Jacques P. Barber

Therapist Adherence/Competence and Treatment Outcome: A Meta-Analytic Review

OBJECTIVE The authors conducted a meta-analytic review of adherence-outcome and competence-outcome findings, and examined plausible moderators of these relations. METHOD A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria. RESULTS R-type effect size estimates were derived from 32 adherence-outcome and 17 competence-outcome findings. Neither the mean weighted adherence-outcome (r = .02) nor competence-outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence-outcome and competence-outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence-outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance. CONCLUSIONS One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence-outcome and competence-outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed.

The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis

OBJECTIVES The efficacy of short-term psychodynamic psychotherapy (STPP) for depression is debated. Recently, a number of large-scale and high-quality studies have been conducted. We examined the efficacy of STPP by updating our 2010 meta-analysis. RESULTS After a thorough literature search, 54 studies (33 randomized clinical trials) totaling 3946 subjects were included. STPP was significantly more effective than control conditions at post-treatment on depression, general psychopathology and quality of life measures (d=0.49 to 0.69). STPP pre-treatment to post-treatment changes (d=0.57 to 1.18) indicated significant improvements on all outcome measures, which either significantly improved further (d=0.20 to 1.04) or were maintained from post-treatment to follow-up. No significant differences were found between individual STPP and other psychotherapies at post-treatment (d=-0.14) and follow-up (d=-0.06) in analyses that were adequately powered to detect a clinically relevant difference. STPP was significantly more efficacious than other psychotherapies on anxiety measures at both post-treatment (d=0.35) and follow-up (d=0.76). CONCLUSION We found clear indications that STPP is effective in the treatment of depression in adults. Although more high-quality studies are needed, particularly to assess the efficacy of STPP compared to control conditions at follow-up and to antidepressants, these findings add to the evidence-base of STPP for depression.

On second thought: Where the action is in cognitive therapy for depression

In this paper, we attempt to put forward an oft-ignored model for describing cognitive change during cognitive therapy for depression, while discussing the strengths and weaknesses of the three models of change described by Hollon, Evans, and DeRubeis. Along the way we point out some of the conceptual ambiguities regarding cognitive processes and contents as they have been applied in the cognitive therapy literature. We propose that short-term cognitive therapy works primarily through the teaching of compensatory skills. Our proposal is motivated, in part, by the paucity of differential effects of cognitive therapy when compared with antidepressant medications on existing cognitive measures, when at the same time there are reports of differential relapse prevention for these two treatments. In addition, we describe a set of features that a measure of compensatory skills should possess.

Toward a working through of some core conflicts in psychotherapy research

Abstract The author discusses the evidence for six basic statements that many, but not all, psychotherapy researchers adhere to: (1) The therapeutic alliance has a causal role in outcome, (2) therapeutic techniques explain patients’ outcome, (3) therapists determine outcome, (4) patients determine therapy outcome, (5) randomized controlled trials (RCTs) provide valuable data, (6) data from RCTs are almost worthless. These “truths” combine to form three core conflicts: Is psychotherapy about the alliance or techniques? Does the patient or therapist determine the outcome? Are RCTs a blessing or a curse? After showing that these statements oversimplify the research of the therapeutic process, the author recommends keeping both sides of the conflict in awareness and endorses a pluralistic methodological approach for the study of both efficacy and the mechanisms of psychotherapy.

PRETREATMENT EXPECTATIONS, INTERPERSONAL FUNCTIONING, AND SYMPTOMS IN THE PREDICTION OF THE THERAPEUTIC ALLIANCE ACROSS SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY AND COGNITIVE THERAPY

Therapeutic alliance has been a robust predictor of therapy outcome, yet little is known about which patient variables predict the development of an alliance between patient and therapist in time-limited manualized therapies. The authors evaluated pretreatment predictors of therapeutic alliance, controlling for symptom change before its assessment, using a large sample of patients treated with either supportive-expressive (SE) dynamic psychotherapy or cognitive therapy. They found that SE patients with greater pretreatment expectations of improvement formed better alliances with their therapist at Session 2, and expectations significantly predicted alliance at Session 10 for both treatment groups. Further, patients in the SE condition demonstrated a significant relation between positive expectations and growth in alliance. Women achieved better alliances at Session 10. Finally, hostile-dominant interpersonal problems significantly predicted poor alliance. Pretreatment symptom level was not significantly predictive of alliance.

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention.

Unique and Common Mechanisms of Change across Cognitive and Dynamic Psychotherapies.

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.

Hamilton anxiety rating scale interview guide: Joint interview and test-retest methods for interrater reliability

The Hamilton Anxiety Rating Scale (HARS) is the most widely used semistructured assessment scale in treatment outcome studies of anxiety. Interrater reliability coefficients for the HARS have been previously reported. However, differences in the way clinicians assess symptom severity may reduce reliability. A structured interview guide--The Hamilton Anxiety Rating Scale Interview Guide (HARS-IG)--was developed to standardize clinical probe questions and to minimize interrater variance. Joint-interview and test-retest methods of interrater reliability assessment were used in a group of 30 inpatients. Intraclass coefficient calculations revealed improved interrater agreement with the HARS-IG versus the HARS. The findings of this study demonstrate that the HARS-IG is a more reliable assessment instrument than the semistructured HARS and that it meets established standards of reliability assessment.

A conceptual and empirical review of the meaning, measurement, development, and teaching of intervention competence in clinical psychology

Through the course of this paper we discuss several fundamental issues related to the intervention competence of psychologists. Following definitional clarification and proposals for more strictly distinguishing competence from adherence, we interpret Dreyfus and Dreyfuss [Dreyfus, H.L., & Dreyfus, S.E. (1986). Mind over machine: The power of human intuition and expertise in the age of the computer. New York: Free Press.] five stage theory of competence development (from novice to expert) within a strictly clinical framework. Existing methods of competence assessment are then evaluated, and we argue for the use of new and multiple assessment modalities. Next, we utilize the previous sections as a foundation to propose methods for training and evaluating competent psychologists. Lastly, we discuss several potential impediments to large scale competence assessment and education, such as the heterogeneity of therapeutic orientations and what could be termed a lack of transparency in clinical training.

Relation of Transference Interpretations to Outcome in the Early Sessions of Brief Supportive-Expressive Psychotherapy

Transference interpretations have been considered an important technique in models of short-term dynamic psychotherapy. The purpose of the current investigation was to explore the role of transference interpretations in the early sessions of 29 patients treated with Supportive-Expressive (SE) psychotherapy for depression. Hierarchical multiple regressions were used to evaluate the relationship between proportion of transference interpretations and treatment outcome measured across levels of quality of interpersonal relationships. High levels of transference interpretations were significantly associated with poor treatment outcome for patients with poor interpersonal functioning. The results suggest that transference interpretations should be used sparingly in the early sessions of SE psychotherapy with patients who demonstrate a poor quality of interpersonal relationships prior to treatment. Ubertragungsdeutungen gelten als wichtige Technik in den Modellen fur psychodynamische Kurzpsychotherpie. Ziel der ...