Symptom reduction and termination: client change and therapist identified reasons for saying goodbye

Empirical efforts have focused on predicting whether or not clients prematurely terminate therapy, with nonattendance of last session equated to premature termination. However, this fails to explore the relationship between clients’ distress reduction and reasons for termination. With this study, we aimed to understand how clients’ distress change relates to premature termination and examine clients’ distress change in conjunction with therapists’ perceptions of termination reasons. We collected data from 797 clients who prematurely terminated or attended termination but completed therapy a minimum of three individual sessions provided by 38 therapists. Clients completed an assessment of psychological symptoms before each session. At the end of treatment, therapists identified the reasons they believed termination occurred for all clients in the sample. Results demonstrate that total sessions attended and missed predict premature termination, whereas distress change does not. Additionally, clients who were believed to accomplish goals do show greater change. However, therapists’ indicated that over half of clients did not reach goals at termination and they did not perceive nonattendance at last session to equate to drop out in all cases. Implications are discussed with respect to understanding why clients’ terminate, therapeutic goal conceptualization, and review of goals during termination in time-limited psychotherapy.     

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.     

Social phobia: individual response patterns and the effects of behavioral and cognitive interventions

In the present study, the role of individual response patterns in the treatment of social phobic patients was investigated. Seventy-four patients were diagnosed as social phobics. On the basis of extreme scores on a behavioral test (the Simulated Social Interaction Test) and on a cognitive measure (the Rational Behavior Inventory), the response patterns of 39 patients were analyzed, and the patients themselves were classified as either 'behavioral reactors' or 'cognitive reactors'. Half of the patients with each response pattern received a behavioral focused treatment, i.e. social skills training (SST), while the other half received a cognitive oriented treatment, i.e. rational emotive therapy (RET). Patients received group therapy in eight weekly sessions. Within-group differences showed a considerable improvement in all treatment groups. Between-group differences failed to lend support to the hypothesis that treatment that fits a response pattern (i.e. SST for behavioral reactors and RET for cognitive reactors) will result in a greater improvement than one that does not.     

Relational Diagnosis and Psychotherapy Treatment Cost Effectiveness

Despite a call by researchers for estimates of the treatment effectiveness and cost effectiveness for relational problems, very little has been done to answer this call. The present study is an examination of actual treatment costs and recidivism rates for patients treated for a relational problem (either in individual or conjoint therapy sessions) in the Cigna network. Policymakers and third-party payers may use such clinical-effectiveness and cost effectiveness data to make decisions regarding treatment of relational problems and funding allocation. The present study is also the first to compare the costs of couples therapy versus family therapy for relational problems.     

Rorschach changes following brief and short-term therapy.

Two groups of 35 patients each, one treated with brief therapy, averaging 14.2 sessions on a once per week basis, and the other group, treated with a short-term type of therapy, averaging 47 sessions on a once per week basis were administered the Rorschach and the Katz Adjustment Scales-Form S three times. The first administration took place before entering therapy. The brief therapy group was tested a second time at termination of treatment and again 8 to 12 months following termination. The short-term therapy group was tested the second time at therapy termination and the third time 10 to 12 months after termination. Each group reported substantially fewer symptoms at termination and continued to report about the same level of symptom reduction at the second retest. The Rorschach data seem to provide an ample basis from which to argue that considerable improvement occurred in the psychological organization and/or operations of both groups, and this appears to have some confirmation in the self-report data.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.     

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.     

Psychotherapie von Anpassungsstörungen

In this study we examined the effectiveness of an outpatient client-centered psychotherapy of patients with adjustment disorders (ICD-10 F43.2) limited to twelve sessions in comparison to an untreated control group. The patients of each group (n_treatment= 31 and n_control= 19) had been diagnosed with an adjustment disorder in response to one of the following stressful events: either the loss of an important person or performance deficits at work or university. Compared with the untreated control group the immediate therapy group improved significantly on rating scales and questionnaires. These positive treatment effects proved stable at a 3 months follow-up. Individual treatment gains were also analyzed for clinical and statistical significance. The improvements of the treatment group were significantly greater in all used measures than those of the control group. These improvements were interpreted as an effect of the client-centered treatment which resulted in high individual overall treatment gains and in high effectsizes.     

Exposure in vivo vs social skills training for social phobia: long-term outcome and differential effects

This study examined the long-term effectiveness of specific exposure in vivo (individual IE or group GE) and of office-based social skills training (group SST) in two groups of patients with social inhibition (primary social skills deficits or primary social phobia). Seventy-eight outpatients were divided into these two subgroups according to clinical assessment. Twenty-seven patients received SST which consisted of 25 twice a week 90-min group sessions: 32 patients received GE and 17 IE. Exposure in vivo consisted of 4 weekly (8-hr in the group condition included 2 hr discussion; 3 hr in the individual condition included 1 hr discussion) sessions. Self-rating-assessments were carried out at pre- and post-treatment, at 3 months- and 2.5 yr follow-up. The general results indicate that all three treatment modes led to clinically and statistically-significant improvements in the main problem area (social anxiety, skills deficits), in other neurotic complaints (depression, obsessions, psychosomatic complaints) and in attribution-style. Patients with the diagnosis of primary phobia seemed to get the same profit from either treatment and showed slightly better gains (in all treatment modalities) than patients with skills deficits at long-term follow-up. Within the subgroup with skills deficits there was a tendency for superior outcome of group exposure. These results and recommendations for future research are discussed.     

The cost of treating substance use disorders: individual versus family therapy

This study examined the cost of substance use disorders treatment in a large healthcare organization. A survival analysis demonstrated that family therapy utilised the least number of sessions (M = 2.41) when treating substance use disorders followed by individual therapy (M = 3.38) and mixed therapy (M = 6.40). Family therapy was the least costly of the three types, at $124.55 per episode of care for a client, with individual therapy costing $170.22 and mixed therapy $319.55. The ratio of family therapists utilising family therapy was more than three to one compared to other licensed professionals. The percentages of clients coming back for more than one episode of care are fewest for family therapy (8.9%) followed by mixed therapy (9.5%) and individual therapy (12.0%).     

The Use of Time Limits in Brief Psychotherapy: A Comparison of Six-Session,Twelve-Session,and Unlimited Treatment with Families

This study compared the relative effectiveness of two durations of time-limited psychotherapy with time-unlimited treatment and a waiting list control group. Thirty-seven families applying for treatment at a child guidance clinic were randomly assigned to one of four treatment conditions: (a) time-limited therapy of 6 sessions within 8 weeks; (b) time-limited therapy of 12 sessions within 16 weeks; (c) time-unlimited therapy; and (d) a waiting list control group in which families waited approximately four months before beginning treatment. Outcome was assessed from multiple sources: parents, child, therapist, family interaction ratings, and missed and canceled sessions. Analysis of data provided some evidence that families who received treatment fared better than those on the waiting list. There were no consistent differences between 6-session, 12-session, and unlimited therapy. A model is proposed for the further investigation of time-limited treatment.     

the nature and frequency of medicare/medicaid fraud and neutralization techniques among speech,occupational, and physical therapists

ABSTRACT

The current study examines the nature and frequency of Medicare/Medicaid fraud and the techniques of neutralization utilized by a purposeful sample of speech, occupational, and physical therapists working within the context of hospitals, nursing homes, and with home health agencies, in a southern state. Participant observations, surveys, and in-depth interviews were utilized to obtain data for this study. We identified two main fraudulent practices, cutting sessions short while charging for the entire session and charging individual session rates for group therapy sessions. We also identified three techniques of neutralization utilized by the therapists in our study, including: (1) everyone else does it, (2) denial of responsibility, and (3) denial of injury. The implications of our findings are discussed.     

Kurz- und Langzeitbehandlung in der Verhaltenstherapie

In Germany, short and long-term psychotherapy are the two established forms for providing basic outpatient cognitive behavior therapy. The goal of the current study is to describe and discuss empirical evidence for these two structural forms; therefore, results from randomized controlled trials are presented and their implications related to the optimal number of therapy sessions are described. Furthermore, important results of naturalistic process outcome research are outlined. Additionally, the individual needs of patients for specific numbers of sessions are described based on data from the Association of Statutory Health Insurance Physicians. The results of randomized controlled trials generally showed strong empirical evidence for the efficacy of short-term cognitive behavior therapy of 7–20 sessions in patients with simple diagnoses; however, there is less empirical evidence in relation to the general efficacy and differential indications for long-term behavior therapy. These study results are supported by data from 200,000 patients receiving outpatient treatment in the German healthcare system. In two thirds of these patients, less than 25 sessions were sufficient to achieve subjectively adequate clinical improvement; however, approximately 10?% of the patients needed more than 60 therapy sessions. Empirical evidence concerning outcomes of long-term therapy with such a high number of sessions is scarce. Future research should address this research gap in order to identify empirically-based individual adaptation rules concerning the optimal number of treatment sessions in long-term therapy.     

Evaluating Marital Therapy: A Hospital and Community Study

The study investigated the application of marital therapy using three contrasting clinical approaches: conjoint treatment, couples groups, and treating the partner alone. Thirty-six couples comprised the research sample, with eighteen couples being treated in each of two NHS treatment settings. The duration of the treatment was ten weekly sessions each lasting one hour, and couples were followed up six months after termination. Outcome evaluations included marital satisfaction, sexual adjustment, and an assessment of target problems. The analysis of the results showed no significant difference between groups at the post-treatment and follow-up assessments. There was, however, a significant difference in the rates of change between experimental groups. The implications of these results are discussed.     

Utilization of Individual versus Family Therapy Among Adolescents with Severe Emotional Disturbance

Service utilization patterns among children with severe emotional and/or behavioral disturbances are described for 89 children and families, interviewed at two time points across a 6-month period. Children received a greater number of individual therapy sessions than family therapy sessions, and children significantly decreased their levels of internalizing and externalizing behaviors. Family therapy was associated with decreases in internalizing behaviors when children reported outcomes. Individual therapy was not associated with changes in either internalizing or externalizing behaviors regardless of reporter. Symptom severity did not dictate whether children were provided individual or family therapy. Recommendations for individualized treatment plans are offered.     

A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge eating disorder

We performed a randomized controlled study to test the relative efficacy of guided self-help (gsh) cognitive-behavioral therapy (CBTgsh) and behavioral weight loss treatment (BWLgsh) treatments for binge eating disorder (BED). To provide an additional partial control for non-specific influences of attention, a third control (CON) treatment condition was included. We tested the treatments using a guided self-help approach given the promising results from initial studies using minimal therapist guidance. Ninety consecutive overweight patients (19 males, 71 females) with BED were randomly assigned (5:5:2 ratio) to one of three treatments: CBTgsh (N=37), BWLgsh (N=38), or CON (N=15). The three 12-week treatment conditions were administered individually following guided self-help protocols. Overall, 70 (78%) completed treatments; CBTgsh (87%) and CON (87%) had significantly higher completion rates than BWLgsh (67%). Intent-to-treat analyses revealed that CBTgsh had significantly higher remission rates (46%) than either BWLgsh (18%) or CON (13%). Weight loss was minimal and differed little across treatments. The findings suggest that CBT, administered via guided self-help, demonstrates efficacy for BED, but not for obesity. The findings support CBT administered via guided self-help as a first step in the treatment of BED and provide evidence for its specific effects.     

Anorexia nervosa: treatment satisfaction

Patient satisfaction plays a central role in treatment alliance and outcome. Investigating patient expectations and experiences of treatment sheds light on its importance. This study examines adolescent anorexia nervosa patients and their parents' satisfaction with family‐based treatment. Patients and parents answered a questionnaire at the eighteen‐month follow‐up focusing on expectations and experiences of treatment, therapists, aims of treatment and accomplishment. The results show that 73 per cent of the patients and 83 per cent of the parents felt that their pre‐treatment expectations had been fulfilled. The majority agreed that individual patient sessions and parental sessions were of great help, while the patients valued family therapy sessions as being less helpful than did parents. In overall terms, parents were more pleased with the therapists than were the patients. These data suggest that family‐based treatment with individual sessions for patients, in parallel with parental sessions combined with family sessions, corresponds well to patients' and parents' treatment expectations.     

Predictors of treatment attendance among adolescent substance abusing runaways: a comparison of family and individual therapy modalities

This study explored and compared predictors of session attendance among substance abusing runaway adolescents and their parents using three manual‐driven interventions: ecologically‐based family therapy (EBFT), motivational enhancement therapy (MET), and the community reinforcement approach (CRA). Individual and family‐level variables, as well as time between intake and first session were used as predictors of session attendance. Adolescents (N=179) between the ages of 12–17 years old were recruited from the only runaway shelter in Columbus, Ohio. The findings showed that adolescents assigned to EBFT were more likely to attend at least one therapy session than those assigned to either CRA or MET. Fewer days between intake and the first therapy session were associated with higher family therapy attendance. Overall, individual and family factors predicted therapy attendance but these factors differed depending upon the treatment modality.     

Transference and Countertransference: New Horizons

In this exploratory study one set of patients (n – 50) was randomly assigned to either short-term group therapy or short-term individual therapy. Another set of patients was randomly assigned to either long-term group therapy or long-term individual therapy. All patients were rated prior to therapy on fifteen variables which were believed to be important for psychoanalytically oriented therapy. A comprehensive battery of outcome measures was administered both before and after therapy. Univariate and multivariate analyses were conducted in an effort to discover differential predictors of improvement for group therapy and individual therapy. None of the variables was found to be a significant predictor of improvement in one type of therapy and of nonimprovement in the other type. However, a number of variables were found to be significant predictors of improvement for one type of therapy but not for the other. It is suggested that for a given patient, a pattern of scoring on a number of such variables might tend to favor one type of therapy over another. The authors hope that the present study will serve to encourage further research work on the issue of assisting clinicians in their decisions concerning general and differential prediction of therapy outcome.