Jacqueline A. Sparks

Using Client Feedback to Improve Couple Therapy Outcomes: A Randomized Clinical Trial in a Naturalistic Setting.

Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers. A research paradigm called patient-focused research--a method of enhancing outcome via continuous progress feedback--holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy. The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy. Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback. Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived.

Evidence-based practice at a crossroads: The timely emergence of common elements and common factors

Social work is increasingly embracing evidence-based practice (EBP) as a decision-making process that incorporates the best available evidence about effective treatments given client values and preferences, in addition to social worker expertise. Yet, social work practitioners have typically encountered challenges with the application of manualized evidence-supported treatments. For social work, the path to implementing the delivery of science-informed practice remains at a crossroads. This article describes two emergent strategies that offer a plausible means by which many social workers can integrate an EBP model into their service delivery—common factors and common elements. Each strategy will be presented, and related evidence provided. Tools to implement a common elements approach and to incorporate client feedback consistent with a common factors perspective will also be described. These strategies will be placed in the broader context of the EBP framework to suggest possible advances in social work practice and research.

The Alliance in Couple Therapy: Partner Influence, Early Change, and Alliance Patterns in a Naturalistic Sample

OBJECTIVE The purpose of this study was to explore the relationship between the alliance and outcome in couple therapy and examine whether the alliance predicted outcomes over and above early change. The authors also investigated partner influence and gender and sought to identify couple alliance patterns that predicted couple outcomes. METHOD The authors examined the alliances and outcomes at posttreatment and follow-up of 250 couples seeking treatment for marital distress in a naturalistic setting. The Session Rating Scale was used to measure the alliance; the Outcome Rating Scale and Locke Wallace Marital Adjustment Scale were used to measure outcomes. Couples were White, Euro-Scandinavian, and heterosexual, with a mean age of 38.5 years and average number of years together of 11.8. On a subsample (n = 118) that included couples with 4 or more sessions, the authors investigated the relationship between the alliance and outcome controlling for early change, and patterns of alliance development were delineated. RESULTS In the full sample, first-session alliances were not predictive of outcomes, but last-session alliances were predictive for both individuals and their partners. In the subsample, third-session alliances predicted outcome significantly above early change (d = 0.25) that exceeded the reliable change index. Couple alliances that started over the mean and increased were associated with significantly more couples achieving reliable or clinically significant change. Gender influences were mixed. CONCLUSIONS Given the current findings suggesting a potential alliance impact over and above symptom relief as well as the importance of ascending alliance scores, continuous assessment of the alliance appears warranted.

Teaching Accountability: Using Client Feedback to Train Effective Family Therapists

The AAMFT Task Force on Core Competencies (Nelson et al., 2007) proposed that marriage and family therapy (MFT) educators teach and provide evidence of trainee competence beyond coursework and accrued clinical hours. This article describes the integration of a systematic client feedback protocol into an MFT-accredited programs curricula to address the call for outcome-based learning. Outcome management (OM) provides a framework for teaching and assessing trainee effectiveness. Continuous incorporation of client feedback embodies collaborative, strengths-based, integrative, and diversity-centered program values. Students learn a system for being accountable to clients, the profession, and service communities.

Initial Relationship Goal and Couple Therapy Outcomes at Post and Six-Month Follow-Up

The purpose of this study was to investigate the relationship between client initial goal for couple therapy (i.e., improve the relationship or clarify the viability of the relationship) and the outcomes (including their relationship status, i.e., separated or together) at posttreatment as well as at 6-month follow-up. Two hundred forty-nine couples (N = 498 individuals) seeking treatment for relationship distress in a naturalistic setting were treated by 20 therapists. Client initial relationship goal was attained by intake paperwork protocol, which included client initial goal for couple therapy and client perception of partner goal. Clients who reported that their goal was to improve the relationship reported better outcomes at post. Couples who reported their goal was to improve the relationship were less likely to break up at a 6-month follow-up. Of the 115 couples stating they wanted to improve the relationship, only nine (7.8%) couples were separated at 6 months. In contrast, of the 16 couples in which both partners wanted to clarify the relationship prior to therapy, nine (56%) were separated at follow-up. Therapist awareness of each individuals relationship goal prior to couple therapy could enhance outcomes, and treatment tailored according to initial goals could set the stage for positive outcomes however defined.

Evidence-Based Practice at a Crossroads: The Emergence of Common Elements and Factors

Social work is increasingly embracing evidence-based practice (EBP) as a decision-making process that incorporates the best available evidence about effective treatments given client values and preferences, in addition to social worker expertise. Yet, social work practitioners have typically encountered challenges with the application of manualized evidence-supported treatments. For social work, the path to implementing the delivery of science-informed practice remains at a crossroads. This article describes two emergent strategies that offer a plausible means by which many social workers can integrate an EBP model into their service delivery—common factors and common elements. Each strategy will be presented, and related evidence provided. Tools to implement a common elements approach and to incorporate client feedback consistent with a common factors perspective will also be described. These strategies will be placed in the broader context of the EBP framework to suggest possible advances in social work practice and research.

School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change

Abstract The outcomes of school-based counseling incorporating the Partners for Change Outcome Monitoring System (PCOMS) were evaluated using a cohort design, with multilevel modeling to identify predictors of change. Participants were 288 7–11 year olds experiencing social, emotional or behavioral difficulties. The intervention was associated with significant reductions in psychological distress, with a pre-post effect size (d) of 1.49 on the primary outcome measure and 88.7% clinical improvement. Greater improvements were found for disabled children, older children, and where CBT methods were used. The findings provide support for the use of systematic feedback in therapy with children.

The Norway Couple Project: Lessons Learned

Couple therapists in routine practice may find it difficult to apply findings from an increasingly expanding and complex body of couple therapy research. Meanwhile, concerns have been raised that competency in evidence-based treatments is insufficient to inform many practice decisions or ensure positive treatment outcomes (American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist, 2006, 271). This article aims to narrow the research/practice gap in couple therapy. Results from a large, randomized naturalistic couple trial (Anker, Duncan, & Sparks, Journal of Consulting and Clinical Psychology, 2009, 693) and four companion studies are translated into specific guidelines for routine, eclectic practice. Client feedback, the therapeutic alliance, couple goals assessment, and therapist experience in couple therapy provide a research-informed template for improving couple therapy outcomes.

Accounting for therapist variability in couple therapy outcomes: what really matters?

This study examined whether therapist gender, professional discipline, experience conducting couple therapy, and average second-session alliance score would account for the variance in outcomes attributed to the therapist. The authors investigated therapist variability in couple therapy with 158 couples randomly assigned to and treated by 18 therapists in a naturalistic setting. Consistent with previous studies in individual therapy, in this study therapists accounted for 8.0% of the variance in client outcomes and 10% of the variance in client alliance scores. Therapist average alliance score and experience conducting couple therapy were salient predictors of client outcomes attributed to therapist. In contrast, therapist gender and discipline did not significantly account for the variance in client outcomes attributed to therapists. Tests of incremental validity demonstrated that therapist average alliance score and therapist experience uniquely accounted for the variance in outcomes attributed to the therapist. Emphasis on improving therapist alliance quality and specificity of therapist experience in couple therapy are discussed.

Footprints of Couple Therapy: Client Reflections at Follow-Up

This study explores client experiences in couple therapy through analysis of written client responses at 6-month follow-up. A subsample participated in a randomized trial comparing outcomes for couples that used routine client feedback with no-feedback couples. Thematic analysis indicates that clients prefer personable and active therapists who maintain neutrality. Women and men expressed dissatisfaction with lack of therapist structuring and challenge. Lack of therapist initiative and flexibility in scheduling emerged as most problematic, with nonfeedback clients most dissatisfied. Most clients rated use of feedback very helpful. The studys method provides a way to use posttherapy client feedback to improve services.