Ethnic variations in the initial phase of mental health treatment: a study of Sami and non-Sami clients and therapists in northern Norway

Several studies indicate that mental health and mental health service vary with ethnicity. Ethnically linked social differences affect these results. We examined the multiethnic population in northern Norway where social inequalities between the Sami and the non-Sami population are not prominent. Clients (N=347) and therapists (N=32) in outpatient treatments reported demographics, ethnicity and the therapeutic alliance. Clients also reported pretreatment psychosocial status, service utilization and the type of help requested. Therapist recorded clinical and diagnostic assessments and treatment plans. The Sami and non-Sami client groups were similar in demographics and pretreatment psychosocial characteristics. However, the therapists prescribed more sessions and more socially focused interventions when clients were Sami. Verbal therapy was more often used by the non-Sami therapists. Alliance ratings were positively correlated only between Sami therapists and their clients, and Sami therapists rated the largest initial clinical improvement. Clinics located in the high Sami density areas offered their clients more therapy sessions, than in clinics in the high non-Sami density areas. Ethnic similarity between client and therapist were associated with more frequent use of medication and less frequent use of verbal therapy.     

Marital therapy outcome measured by therapist, client, and behavior change

The present research examined marital therapy outcome, in a sample of 88 couples and 22 therapists, through the use of multidimensional criteria from multiple perspectives. Three paper-and-pencil patient self-report instruments were used to measure different aspects of the couple relationship. In addition, therapist post-therapy ratings and objective observer ratings of the couple behavior during therapy were obtained. Past debates about what the "right" criteria might be for measuring therapeutic change prompted our strategy. Special attention was focused on those criteria that could be classified as "inside" or "outside" of the couple relationship. Data analysis revealed a significant relationship between the couples' and therapists' ratings of improvement in therapy. Additionally, husband and wife negative acts (behaviors) in therapy were also significantly correlated with therapists' ratings of improvement. Both statistically significant and clinically significant criteria were employed to evaluate the therapy outcome. Improvement due to therapy as measured by the three self-report instruments varied from 38% to 58%. These differences appeared to stem from the different kinds of information yielded by the specific tests.     

The role of treatment acceptability in the initiation of treatment for ADHD

Approximately 50% of families of children with ADHD fail to pursue, or adhere to, recommended treatments. The present study examines parent ratings of the acceptability of pharmacological and behavioral treatments for ADHD and the relationships between these ratings and subsequent pursuit of treatment. Fifty-five families whose children received an evaluation for ADHD completed questionnaires and were contacted 3 to 4 months later to assess their pursuit of treatment. Consistent with previous research, parents rated behavior therapy as more acceptable than medication. Parent ratings of medication acceptability significantly predict pursuit of pharmacological treatment, whereas ratings of the acceptability of behavior therapy do not predict pursuit of this treatment. Preliminary analyses found that Caucasian parents' ratings of medication are significantly higher than those of non-Caucasian parents. Furthermore, Caucasian families were more likely to pursue a recommendation for pharmacological treatment than non-Caucasian families. The clinical and research implications of these results are considered.     

Acceptability of aversive procedures and medication as treatment alternatives for deviant child behavior

The present investigation evaluated the acceptability of alternative treatments for deviant child behavior. Clinical cases of children who displayed severe behavioral problems at home and at school were described along with three different treatments. The treatments, time-out from reinforcement, locked seclusion, and medication, were rated by psychiatric inpatient children and parents in a 3 × 3 replicated Latin-square design. The investigation also evaluated whether acceptability ratings were influenced by the clinical effectiveness of treatment in altering behavior. Although children and parents did not differ overall in acceptability ratings, they differed in their ranking of different treatments. Children viewed medication as the most acceptable treatment, whereas parents viewed time out as the most acceptable treatment. For both children and parents, treatments described as producing marked effects were rated as more acceptable than treatments producing weaker effects. The results indicated that disturbed children and their parents can readily distinguish the acceptability of alternative treatments. The implications of treatment acceptability for clinical applications of treatment are discussed.Completion of this investigation was facilitated by a Research Scientist Development Award (MH00353) and a grant (MH35408) from the National Institute of Mental Health. The author is grateful for the assistance of the clinical research team of the Child Psychiatric Treatment Service, especially that of Irene Heidish, M.A., who assisted with the data analyses.     

Relative efficacy of methylphenidate and behavior modification in hyperkinetic children: An interim report

Children reported to be hyperactive in school and with behavior difficulties at home were randomly assigned to methylphenidate, behavior therapy and placebo, or behavior therapy with methylphenidate for an 8-week period. Rating scales were obtained from teachers and parents. Independent blind observers rated childrens' classroom behavior on a weekly basis. A behavior therapy program was implemented in the home and at school. Methylphenidate dosage was individualized. Ratings of behavior deviance were significantly reduced by all treatments. However, a significant advantage for the groups receiving methylphenidate was found over the group receiving behavior therapy and placebo. No significant differences between methylphenidate alone and methylphenidate combined with behavior therapy were obtained. Global ratings of improvement done by teachers favored the combined treatment of behavior therapy and methylphenidate over behavior therapy and placebo. No differences among treatments were found in the mothers' global ratings of improvement. The results indicate that though all three treatments were effective, methylphenidate was significantly superior to behavior therapy alone.This study was supported in part by grant MH 18579, and by grant No. 3-621 from the Long Island Jewish-Hillside Medical Center. The authors wish to thank the behavior therapists, Drs. Jeffrey Felixbrod and Marion Pheterson, as well as Ms. Patricia Ramsey, who was responsible for data analysis.     

Pathogenesis: A New Therapist Personality Dimension Related to Therapeutic Effectiveness

The pre-project TATs of ten therapists were rated for “pathogenesis” and these ratings later correlated with their patient's level of functioning after six months of treatment. Outcome was measured in a variety of data modalities: intellectual tests, thought disorder measures, projectives, clinical status interviews, and hospitalization. Significant correlations were obtained on five of eight outcome measures. Patients of more benign (or less pathogenic) therapists demonstrated greater foresight, less schizophrenic thought disorder, greater intellectual functioning, were rated as healthier in the Clinical Status Interview, and spent less time in the hospital than patients of more pathogenic therapists.     

Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes

Family affect was examined as a predictor of difficulty implementing a 9-month, manual-based, psychoeducational family therapy for recently manic bipolar patients. Prior to therapy, family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task. Following family treatment, both therapists and independent observers rated the overall difficulty of treating the family, and therapists also rated each participant's problem behaviors during treatment, in the areas of affect, communication, and resistance. Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family. Relatives' critical behavior toward patients during the pretreatment interaction task predicted both independent observers' ratings of overall treatment difficulty and therapists' perceptions of relatives' affective problems during treatment. Moreover, patients' residual symptoms predicted independent observers' ratings of overall difficulty and therapists' perceptions of patients' resistance to the family intervention. Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic, pretreatment family and clinical assessment.     

Child,mother, and father evaluations of depression in psychiatric inpatient children

The agreement among children and their parents in evaluating the children's depression was examined in 48 families. Newly admitted inpatient children (ages 6–13) and their mothers and fathers independently completed selfreport and interview measures to assess severity and duration of the children's depression. The results indicated that different measures of depression completed by the same rater (child, mother, or father) were highly intercorrelated. Yet there was little or no relationship between childmother and child-father ratings of the children's depression for the same or related measures of depression. Children independently diagnosed (DSM III) as depressed rated themselves and were rated by their parents as more depressed than nondepressed children. Even so, children consistently rated themselves as less depressed across the measures than did their parents. Parent ratings of the children's depression and the correspondence of child-parent ratings varied as a function of several child and family variables, including child IQ, gender, race, and family welfare status.This investigation was supported in part by a Research Scientist Development Award (1 K02 MH00353) to the first author from the National Institute of Mental Health and by a Clinical Research Center Grant for the Study of Affective Disorders (5 P50 MH30915-05) from the National Institute of Mental Health. The authors are grateful to the clinical research team of the Child Psychiatric Treatment Service.     

The Association Between Therapeutic Alliance and Treatment Outcomes in a Group Triple P Intervention

A growing literature has examined the association between therapeutic alliance and treatment outcomes in child therapy. Few studies, however, have specifically investigated the role of therapeutic alliance within evidence-based parenting programs for children with externalizing behavioural difficulties. The current study prospectively collected measures of therapeutic alliance for 117 families completing a Triple P parenting program in a community children’s mental health center. Higher levels of mother and father rated therapeutic alliance were associated with greater gains in parenting skills and parental sense of competence. Parental rated therapeutic alliance was also associated with greater improvements in child conduct problems for mothers, but not fathers. However, therapist ratings of therapeutic alliance had limited associations with treatment improvement. The implications of the findings for clinical practice are discussed.     

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.     

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.     

The Family Environment Scale: comparison with the construct of Expressed Emotion

The Family Environment Scale (FES) was completed by parents of 30 children with conduct disorders (CD), 30 children with emotional disorders (ED), and 30 well-functioning controls. Parents were also interviewed and rated for Expressed Emotion (EE), and mothers completed the Child Behaviour Checklist (CBCL). Clinical families had significantly lower ratings of Cohesion, Expressiveness, Intellectual-Cultural and Active-Recreational Orientation. These differences were not specific to either diagnostic group. Maternal Criticism was associated with reported conflict in the CD group. The EE scales of Criticism and Warmth (absence of warmth) were correlated with child behaviour ratings in the CD group, in contrast with FES sub-scales. Maternal scores of Cohesion were significantly associated with social competence in the ED and the control group. Maternal ratings of Conflict predicted dropping-out of treatment (CD group), and ratings of Cohesion and Control had some value in predicting clinical outcome. The implications for the future use of the Family Environment Scale and other self-rated measures of family functioning are discussed.     

Ambulante Psychotherapie in Deutschland aus Sicht der Patienten

This study analyzed the provision of outpatient psychotherapy services in Germany in standard practice settings. A total of 1,212 subjects who received or were still receiving outpatient psychotherapy during the past 6 years provided information about their experiences via a telephone survey. Outpatient psychotherapy was sought for many different conditions and was rated as highly effective. The improvement rates for all complaints were higher than 50%, except for obesity (37%) and sexual dysfunctions (44%). Patient ratings of worsening were less than 8% throughout. Treatment had very positive results not only for target symptoms but also for other aspects of patients?? lives. Almost 90% of those questioned stated that they were satisfied with their therapist. High agreement ratings were reported specifically with respect to positive therapeutic relationship, stable working alliance, experience of autonomy during therapy and therapists?? competency and ethical conduct. Patients gave their psychotherapists excellent evaluations and were highly satisfied with the changes achieved through treatment.     

Using consumer preference information to increase the reach and impact of media-based parenting interventions in a public health approach to parenting support

Within a public health approach to improving parenting, the mass media offer a potentially more efficient and affordable format for directly reaching a large number of parents with evidence-based parenting information than do traditional approaches to parenting interventions that require delivery by a practitioner. Little is known, however, about factors associated with parents' interest in and willingness to watch video messages about parenting. Knowledge of consumer preferences could inform the effective design of media interventions to maximize parental engagement in the parenting messages. This study examined parents' preferred formats for receiving parenting information, as well as family sociodemographic and child behavior factors that predict parents' ratings of acceptability of a media-based parenting intervention. An ethnically diverse sample of 162 parents of children ages 3-6 years reported their preferences for various delivery formats for parenting information and provided feedback on a prototype episode of a video-format parenting program based on the Triple P Positive Parenting Program. Parents reported the strongest preference for self-administered delivery formats such as television, online programs, and written materials; the least preferred formats were home visits, therapists, and multiweek parenting groups. Parents' ratings of engagement, watchability, and realism of the prototype parenting episode were quite strong. Parents whose children exhibited clinical levels of problem behaviors rated the episode as more watchable, engaging, and realistic. Mothers also rated the episodes as more engaging and realistic than did fathers. Lower income marginally predicted higher watchability ratings. Minority status and expectations of future problems did not predict acceptability ratings. The results suggest that the episode had broad appeal across groups.     

Treating Parents and Children Together

SUMMARY

In this paper I look at two traditions of psychotherapy with children: family therapy {here considered in its common paradigm of systems theory and not in its diversity of approaches) and individual psychodynamically oriented child therapy. The author examines how, in these two modalities of treatment, the real world of the parent-child relationship, which remains mostly a world of women and children, tends to be left out in practice. Many family therapists “exclude” children from their sessions and concentrate on the marital relationship while child therapists “exclude” parents from the core of the therapeutic process. The issues for therapists and the consequences for adults and children in families in this com-partmentalization of services are examined within a feminist framework. The development which is advocated is for therapists to expose themselves fully to the world of the parent-child relationship as a fust step in reexamining their stereotypical views of motherhood and fatherhood which trap women in conflicted and potentially exploitative situations and do not consider that children actively construct their own relationships.     

Videotaped simulated families as a tool in family therapy outcome research

Twenty-two therapists who had treated 57 families in brief conjoint family therapy under supervision responded to a videotaped simulated family as if they were treating it. Their responses were audiotaped and coded on a system devised for this study. Positive relationships were found between the ratings of expertise based on the coding system, and independent ratings of the treated families' satisfaction with treatment and the status of the presenting symptoms 6 months after termination. Videotaped simulated families are potentially useful as standardizable methods of revealing individual differences in therapists for family therapy outcome research.     

Perceptions of the therapist in family therapy

Thirty-five families completed ratings describing their perceptions of their therapists. These ratings were then correlated with measures of outcome to assess whether there was a relationship between experiences of the therapist and treatment outcome. Further, the study addresses whether some family members' perceptions are more influential in affecting the course of treatment. The results showed that family members' perception of the therapist does have an impact on treatment outcome, but not all members affect the outcome equally. Further results and their implications are discussed.     

Parent Perspectives of an Evidence-Based Intervention for Children with Autism Served in Community Mental Health Clinics

Research suggests that improvements to community mental health (CMH) care for children with autism spectrum disorders (ASD) are needed. Recent research examining the feasibility of training CMH therapists to deliver a package of evidence-based practice intervention strategies (EBPs) targeting challenging behaviors for school-age children with ASD offers initial support for such efforts to improve care. Specifically, quantitative data from a recent pilot study indicate that CMH therapists with limited ASD experience can deliver an EBP intervention with fidelity and perceive it as useful to their practice. Further, client attendance is high and children demonstrate improvement on standardized measures. To further understand the feasibility and impact of training CMH therapists to deliver EBPs, this mixed-methods study examined parent perspectives of the process and impact of outpatient psychotherapy for 13 parents of children ages 5–13 with ASD whose therapists were trained to deliver the EBP intervention. Results complement and expand previously reported quantitative data on psychotherapy process indicating that parents are highly involved in treatment for their children, perceive a strong therapeutic alliance with their children’s therapist, and highlight that treatment was different once therapists began delivering the intervention. Results also indicate themes related to parents’ perceptions of positive child and parent outcomes that provide important details on the specific gains that were observed during treatment. Study findings underscore the importance of parent perspectives in understanding the process and impact of implementing EBPs in CMH settings for families of children with ASD.     

Homework Compliance Counts in Cognitive-Behavioral Therapy

Background: Prior research has demonstrated that there is some association between treatment engagement and treatment outcome in behavioral therapy for anxiety disorders. However, many of these investigations have been limited by weak measurement of treatment engagement variables, failure to control for potentially important baseline variables, and failure to consider various treatment engagement variables simultaneously. The purpose of the present study is to examine the relationship between two treatment engagement variables (treatment expectancy and homework compliance) and the extent to which they predict improvement from cognitive-behavioral therapy (CBT) for anxiety disorders. Methods: 84 adults with a DSM-IV-defined principal anxiety disorder took part in up to 12 sessions of CBT or acceptance and commitment therapy. Pre- and post-treatment disorder severity was assessed using clinical severity ratings from a semi-structured diagnostic interview. Participants made ratings of treatment expectancy after the first session. Homework compliance was assessed each session by the treating clinician. Results: Contrary to hypotheses, treatment expectancy and homework compliance were poorly correlated. Regression analyses revealed that homework compliance, but not treatment expectancy, predicted a significant portion of the variance in treatment outcome (10%). Conclusions: The present research suggests that although treatment expectation and homework compliance likely represent unique constructs of treatment engagement, homework compliance may be the more important treatment engagement variable for outcomes. The present research suggests that improvement of homework compliance has the potential to be a highly practical and effective way to improve clinical outcomes in CBT targeting anxiety disorders.     

Mothers and Fathers in Family Cognitive-Behavioral Therapy for Anxious Youth

Cognitive-behavioral therapy (CBT) for anxiety disorders in youth has been evaluated in randomized clinical trials and found to be an efficacious treatment. Studies have investigated the effects of increased parental/family involvement in treatment. In the majority of these studies, however, parental involvement is synonymous with maternal involvement leaving the role of fathers unknown. Studies including parents in treatment have yet to examine the independent contribution of mothers and fathers to child outcome. We examined the relationship between both mother (n = 45) and father (n = 45) attendance and engagement in therapy sessions, maternal and paternal psychopathology, and child (n = 45) treatment outcome when parents were included in a Family CBT program for anxiety-disordered youth. Some indications were found for the notion that greater rates of mother and father attendance in session, as well as higher ratings of mother and father engagement in session, are associated with improved child outcome. Parental psychopathology was not associated with attendance, engagement, or child outcome. Recommendations for future research are offered.