Kenneth I. Howard

Evaluation of Psychotherapy Efficacy, Effectiveness, and Patient Progress

Treatment-focused research is concerned with the establishment of the comparative efficacy and effectiveness of clinical interventions, aggregated over groups of patients. The authors introduce and illustrate a new paradigm-patient-focused research-that is concerned with the monitoring of an individuals progress over the course of treatment and the feedback of this information to the practitioner, supervisor, or case manager.

A phase model of psychotherapy outcome: causal mediation of change.

A 3-phase model of psychotherapy outcome is proposed that entails progressive improvement of subjectively experienced well-being, reduction in symptomatology, and enhancement of life functioning. The model also predicts that movement into a later phase of treatment depends on whether progress has been made in an earlier phase. Thus, clinical improvement in subjective well-being potentiates symptomatic improvement, and clinical reduction in symptomatic distress potentiates life-functioning improvement. A large sample of psychotherapy patients provided self-reports of subjective well-being, symptomatic distress, and life functioning before beginning individual psychotherapy and after Sessions 2, 4, and 17 when possible. Changes in well-being, symptomatic distress, and life functioning means over this period were consistent with the 3-phase model. Measures of patient status on these 3 variables were converted into dichotomous improvement-nonimprovement scores between intake and each of Sessions 2, 4, and 17. An analysis of 2 x 2 cross-classification tables generated from these dichotomous measures suggested that improvement in well-being precedes and is a probabilistically necessary condition for reduction in symptomatic distress and that symptomatic improvement precedes and is a probabilistically necessary condition for improvement in life functioning.

Using significance tests to evaluate equivalence between two experimental groups.

Equivalency testing, a statistical method often used in biostatistics to determine the equivalence of 2 experimental drugs, is introduced to social scientists. Examples of equivalency testing are offered, and the usefulness of the method to the social scientist is discussed.

Patterns of symptomatic recovery in psychotherapy.

Using the psychotherapy dosage model in which effect was probability of recovery, this study compared treatment response rates for psychological symptoms. Symptom checklists were administered to 854 psychotherapy outpatients at intake and during treatment. Sixty-two symptoms were grouped into 3 classes on the basis of probit analysis results. Chronic distress symptoms demonstrated the fastest average response rate, whereas characterological symptoms demonstrated the slowest. Acute distress symptoms showed the highest average percentage of patients recovered across doses. A typical outpatient needed about a year of psychotherapy to have a 75% chance of symptomatic recovery. The model holds promise for establishing guidelines for the financing of psychotherapy.

The Therapeutic Bond Scales: Psychometric Characteristics and Relationship to Treatment Effectiveness

The Therapeutic Bond Scales assess the quality of the therapeutic relationship from the patients perspective. The therapeutic bond is composed of 3 aspects: working alliance, empathic resonance, and mutual affirmation. Scales were developed to measure these aspects and the therapeutic bond as a whole. The correlations between these scales and 2 measures of outcome (session quality assessed by the patient and termination outcome evaluated by nonparticipan t raters) were examined. All scales were significantly correlated with session quality. Therapeutic bond was significantly correlated with termination outcome in both a linear and a curvilinear fashion, suggesting that, at least in the initial phase of therapy, the therapeutic bond can be too high as well as too low. A substantial accumulation of empirical findings exists relating psychotherapy process variables to treatment outcome (cf. Orlinsky & Howard, 1986a). One of the most consistent findings in the psychotherapy research literature is that the quality of the relationship between the patient and the therapist is a major determinant of psychotherapeutic effectiveness (e.g., the therapeutic alliance literature: Alexander & Luborsky, 1986; Marmar, Horowitz, Weiss, & Marziali, 1986). Reviews (Gurman, 1977; Lambert, Shapiro, & Bergin, 1986; Orlinsky & Howard, 1986a; Patterson, 1984) consistently demonstrate that (a) a good therapeutic relationship is at least a major contributing factor, if not a necessary and sufficient condition (Rogers, 1957), for successful treatment, and (b) that the patients perception of the quality of the relationship is most consistently positively related to outcome. Yet most systems for measuring this aspect of the therapeutic relationship are based on the nonparticipant observer perspective. The primary goal of the present study was to develop a reliable measure of the quality of the therapeutic relationship, from the patients perspective, based on a theoretical model of the therapeutic bond. We also investigated the relationship between the quality of the bond, measured in this way in the early stage of therapy, and two measures of therapeutic effectiveness: an

The Altering of Reported Experiences

OBJECTIVES The unreliability of human memory is well documented in the literature, yet psychiatrists and other mental health care professionals rely on patient self-report in history-taking. This study provides new evidence from a longitudinal study of autobiographical memory and discusses implications for the development and implementation of appropriate treatment plans and goals. METHOD Seventy-three mentally healthy 14-year-old males were studied in 1962. Sixty-seven of these subjects were reinterviewed face-to-face at age 48. Questions concerning areas of family relationships, home environment, dating, sexuality, religion, parental discipline, and general activities were asked in both interviews. RESULTS Significant differences were found between adult memories of adolescence and what was actually reported during adolescence. Accurate memory was generally no better than expected by chance. CONCLUSIONS If the accurate memory of ones past is not better than chance in the mentally healthy individual, even more care probably should be taken in obtaining accurate historical information in the medically, psychologically, or otherwise health-compromised individual. It would be more constructive to treat recollections as existential reconstructions.

The Response of Interpersonal Problems to Varying Doses of Psychotherapy

This investigation reports changes in interpersonal problems over the course of outpatient psychotherapy. Endorsement patterns for distress related to interpersonal problems for patient and non-patient samples were compared. For the patient sample, a 26-item version of the Inventory of Interpersonal Problems was administered at intake and at selected sessions of psychotherapy. Three factors were identified: (1) Control (e.g., It is hard to accept another persons authority over me); (2) Detached (e.g., I keep other people at a distance too much), and; (3) Self-effacing (e.g., I worry too much about disappointing other people). Using session 2 as a base, the dose-response curve for the Control scale inflected at session 10 and was followed by a monotonic increase in improvement. For the Detached scale, there was an inflection at session 17 followed by a monotonic increase. The Self-effacing scale did not show any response to treatment.

Gender Differences in Adolescent Symptomatology: A Normative Study

A widespread belief that adolescence is marked by disturbance may have contributed to a lack of interest in psychiatric symptomatology in adolescents. There are few studies of adolescent gender differences. Adolescents (N = 497) from three Chicago area high schools, representing a broad socioeconomic spectrum, were administered the Offer Self-Image Questionnaire, the Delinquency Checklist, and the Symptom Checklist in which they self-report on self-image, experience of symptoms, and delinquent behavior, respectively. Results show that adolescent girls are more prone to report inwardly directed psychiatric symptomatology, such as depression and anxiety, than are adolescent boys; adolescent boys are more prone to report acting out behaviorally. Gender is an important aspect of treating adolescent patients.

Exploring individual change.

In the analysis of the impact of clinical interventions, the received wisdom has been that posttreatment scores, with pretreatment scores equated by random assignment or statistically partialed out, should be used to evaluate treatment outcomes. However, posttreatment scores are not generally more reliable than, nor equivalent to, change scores, even with pretreatment scores partialed out of both. Moreover, there are data-analytic methods that indicate how individual patients change, in terms of response curves over time, rather than indicate only how much groups change on the average. These methods take researchers back to the individual data that they ought to use for choosing the specific models of change to be used. To maximize relevance for clinical practice, the results of treatment research should always be reported at this most disaggregated or individual change level, as well as, when appropriate, at more aggregated statistical levels.

Program evaluation in the public interest: A new research methodology

For every social welfare or social control service program there are several parties, each with different interests: patients, clients, staff, management, and sponsors. Evaluation of such a program in the public interest must take the interests of each of these parties into account. To do so requires an untraditional methodology, that of a second-person, or communal, science, which is not above the conflict of parties and their interests in specifying the variables, staffing the research, balancing considerations of intrusion against those of bias, considering the action implications of the data, sequentially staging the research, or even publishing findings. This all makes evaluation in the public interest a highly political process often unlikely to be logically decisive about intervariable relationships, to yield generalizable results, or even to be completed.