Patient activity and outcome in group psychotherapy: new findings

The relation of patient verbal activity to pretherapy symptom status and outcome was examined for ninety patients in time-limited group psychotherapy. For each half-hour segment the most verbally active member, or main actor (MA), was identified. Verbal activity was measured by counting the number of times each patient was MA during the course of the group. Outcome was assessed by administering a battery of instruments pre- and posttherapy and by obtaining direct ratings of patient benefit from the patient, therapist, and an independent rater: the number of times MA was found to be significantly correlated with four pretherapy measures, indicating that the most disturbed patients were most active in these groups; the number of times MA was also correlated with patient and therapist benefit ratings, indicating that therapists and patients themselves agreed that those who spoke the most benefited the most. However, partial correlations between number of times MA and other outcome measures did not produce any significant relationships. Thus, it does not appear that patient verbal activity is related to outcome, as measured by objective instruments.     

The contribution of feedback to outcome in long-term group psychotherapy

Two long-term analytic inpatient psychotherapy groups, comprised of severely disturbed neurotic and personality disordered patients, were intensively investigated using process ratings and therapist and patient reports to examine the contribution of interpersonal feedback to treatment outcome. We found that feedback was important throughout the course of therapy, and that patients who derived the most benefit from the groups were those who experienced a greater level of group cohesiveness and were most active in terms of self-disclosure, receipt of feedback, and making significant behavioral modifications within treatment. These successful patients received both positive and negative feedback, primarily from other group members, and worked effectively toward the goals that brought them to treatment.     

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.     

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.     

Borderline functioning, work, and outcome in intensive evening group treatment.

Cluster analysis was used to identify subgroups of a sample of 40 patients with borderline personality disorder (BPD). The BPD patients were part of a larger sample that had participated in an intensive, group-oriented Evening Treatment Program. A set of pretherapy outcome measures was used to represent patient "attributes" for the cluster analysis. Eight clusters were identified. Two, each defined by a single patient with pronounced pathology, were deleted from further analyses. In a discriminant-function analysis, four dimensions emerged that differentiated the six remaining clusters. Significant relationships among the four dimensions and measures of therapeutic work and treatment outcome were identified. The relationships reflected the impact of behavioral characteristics associated with BPD on participation in and benefit from intensive group-oriented evening treatment. Implications of these exploratory findings for the understanding and treatment of BPD are discussed.     

Female Sexuality by Marie Bonaparte

Cluster analysis was used to identify subgroups of a sample of 40 patients with borderline personality disorder (BPD). The BPD patients were part of a larger sample that had participated in an intensive, group-oriented Evening Treatment Program. A set of pretherapy outcome measures was used to represent patient “attributes” for the cluster analysis. Eight clusters were identified. Two, each defined by a single patient with pronounced pathology, were deleted from further analyses. In a discriminant-function analysis, four dimensions emerged that differentiated the six remaining clusters. Significant relationships among the four dimensions and measures of therapeutic work and treatment outcome were identified. The relationships reflected the impact of behavioral characteristics associated with BPD on participation in and benefit from intensive group-oriented evening treatment. Implications of these exploratory findings for the understanding and treatment of BPD are discussed.     

THERAPIST DEFENSIVENESS AND MARITAL THERAPY PROCESS AND OUTCOME

Abstract

This study examined the effect of couple socioeconomic status (SES); pretherapy marital adjustment; and therapist, husband, and wife defensiveness during the third session of marital therapy on posttherapy marital adjustment. Participants were 22 therapists and 88 couples. Each therapist treated 4 couples, 2 from the middle SES level and 2 from the lower SES level. Path analyses revealed that for husbands higher marital satisfaction before therapy was associated with higher adjustment at the end of therapy, but defensive therapist behavior during therapy was associated with lower posttherapy adjustment. A similar pattern was found for wives, but this should be interpreted with caution owing to potential dependencies in the wives' posttherapy adjustment scores. Neither SES nor pretherapy adjustment predicted therapist defensive behavior in therapy, and SES did not predict marital therapy outcome variance. Results suggest that therapist defensive behavior may reflect a style or characteristic of some marital therapists.     

Matching Patient and Therapist Anaclitic–Introjective Personality Configurations Matters for Psychotherapy Outcomes

Decades of psychotherapy research suggest that patient–therapist match accounts for outcome beyond single patient or therapist variables. This study examines the associations between different patterns of patient–therapist matching (in terms of orientation on relatedness or self-definition) and outcomes at termination of psychoanalytic psychotherapy with young adults. Thirty-three patients and their therapists were classified as predominately anaclitic or introjective at baseline. Patients in the convergent patient–therapist dyads (both anaclitic or both introjective) showed significantly greater symptom reduction and increased developmental levels of representations of mother than patients in the complementary dyads (opposite personality configurations). Moreover, convergent patient–therapist match was connected with larger effect sizes on all outcome measures and lower proportion of non-improved patients. These findings suggest the importance of the therapists’ early adjusting their orientation on relatedness or self-definition to their patients’ predominant personality configuration in order to enhance treatment outcomes.     

A multistudy analysis of socioeconomic status (SES) and the measures and outcomes of cognitive-behavioral treatment with children

The relationship of the child's socioeconomic status (SES) to improvement and generalization from cognitive behavioral-treatment was investigated by comparing high and low SES groups on teacher ratings, performance measures, and judges' ratings of improvement and maintenance of positive change. Fifty-eight teacher referred classroom problem children (grades 2–6) who had served as treated subjects in one of three treatment outcome studies were examined. SES data were collected by administration of a questionnaire to the head of each household. The judges' ratings were performed on clusters of teacher ratings and clusters of performance measures that were present in each study. Results indicated that, despite SES group variation in level of performance, improvement, when it occurred, was evident for both high and low SES groups. In addition, there were significant differences on a number of the performance measures at pretreatment, posttreatment, and follow-up. Initial SES group differences in verbal ability as measured by the Peabody Picture Vocabulary Test (PPVT) appear to have been an important factor in these performance differences.This research was supported by grant number 441 0749 5236 02 from the Graduate School of the University of Minnesota, awarded to Philip C. Kendall. Portions of this research were presented at the Association for the Advancement of Behavior Therapy Convention, San Francisco, December 1979. Portions of the material were prepared while the second author was at the Center for Advanced Study in the Behavioral Sciences and supported by NIMH (No. 5-T32-MH 14581-05) and the MacArthur Foundation. The authors wish to thank Dorothy Raney for her valuable assistance.     

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.     

Neuropsychological functioning in a patient with essential tremor with and without bilateral VIM stimulation

The effects of deep brain stimulation on motor functions, cognitive abilities, and mood were assessed in an 80-year-old, right-handed male with a chronic history of essential tremor. Electrodes were implanted bilaterally in the ventral intermediate nucleus of the thalamus during a single operation. Upon evaluation at 3 months postsurgery, bilateral stimulation was associated with a clinically significant reduction in tremor ratings and improvement in manual dexterity. At that time, a battery of neuropsychological measures was administered with and without bilateral stimulation. The patient demonstrated comparable performances on measures of visuospatial perception, attention, mental tracking, verbal learning, and verbal recognition memory in both the "on" and "off" conditions. Without stimulation, the patient demonstrated declines of greater than 1 SD on measures of verbal fluency and verbal recall compared to when the stimulators were active. Responses to mood rating scales also indicated greater subjective distress without stimulation. Results are discussed in the context of previous studies of the effects of thalamic stimulation on neurocognitive functioning.     

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.     

Evaluation of self-administered rational emotive therapy programs for interpersonal anxiety

Self-administered rational emotive therapy (RET), withA New Guide to Rational Living (Ellis & Harper, 1975), as the treatment manual, was evaluated by comparing three groups which varied in terms of therapist contact (therapist administered, minimal contact, self-administered). University students who volunteered for the research program involving the treatment of interpersonal anxiety were randomly assigned to one of these treatments or to a wait-list control group. The results for 72 subjects who completed the 5-week program indicated the three treatment groups made significant gains over untreated controls on some of the self-report measures. No between-group differences appeared on ratings by significant others. A four- to five-month follow-up, which obtained data from 41 (58%) of the subjects, provided some support for the maintenance of treatment effects for the therapist administered and minimal contact groups. Correlations of assessed irrational beliefs with outcome measures provided some support for the RET model.Norris D. Vestre, Ph.D., is a Professor in the Department of Psychology, Arizona State University. Terrence J. Judge, M.C., R.N.C., is a nurse therapist at Camelback Vista Treatment Center, Scottsdale, Arizona.     

Attention deficit,conduct, oppositional,and anxiety disorders in children: III. Laboratory differences

Children aged 5–13 years with DSM-III diagnoses of Attention Deficit (ADDH), Anxiety, (ANX), or Conduct plus ADDH (HC) Disorder and matched normal controls were compared on a set of laboratory measures of impulsivity, arousal, motor performance, activity level, and cognition, and on behavior ratings during testing. While ANX patients did not differ from their controls, ADDH and HC patients did on Verbal IQ, most of the behavior ratings, and on about one-third of the test variables. ANX patients were about 1 year older, and more likely to be female, than ADDH and HC patients. When age, sex, and verbal IQ effects were partialed out, very few differences among the three diagnostic groups remained. The importance of precise control of such variables is emphasized and the impact of the failure to do so in past studies is discussed. The question is raised whether the deficit in verbal IQ is not so much a defect of matching as the essential feature of ADDH from which most of the other commonly reported cognitive symptoms stem.This research was supported by the Medical Research Council of New Zealand.     

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.     

Use of Groups in Various Modalities of Hospital Treatment

The authors provide a comprehensive survey of the research literature on pretherapy training for group psychotherapy. The twenty studies identified during the twenty-five-year period 1962–1987 were fraught with various methodological and design inadequacies. Despite the widespread positive endorsement found in the clinical literature, the research evidence for the benefit of pretherapy training is not particularly impressive. While there is evidence of certain immediate effects (e.g., improved attendance), results concerning process and outcome effects are, at best, only suggestive. In the face of the disappointing findings, the authors are nonetheless optimistic regarding the potential value of pretherapy training.     

Therapeutic factors in two forms of inpatient group psychotherapy: Music therapy and verbal therapy

Therapeutic processes in one type of creative arts group psychotherapy, music therapy, were compared with verbal group psychotherapy. Sixty-one short-term inpatients ranked group psychotherapy curative factors and completed satisfaction ratings. Therapists rated 201 group therapy sessions— 109 music therapy and 92 verbal therapy. Statistical analysis revealed that patients highly valued both group formats. The mean curative factor rankings for both groups included cohesiveness, instillation of hope, and altruism among the most helpful factors. Therapists' ratings indicated qualitative differences between the two groups. Music therapy involved more therapeutic interaction among patients and emotional expression, whereas verbal therapy emphasized concrete problem solving.Supported in part by Biomedical Research Support Grant Program grant #S07-RR05755 from the Division of Research Resources, National Institutes of Health.     

Brief crisis group psychotherapy versus the initial sessions of long-term group psychotherapy: An exploratory comparison

An attempt was made to specify the therapist behaviors characteristic of the brief crisis group (BCG) approach, to assess how patients experience BCG on dimensions of session impact and group climat, and to describe the changes possible from BCG on measures of outcome by contrasting this modality with the initial sessions of traditional long-term therapy groups in a preexperimental design. Data obtained from four eight-session BCGs and three beginning long-term groups (LTG) were used for analyses. Patients were administered the Session Evaluation (SEQ) and Group Climate (GCQ) Questionnaires at the end of each group session. Two judges sat in on each session and coded the types of therapist interventions using the Therapist Behavior Categories (TBC) system. Aspects of self-esteem and symptomatology were assessed as indices of change over the 8-week period in a pre-post fashion. Therapists in BCG evidenced a distinct pattern of interventions during midpoint group sessions (sessions 3–6), placing a greater emphasis on challenging patient perceptions and providing information than their LTG counterparts. The therapists' use of self as an issue in BCG increased as termination approached and apparently served a more limited function than in LTG. Patients in BCG reported a more rapid development of a working group and experienced greater session benefit. Patients in BCG also reported lower levels of conflict and avoidance and a greater decrease in these resistance behaviors. As expected, BCG patients reported substantially greater improvement on most outcome dimensions at the end of the 8-week period. Results are considered as clarifying the approach to and impact of BCG psychotherapy.An earlier version of this paper was presented at the 15th Annual Meeting of the Society for Psychotherapy Research, Lake Louise, Alberta, June 19–23, 1984.     

More than talk: Relations between emotion understanding and positive behaviour in toddlers

Background. Associations between positive behaviour, emotion understanding and verbal ability have been reported in studies of preschoolers ( Cassidy, Werner, Rourke, Zubernis, & Balaraman, 2003 ), but have yet to be investigated in younger children. Methods. In this study the performance of 36 toddlers (17 boys and 19 girls; mean age = 29 months, SD = 3.9 months) on standardized verbal ability assessments and four simple tests of emotion understanding was examined in relation to three measures of positive behaviour: maternal ratings of prosocial behaviour (Strengths and Difficulties Questionnaire; Goodman, 1997 ), and video‐based coding of the toddlers in 20‐minutes dyadic play with (i) mothers and (ii) familiar peers. Results. Relations between the three measures of positive behaviour were rather modest, and only significant for the association between maternal ratings and observed positive behaviours with peers. Maternal ratings of prosocial behaviour were significantly correlated with performance on the emotion‐understanding tasks, even when age effects were controlled. Together, emotion understanding and verbal ability explained over half the variance in maternal ratings of prosocial behaviour; unique predictive effects were significant for emotion understanding but not verbal ability. Further, emotion understanding mediated the relationship between verbal ability and mothers' ratings of prosocial behaviour. Conclusions. These findings highlight the importance of emotion understanding as a proximal influence on very early prosocial behaviour.