The Relationship Between Dropout and Outcome in Naturalistic Cognitive Behavior Therapy

Dropout from psychotherapy is frequent and limits the benefits patients can receive from treatment. The study of factors associated with dropout has the potential to yield strategies to reduce it. This study analyzed data from a large sample of adults (N = 1,092) receiving naturalistic cognitive behavioral therapy (CBT) to test the hypotheses that dropouts, as compared to completers, had (1) higher symptom severity at treatment termination, (2) a slower rate of symptom change during treatment, and (3) a higher odds that the therapist rated treatment as ending for reasons related to poor outcome. Results showed that although dropouts ended treatment with higher symptom severity than completers, dropouts and completers did not differ in their rate of symptom change during treatment, suggesting that dropouts had higher symptom severity at termination because they received fewer sessions of treatment, not because their symptoms changed at a slower rate. Dropout was also associated with a higher odds of having a therapist-rated termination reason indicating a poor outcome, suggesting that dropout is more likely if patients are dissatisfied with some aspect of the therapy outcome or process. These findings suggest that strategies for monitoring and enhancing patient satisfaction with the process and outcome of treatment may help patients stay in treatment longer and end treatment with fewer symptoms than if they had dropped out.     

Affective and health-related outcome expectancies for physical activity in older adults

This study tests the effects of affective and health-related outcome expectancies on physical exercise, assuming stronger direct and indirect (via intention) effects from affective outcome expectancy to physical exercise than from health-related outcome expectancy to exercise. Physical exercise and social cognitive variables were assessed at baseline, and 6- and 12-month follow-up in 335 older adults (60-95 years of age). Applying structural equation modelling, there was a direct effect from affective, but not from health-related outcome expectancy on intentions and behaviour. Also, the indirect effect from self-efficacy on physical exercise via affective outcome expectancy was significant, whereas the mediation via health-related outcome expectancy was not. These findings emphasise the relative importance of affective versus health-related outcome expectancies in predicting intentions and physical exercise in older adults and highlight the importance to separate these facets at a conceptual level to enhance both theory development and health promotion.     

Affective and health-related outcome expectancies for physical activity in older adults

This study tests the effects of affective and health-related outcome expectancies on physical exercise, assuming stronger direct and indirect (via intention) effects from affective outcome expectancy to physical exercise than from health-related outcome expectancy to exercise. Physical exercise and social cognitive variables were assessed at baseline, and 6- and 12-month follow-up in 335 older adults (60–95 years of age). Applying structural equation modelling, there was a direct effect from affective, but not from health-related outcome expectancy on intentions and behaviour. Also, the indirect effect from self-efficacy on physical exercise via affective outcome expectancy was significant, whereas the mediation via health-related outcome expectancy was not. These findings emphasise the relative importance of affective versus health-related outcome expectancies in predicting intentions and physical exercise in older adults and highlight the importance to separate these facets at a conceptual level to enhance both theory development and health promotion.     

Effects of Communication Expectancies,Actual Communication,and Expectancy Disconfirmation on Evaluations of Communicators and Their Communication Behavior

The current investigation addressed (a) the perseverance of preinteraction expectancies in the face of actual communication behavior, (b) the separate effects of personal attribute and communication expectancies, and (c) the role of expectancy confirmation or disconfirmation on postinteraction evaluations. Participant perceivers were induced to hold positive or negative expectancies regarding a target partner's general personal attributes and specific communication behavior prior to a problem-solving discussion. They then interacted with a confederate target who communicated in a pleasant, involved fashion or its opposite, after which perceivers evaluated target personal attributes and communication behavior. All three hypotheses received at least partial support. Preinteractional expectancies, especially personal attribute ones, caused perceivers to evaluate targets and their communication behavior differently, with negatively valenced expectancies serving as negative violations. Relative to a pleasant, involved communication style, unpleasant, uninvolved communication was less expected and evaluated negatively, thus functioning as a negative violation; it also reduced credibility, attraction, and perceived rewardingness of the target. Finally, disconfirmatory communication altered target evaluations relative to confirmatory communication, especially for high-valence targets. These results lend support to the premises and predictions of expectancy violations theory.     

A Community Mental Health Implementation of Parent–Child Interaction Therapy (PCIT)

Parent–Child Interaction Therapy (PCIT) has been identified as an evidence-based practice in the treatment of externalizing behavior among preschool-aged youth. Although considerable research has established its efficacy, little is known about the effectiveness of PCIT when delivered in a community mental health setting with underserved youth. The current pilot study investigated an implementation of PCIT with primarily low-socioeconomic status, urban, ethnic minority youth and families. The families of 14 clinically referred children aged 2–7 years and demonstrating externalizing behavior completed PCIT initial assessment, and 12 began treatment. Using standard PCIT completion criteria, 4 families completed treatment; and these families demonstrated clinically significant change on observational and self-report measures of parent behavior, parenting stress, and child functioning. Although treatment dropouts demonstrated more attenuated changes, observational data and parent-reported problems across sessions indicated some improvements with lower doses of intervention. Attendance and adherence data, referral source, barriers to treatment participation, and treatment satisfaction across completers and dropouts are discussed to highlight differences between the current sample and prior PCIT research. The findings suggest that PCIT can be delivered successfully in an underserved community sample when families remain in treatment, but that premature dropout limits treatment effectiveness. The findings suggest potential directions for research to improve uptake of PCIT in a community service setting.     

The Nature,Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.     

Gender and Context Differences in Alcohol Expectancies

Abstract

In 2 studies, the authors investigated gender and context effects of alcohol expectancies among U.S. college students. In Study 1, they examined the responses of 771 women and 493 men to the Sexual Enhancement (SE) subscale and the Relaxation and Tension Reduction (TR) subscale of the Alcohol Expectancy Questionnaire (S. A. Brown, B. A. Christiansen, & M. S. Goldman, 1987). They found no gender differences when they controlled for drinking quantity. When they controlled for drinking frequency, the men scored significantly higher on the TR subscale than the women did. In Study 2, also among U.S. college students, 41 women and 21 men first imagined that they were on blind dates or in long-term relationships and then completed the SE and TR subscales. On the SE subscale, the women scored higher in the relationship context than in the blind-date context, whereas the men did not vary between contexts. All the participants also reported more tension-reduction expectancies in the relationship context than in the blind-date context.     

Gender and context differences in alcohol expectancies

In 2 studies, the authors investigated gender and context effects of alcohol expectancies among U.S. college students. In Study 1, they examined the responses of 771 women and 493 men to the Sexual Enhancement (SE) subscale and the Relaxation and Tension Reduction (TR) subscale of the Alcohol Expectancy Questionnaire (S. A. Brown, B. A. Christiansen, & M. S. Goldman, 1987). They found no gender differences when they controlled for drinking quantity. When they controlled for drinking frequency, the men scored significantly higher on the TR subscale than the women did. In Study 2, also among U.S. college students, 41 women and 21 men first imagined that they were on blind dates or in long-term relationships and then completed the SE and TR subscales. On the SE subscale, the women scored higher in the relationship context than in the blind-date context, whereas the men did not vary between contexts. All the participants also reported more tension-reduction expectancies in the relationship context than in the blind-date context.     

Expectancy Accessibility and the Influence of Outcome Expectancies on Adolescent Smokeless Tobacco Use

This study investigated the moderating influence of expectancy accessibility on the relation between outcome expectancies and drug use intentions. Specifically, it was hypothesized that expectancies made temporarily more accessible would predict smokeless tobacco intentions to a greater degree than would less accessible expectancies. In addition, it was anticipated that expectancies regarding positive outcomes of smokeless tobacco use would be better predictors of intention than would expectancies about negative outcomes. Results partially supported the accessibility hypothesis, but this effect occurred for positive outcome expectancies only. In addition, the anticipated prepotency of positive over negative expectancies in predicting drug use intentions was strongly supported. These findings are consistent with theories of problem behavior which differentiate between positive and negative outcome expectancies and which postulate that accessibility of expectancies plays an important role in expectancy-behavior relations.     

Thinness and eating expectancies predict subsequent binge-eating and purging behavior among adolescent girls

One's expectancies for reinforcement from eating or from thinness are thought to represent summaries of one's eating-related learning history and to thus influence the development of binge-eating and purging behavior. In a 3-year longitudinal study, the authors tested this hypothesis and the hypothesis that binge eating also influences subsequent expectancy development. The authors used trajectory analysis to identify groups of middle school girls who followed different trajectories of binge eating, purging, eating expectancies, and thinness expectancies. Initial eating and thinness reinforcement expectancies identified girls whose binge eating and purging increased during middle school, and expectancies differentiated girls who began these problem behaviors from girls who did not. Initial binge-eating scores differentiated among eating expectancy developmental trajectories. The onset of most behaviors can be understood in terms of learned expectancies for reinforcement from these behaviors. The same model can be applied to the risk for eating disorders.     

Self-fulfilling effects of stigmatizing information on children's social interactions.

The stigmatizing effects of negative expectancies were examined in observations of interactions between children with and without a behavior problem. Ss were 68 pairs of unacquainted boys in Grades 3-6. In each dyad, a normal boy was either told that his partner had a behavior problem or given no expectancy; this expectancy manipulation was crossed with the partner's actual diagnostic status with respect to hyperactivity. The perceivers' expectancy that their partner had a behavior problem as well as the actual diagnostic status of the target adversely affected the boys' interactions. Behavioral data suggest how the expectancies were communicated to the target. The processes underlying interpersonal expectancy effects and the ways in which a childhood stigma can act as a self-fulfilling prophecy are discussed.     

The Influence of Outcome Expectancy and Self-Efficacy on the Behavioral Intentions of Novice Exercisers

The present study was based upon self-efficacy (SE) theory (Bandura, 1986). Its purpose was to examine whether incentives, defined as the product of outcome expectancy and outcome value, would help to predict the behavioral intentions of novice exercisers when coupled with SE expectations for a specific form of exercise. Fifty- three volunteers who were novices at weight training for exercise, participated in a 2-day learn-to-weight-train clinic offered at a university. They completed pre- and postclinic measures of SE for weight training, expectancy-value ratings of outcomes primary and secondary to 1 month's weight-training participation, and a strength- of-intention measure of multiple actions consequent to clinic participation. Results indicated that primary physical health outcomes expected of postclinic participation independently predicted the variability in pre- and postclinic future intentions beyond the variance predicted by SE. Further, incentives and SE clearly discriminated between individuals extreme in the strength of their intentions at pre- and postclinic. Discussion concerns the inclusion of measures of incentive in studies using self-efficacy theory in order to examine individuals who begin exercise and then move through various decision stages about exercise adoption and maintenance. Rather than merely assuming the influence of incentives necessary and sufficient to encourage a cognitive or behavioral impact of efficacy, arguments are made for actively examining incentive as manifested through outcome expectations.     

Activity involvement among suicidal and nonsuicidal high-risk and typical adolescents

The purpose of this study was to compare weekly activities among four groups of randomly selected high-risk and typical high school students: (1) potential dropouts at suicide risk, (2) typical youth at suicide risk, (3) potential dropouts not at suicide risk, and (4) typical youth not at suicide risk. Of the 1,286 participants, 39.4% of the high-risk and 30.1% of typical high school students screened in at suicide risk. Weekly activity comparisons across the four groups showed that suicide-risk adolescents, regardless of potential dropout status, engaged in more solitary activities on weekdays and weekends than did their nonsuicide risk peers. High-risk potential dropout youth engaged in less homework and more social activities during weekdays and weekends than did the typical high school students. These results provide important insight into the weekly activity involvement of at-risk youth while helping to gain a better understanding of suicide-risk adolescents. Implications of these findings are discussed for identifying youth at risk for suicidal behavior and for prevention programming.     

青少年饮酒期望与饮酒行为的关系:追踪研究的证据

通过对1000余名青少年为期一年的追踪调查,探讨了青少年饮酒期望与饮酒行为之间的关系,同时考察了饮酒期望的发展和性别差异。研究结果表明:(1)一年来青少年的饮酒行为、饮酒消极期望和饮酒积极期望都显著增加;女生的饮酒行为和饮酒积极期望的增加都显著高于男生。(2)第二次测查时,青少年的饮酒行为、饮酒积极期望和饮酒消极期望高于一年前原同年级的学生。(3)饮酒积极期望、消极期望和饮酒行为之间的基本关系一年来没有发生变化:消极期望可能降低饮酒行为,积极期望可能增加饮酒行为,消极期望对积极期望与饮酒行为的关系具有显著的调节作用。但是消极期望对饮酒行为的作用降低,积极期望的作用升高。     

The Drinking Expectancy Questionnaire: A revised measure of alcohol-related beliefs

Alcohol-related expectancies have been recently proposed as potentially important determinants of drinking behavior. This study describes the development of a New Zealand measure of such beliefs, the Drinking Expectancy Questionnaire (DEQ). Items selected through interviews, literature review, and the modification of other relevant questionnaires were piloted on 333 drinkers in a community sample and 275 college students. Factor analyses of both samples revealed nine alcohol reinforcement domains relating to assertiveness, affective change, sexual enhancement, social enhancement, relaxation, cognitive impairment, dependence, carelessness, and aggression. The potential clinical and research possibilities using this revised expectancy measure are briefly discussed, along with the scale's strength and weaknesses.The financial assistance of the Alcoholic Liquor Advisory Council of New Zealand in conducting this study is gratefully acknowledged.     

Effects of performance expectancy and self-focused attention on social interaction

We investigated the impact of performance expectancies and self-focused attention on social performance in a mixed-sex dyad. A group of 48 undergraduate men with self-reported moderate social anxiety were divided into two groups on the basis of their high or low performance expectancies. Subjects were asked to respond to several self-report questionnaires before and after making a 4-5-min phone call to a female confederate for the purpose of getting acquainted. Half of the subjects in each expectancy group performed in the presence of a self-focusing stimulus (video camera). When anxiety level was controlled for, focus of attention alone had a very limited effect on performance. Expectancy had a significant influence on social performance, but only if subjects were self-focused. Thus confident subjects were rated by judges as more socially skilled than were doubtful subjects, but only when the camera was present. The interaction between these variables parallels previous research and supports the self-regulation model of Carver and Scheier.     

Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content

Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients’ written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.     

Depressive symptoms interfere with post-rehabilitation exercise: Outcome expectancies and experience as mediators

The aim of the study was to examine the relationship between depressive symptoms and physical exercise by unveiling how outcome expectancies regarding exercise and positive exercise experience could mediate between depressive symptoms and exercise. A longitudinal study included 178 cardiac and orthopedic rehabilitation patients in Germany. Patients responded to psychometric scales at two points in time with a six-week interval, assessing depressive symptoms (Time 1), outcome expectancies regarding exercise (Time 1), exercise experiences (Time 2), and exercise behavior (Times 1 and 2). Depressive symptoms were negatively related to physical exercise (r?=-?0.18), to positive outcome expectancies (r?=-?0.23), and to positive exercise experiences (r?=-?0.26). In a multiple-step mediation model, expectancies and experiences mediated between depressive symptoms and exercise. In total, 15% of the exercise variance was accounted for. Outcome expectancies and a lack of positive experience seem to partly explain why depressed individuals are less likely to exercise.     

„Intention to treat“ oder „treatment as received“ – Umgang mit Abbrechern in der Forschung zur Straftäterbehandlung

Lack of internal validity is a frequent problem in evaluation studies of offender treatment, as randomized controlled trials are difficult to implement and comparison groups in quasi-experimental studies are often not completely equivalent. Special matching procedures or statistical control of selection bias by using potentially interfering variables as covariates can provide a solution to some of these problems; however, a high dropout rate from offender treatment programs presents another problem, as the variables that cause attrition are often risk factors for reoffending. It is argued that a treatment-as-received (TR) approach which compares treatment completers with the comparison group may confound genuine treatment effects with selection effects. Particularly high recidivism rates in dropouts may be due to negative effects of attrition (e.g. stigmatization) but may more likely reflect a higher a priori risk for reoffending. Using data from some recent treatment studies, the authors show that alleged positive effects often disappear when a more adequate intention-to-treat (ITT) approach is used in which dropouts are retained in the treatment sample.