Family members' perceptions of live observation/supervision: An exploratory study

This ex post facto survey examined 75 client family members' perceptions of live observation/supervision of family therapy at a university clinic. The results seem to reflect the subjects' general satisfaction with the process, although this general satisfaction did not significantly predict outcome on either family or therapist goal attainment scores. Family members whose therapists were female reported greater satisfaction with the process than those with male theapists, although no differences by therapist gender were found on either therapist or family goal attainment scale scores. Open-ended responses suggested that some family members were aware of the purposes of certain strategic team interventions. Implications of findings for the practice and research of live supervision and/or observation are discussed.The authors would like to acknowledge the aid of Judith Myers Avis, Marcia Brown Standridge, Cleveland Shields, Linda Stone Fish, and Joseph Wetchler in various aspects of this research project.     

Family functioning and the social adaptation of hearing-impaired youths

This study examined the associations between important aspects of family functioning and the adjustment of hearing-impaired youths. Participants were 75 hearing-impaired youths and their hearing parents. The dependent variables were mothers' and fathers' ratings of child behavior problems and social competence. Independent variables included parental symptomatology, parental ratings of family stress, and family members' perceptions of family cohesion and family adaptability. Demographic characteristics and the youth's degree of hearing loss and mode of communication were used as control variables. Results from multiple regression analyses showed that parental ratings of the youths' behavior problems were linked with parental symptomatology, and that maternal ratings of the youths' behavior problems were associated with low family adaptability. Parental ratings of the youths' social competence were predicted by family stress. Overall, key aspects of family functioning accounted for considerably more variance than did the control variables. The methodological and conceptual implications of the findings are discussed.     

Level validity of self-report whole-family measures

This article introduces an approach to testing the level validity of family assessment instruments (i.e., whether a family instrument measures family functioning at the level of the system it purports to assess). Two parents and 2 adolescents in 69 families rated the warmth in each of their family relationships and in the family as a whole. Family members' ratings of whole-family warmth assessed family functioning not only at the family level (i.e., characteristics of the family as a whole) but also at the individual level of analysis (i.e., characteristics of family members as raters), indicating a lack of level validity. Evidence was provided for the level validity of a latent variable based on family members' ratings of whole-family warmth. The findings underscore the importance of assessing the level validity of individual ratings of whole-family functioning.     

Therapy Outcomes: Client Perception and Similarity with Therapist View

This study examined clients' perceptions of therapy outcome and how those perceptions related to therapist views. Additionally, the effects of client and therapist gender and ethnicity, and the match on these variables (e.g., female therapist-female client) were examined. Results showed that clients generally improved from both the client and therapist perceptions, although therapists' views were influenced by client ethnicity. There was no difference between gender or ethnicity matches on perception of outcome. Further examination showed that gender and ethnicity interacted to influence both client and therapist perceptions of outcome. The authors discuss the research and practice implications of these findings.     

The incremental validity of the MMPI-2: when does therapist access not enhance treatment outcome?

The present study examined whether therapist access to the Minnesota Multiphasic Personality Inventory (MMPI-2) predicted favorable treatment outcome, above and beyond other assessment measures. A manipulated assessment design was used, in which patients were randomly assigned either to a group in which therapists had access to their MMPI-2 data or to a group without therapist access to such information. Illness severity, improvement ratings, number of sessions attended, and premature termination were indicators of therapy outcome. Results indicated that therapist access to the MMPI-2 data did not add to the prediction of positive treatment outcome beyond that predicted by other measures in this setting. Findings from this initial study suggest that, compared with other resources, perhaps in clinical settings with an emphasis on diagnosis-based and evidence-based treatment, the MMPI-2 may not provide incrementally valid information. However, these effects warrant replication across different settings and samples. Guidelines for future studies are discussed.     

The Influence of Parental Factors on Therapist Adherence in Multi-systemic Therapy

Therapist treatment adherence has received a great deal of attention in recent years, in part because of its relation to treatment outcomes. Although certain therapist behaviors have been found to be associated with treatment outcomes, little is known about client factors impacting on therapists’ ability to adhere to treatment protocols. In this study, we evaluated effects of parental beliefs, psychopathology, and interaction styles on therapists’ adherence to Multi-systemic Therapy (MST) principles. Eighty-two parents participating in a clinical trial of MST completed baseline measures assessing psychopathology, family functioning, and treatment expectations. Analyses indicated that parental perceptions of therapist adherence were established within the first 4 weeks of treatment, and that parental psychopathology, motivation, expectations, and child rearing practices were related to parental ratings of therapist adherence. Results were essentially unchanged when controlling for parental positive response style. Clinical and research implications of the findings are discussed.     

Operational Sequence in Group Therapy with Young Offenders

Abstract

Attachment has increasingly been identified as central to therapy process and outcome. Attachment theory proposes that an individual’s prior interactions with attachment figures develop into templates that will guide the way they form connections and perceive their relationships with others. This study examined clients’ ratings of their relationship with the therapist as well as their ratings of group climate at multiple discrete points during treatment. These variables were examined in relation to attachment classification prior to therapy. Participants were 62 women attending the Women Recovering from Abuse Program (WRAP), a primarily group-based day-treatment program for childhood interpersonal trauma, at Women’s College Hospital in Toronto, Ontario, Canada. Results demonstrated that clients’ perceptions of relationships in group therapy varied as a function of attachment classification.     

Differences in inter-rater reliability and accuracy for a treatment adherence scale

Inter-rater reliability and accuracy are measures of rater performance. Inter-rater reliability is frequently used as a substitute for accuracy despite conceptual differences and literature suggesting important differences between them. The aims of this study were to compare inter-rater reliability and accuracy among a group of raters, using a treatment adherence scale, and to assess for factors affecting the reliability of these ratings. Paired undergraduate raters assessed therapist behavior by viewing videotapes of 4 therapists' cognitive behavioral therapy sessions. Ratings were compared with expert-generated criterion ratings and between raters using intraclass correlation (2,1). Inter-rater reliability was marginally higher than accuracy (p = 0.09). The specific therapist significantly affected inter-rater reliability and accuracy. The frequency and intensity of the therapists' ratable behaviors of criterion ratings correlated only with rater accuracy. Consensus ratings were more accurate than individual ratings, but composite ratings were not more accurate than consensus ratings. In conclusion, accuracy cannot be assumed to exceed inter-rater reliability or vice versa, and both are influenced by multiple factors. In this study, the subject of the ratings (i.e. the therapist and the intensity and frequency of rated behaviors) was shown to influence inter-rater reliability and accuracy. The additional resources needed for a composite rating, a rating based on the average score of paired raters, may be justified by improved accuracy over individual ratings. The additional time required to arrive at a consensus rating, a rating generated following discussion between 2 raters, may not be warranted. Further research is needed to determine whether these findings hold true with other raters and treatment adherence scales.     

Improving health outcomes among youth with poorly controlled type I diabetes: the role of treatment fidelity in a randomized clinical trial of multisystemic therapy.

The purpose of the study was to assess whether therapist treatment fidelity was a predictor of treatment outcome in a randomized clinical trial of multisystemic therapy with 10- to 16-year-old youths with chronically poorly controlled Type I diabetes (N = 40). Treatment fidelity was assessed by objective ratings of therapy sessions and questionnaires completed by caregivers and by therapists. Relationships between fidelity measures were assessed. Structural equation modeling (SEM) was used to test whether high fidelity would lead to improved regimen adherence and to improved metabolic control outcomes via regimen adherence. Objective ratings of treatment fidelity were significantly related to therapist-reported but not to caregiver-reported treatment fidelity. SEM results supported a completely mediated pathway between treatment fidelity and metabolic control, with regimen adherence mediating the relationship. Results suggest that conducting complex behavioral interventions with a high degree of fidelity can improve treatment outcomes among youths with chronic illnesses.     

Cohesion and outcome in short-term psychodynamic groups for complicated grief

This study used two measures of cohesion for the process analysis of 12 short-term, time-limited groups for complicated grief. The measures had similar theoretical definitions but differed in terms of rater source (member vs. observer), measurement score (mean of items vs. global rating), and rating unit (individual vs. group). We examined the relationship between the measures, assessed the development of cohesion over the life of the group, and evaluated each measure's relationship to outcome. A principal components analysis with each measure yielded one cohesion component, which supported a unidimensional model; however, the two cohesion components were independent of each other, which supported a multidimensional model. Repeated measures analyses indicated that observer-rated cohesion developed in a quadratic manner (v pattern) across sessions, while member-rated cohesion developed in a linear manner. The object focus (the group, other members, the therapist) of the members' ratings determined whether cohesion increased or decreased across sessions. No significant relationships between cohesion and outcome were identified. Implications of the findings for the understanding of group cohesion are considered.     

Differences in Inter‐Rater Reliability and Accuracy for a Treatment Adherence Scale

Inter‐rater reliability and accuracy are measures of rater performance. Inter‐rater reliability is frequently used as a substitute for accuracy despite conceptual differences and literature suggesting important differences between them. The aims of this study were to compare inter‐rater reliability and accuracy among a group of raters, using a treatment adherence scale, and to assess for factors affecting the reliability of these ratings. Paired undergraduate raters assessed therapist behavior by viewing videotapes of 4 therapists' cognitive behavioral therapy sessions. Ratings were compared with expert‐generated criterion ratings and between raters using intraclass correlation (2,1). Inter‐rater reliability was marginally higher than accuracy (p = 0.09). The specific therapist significantly affected inter‐rater reliability and accuracy. The frequency and intensity of the therapists' ratable behaviors of criterion ratings correlated only with rater accuracy. Consensus ratings were more accurate than individual ratings, but composite ratings were not more accurate than consensus ratings. In conclusion, accuracy cannot be assumed to exceed inter‐rater reliability or vice versa, and both are influenced by multiple factors. In this study, the subject of the ratings (i.e. the therapist and the intensity and frequency of rated behaviors) was shown to influence inter‐rater reliability and accuracy. The additional resources needed for a composite rating, a rating based on the average score of paired raters, may be justified by improved accuracy over individual ratings. The additional time required to arrive at a consensus rating, a rating generated following discussion between 2 raters, may not be warranted. Further research is needed to determine whether these findings hold true with other raters and treatment adherence scales.     

Therapist-Parent Interaction Patterns in Home-Based Treatments: Exploring Family Therapy Process

At the current stage of development in the family therapy field, exploratory, small-scale process studies are necessary in order to understand through what interpersonal processes child and family change occur. The goal of this article is to show how relevant therapist-parent interactions within family-based approaches can be explored and linked to the reduction in childrearing and behavior problems. Sequential analyses on 13 treatments using the Family Project Approach revealed that, within the most successful treatments, therapist and parent interact in a collaborative way in the phase of Direct Influence. In the beginning of this treatment phase, the therapist must activate the parents to tackle the problems actively. Further explorations indicated that a collaborative interaction pattern between therapist and mother during the first three sessions of therapy contributes to a better outcome.     

Attributions and affective reactions of family members and course of schizophrenia.

The authors tested an attribution-affect model of schizophrenic relapse attending to the role of families' positive affect (warmth) and negative affect (criticism). Coders listened to interviews of 40 family members taken from C. E. Vaughn, K. S. Synder, S. Jones, W. B. Freeman, and I. R. Falloon (1984) and rated their attributions of controllability for the symptoms and behaviors of their relatives with schizophrenia. For family members not designated as emotionally overinvolved, perceptions that their ill relatives' symptoms and behaviors were under the patients' control were related to family members' warmth and criticism and to patients' clinical outcomes. Of the affective reactions, only criticism predicted outcome. In addition, patients' use of street drugs was related to attributions, criticism, and outcome. Together these findings suggest that families' attributions and criticism are important in understanding the relationship between family factors and course of illness.     

Real relationship,working alliance,transference/countertransference and outcome in time-limited counseling and psychotherapy

Six client/therapist dyads (three therapists each working with two clients) were studied to determine how the real relationship unfolds over the course of time-limited treatment and how this unfolding relates to the development of the client/therapist working alliance, client transference, and therapist countertransference. We also examined how these indices of the relationship fluctuate as a function of treatment outcome. Results indicate that in general for all six dyads, therapists’ and clients’ ratings of the real relationship and working alliance were strong throughout treatment. However, patterns of real relationship and working alliance over the course of treatment varied between dyads categorized as more vs. less successful. Therapists’ countertransference was low, as was client transference, but differences in ratings were evident when the dyads were classified by outcome.     

Mothers’ Perceptions of Young Children,Parenting, and Young Children's Behavior Problems

Historically, research demonstrates that mothers’ attitudes and characteristics of their parenting are intertwined. More recently, mothers’ perceptions of their children are becoming a new focus of interest. To further understand the relationships among mothers’ perceptions of their young children, their parenting behaviors, and their ratings of their young children's behavior problems, this study examines the ratings of a diverse group of mothers who have young children. Correlational results of this study demonstrate that these variables are related in the anticipated directions. Further, results of regression analyses suggest that mothers’ positive and negative perceptions of their young children and their use of limit setting are important in predicting children's behavior problems. These findings suggest that interventions focusing on changing mothers’ perceptions of their young children as well as their parenting behaviors may be related to decreases in young children's behavior problems.     

Effects of LMX and differential treatment on work unit commitment

The Leader-Member exchange (LMX) theory of leadership states that leaders do behave differently towards the various members in their work unit. Relatively little attention has been devoted to the question of whether members' perceptions of differential treatment on the part of the leader affects their commitment to the work unit. Perceptions of the amount of differential treatment within their work unit did not explain additional variance in members' work unit commitment after the effects of LMX quality were accounted for. There was, however, a significant interaction effect of LMX quality and differential treatment on work unit commitment. The perception of a large number of differential treatment incidents seems to act as a neutralizer with respect to the positive effects LMX quality may have.     

Do Better Trainees Make Worse Family Therapists? A Followup Study of Client Families

This study was designed to evaluate the effects of training on family therapy outcome and to validate measures of cognitive/perceptual and executive skills. Followup data on family satisfaction were obtained from 176 individuals (73 families) treated by 12 trainee family therapists in their first or second year of training. The prediction that clients' scores on a scale of family satisfaction with therapy (FSS) would increase with training was not confirmed. Instead, there was a tendency for FSS scores to decrease with training. However, trainees' ratings of outcome did increase significantly as training progressed. Cognitive/perceptual and executive skill measures were not validated by the FSS, but negative associations indicated a tendency for trainees with high course-skills to receive poor FSS scores. The results suggest that trainees became more confident as they acquired technical skills, but that they put aside their nonspecific therapist skills as training progressed, to the dissatisfaction of families.     

Behavioral Versus Nonbehavioral Guided Self-Help for Parents of Children With Externalizing Disorders in a Randomized Controlled Trial

Self-help interventions for parents, which have a behavioral basis, are considered to be an effective treatment option for children with externalizing disorders. Nonbehavioral approaches are widely used but have little empirical evidence. The main objective of this trial was to compare the efficacy of a behavioral and a nonbehavioral guided self-help program for parents. Families of children (aged 4–11 years) diagnosed with attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) were randomized to either a behavioral or a nonbehavioral guided self-help program including 8 parenting booklets and 10 counseling telephone calls. The analyses considered the ratings of 5 informants: blinded clinician, therapist, participant, (her or his) partner, and teacher. Of the 149 families randomized to treatment (intention-to-treat sample [ITT]), 110 parents completed the intervention (per-protocol sample [PP]). For the 4 primary outcome measures (blinded clinician- and participant-rated ADHD and ODD) at post-assessment, the analysis revealed a treatment advantage for the behavioral group in blinded clinician-rated ODD symptoms (ITT: d = 0.37; PP: d = 0.35). Further treatment differences, all in favor of the behavioral group (ITT and PP), were detected in therapist ratings (i.e., ODD) and participant ratings (e.g., parental self-efficacy [only PP], negative parenting behavior, parental stress). In both samples, no differences were found at post-assessment for ratings of the partner and the teacher, or at the 12-month follow-up (only participant ratings available). Behavioral guided self-help shows some treatment advantage in the short term. No superiority over nonbehavioral therapy was detected 12 months after treatment termination.     

Cultural ruptures in short‐term therapy: Working alliance as a mediator between clients' perceptions of microaggressions and therapy outcomes

Aim: To determine whether or not clients' perceptions of microaggressions varied based on their own and the therapist's race/ethnicity and whether or not they would be negatively related to the effectiveness of therapy and if the working alliance would mediate this effect. Method: The study utilised a cross‐sectional, retrospective, methodology. Clients were recruited from a large university counselling centre in the United States (N=232 clients and 29 therapists). Results: Neither clients' race/ethnicity, therapists’ race/ethnicity, nor client‐therapist ethnic matching predicted perceptions of microaggressions. Clients' ratings of microaggressions were negatively associated with their psychological wellbeing; however, this effect was mediated by clients' ratings of the working alliance. Implications: Therapists should take into account the cultural messages they may be conveying to both white and racial/ethnic minority clients. Therapists should develop strategies that are consistent with a general therapeutic approach that promotes discussions about culture with their clients and, most importantly, should attend to the therapeutic relationship.