges are signs (e.g., words, images, gestures, narratives) that have similar meaning to author and addressee, that is, to the signs' producer and recipient, which may be different people or interacting internal voices. Building meaning bridges is thus a process of coming to terms with problematic voices, which reduces distress and gives access to experiential resources within the self. This article describes and illustrates meaning bridges, voices, signs, and associated concepts as elaborated in a program of research on the assimilation model.
This study aimed to investigate (a) what clients’ within-treatment activity preferences were; (b) whether a match between preferences and psychotherapy approach predicted outcomes and alliance; (c) ...whether scores on preference dimensions, per se, predicted outcomes and alliance. Participants were 470 clients engaging in one of five approaches with trainee psychotherapists. We used the Cooper–Norcross Inventory of Preferences to identify clients’ within-treatment activity preferences; and multilevel modelling to examine the relationship between these preferences – and a match on these preferences – to outcomes and alliance. Clients had an overall preference for therapist directiveness and emotional intensity. We found no evidence of a preference matching effect. Clients who expressed a desire for focused challenge over warm support showed greater progress. Client preferences for focused challenge may be indicative of their readiness to change and indicate a positive prognosis. Further research should directly observe therapeutic practices and assess a range of client variables.
Psychotherapy's equivalence paradox is that treatments tend to have equivalently positive outcomes despite non-equivalent theories and techniques. We replicated an earlier comparison of treatment ...approaches in a sample four times larger and restricted to primary-care mental health.
Patients (n=5613) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) or psychodynamic therapy (PDT) at one of 32 NHS primary-care services during a 3-year period (2002-2005) completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) at the beginning and end of treatment. Therapists indicated which approaches were used on an End of Therapy form. We compared outcomes of groups treated with CBT (n=1045), PCT (n=1709), or PDT (n=261) only or with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1 (n=1035), PCT+1 (n=1033), or PDT+1 (n=530), respectively.
All six groups began treatment with equivalent CORE-OM scores, and all averaged marked improvement (overall pre/post effect size=1.39). Neither treatment approach nor degree of purity ('only' v. '+1') had a statistically significant effect. Distributions of change scores were all similar.
Replicating the earlier results, the theoretically different approaches tended to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, incomplete data, and other issues. Insofar as these routine treatments appear effective for patients who complete them, those who fail to complete (or to begin) treatment deserve attention by researchers and policymakers.
This study examined rates of improvement in psychotherapy as a function of the number of sessions attended. The clients (
N
= 1,868; 73.1% female; 92.4% White; average age = 40), who were seen for a ...variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had planned endings, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and clinically significant improvement (RCSI) on the CORE-OM did not increase with number of sessions attended. Among clients who began treatment above the CORE-OM clinical cutoff (
n
= 1,472), the RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12 sessions (
r
= −.91). Previously reported negatively accelerating aggregate curves may reflect progressive ending of treatment by clients who had achieved a
good enough level
of improvement.
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