William B. Stiles

QUALITY CONTROL IN QUALITATIVE RESEARCH

Abstract Qualitative investigations of human experience typically report linguistic rather than exclusively numeric results, use empathy with participants as an observation strategy, interpret observations contextually and polydimensionally, accommodate nonlinear (technically chaotic) causal processes, and may seek to empower participants. Their interpretations are often tentative rather than lawlike statements, amenable to expression in narrative and hermeneutic forms rather than exclusively in didactic discourse. By revealing rather than avoiding the investigators orientation and personal involvement in the research and by evaluating interpretations according to their impact on readers, investigators, and participants, qualitative research shifts the goal of quality control from the objective truth of statements to understanding by people.

The Medical Interview Satisfaction Scale: development of a scale to measure patient perceptions of physician behavior.

Patient satisfaction is a variable of increasing interest to researchers, clinicians, and medical educators. Of several studies reviewed, only a few have shown evidence of careful methodology. Most surveys have focused on general evaluations of doctors and/or health care services or of a particular facility. The present article reports the development of a scale to measure patient satisfaction with an encounter with a physician or other primary care provider. Methods of item generation and pretesting are detailed. The overall reliability of the scale (Cronbachs coefficientα) is 0.93. The distribution of satisfaction scores is broader than that reported for other scales and approaches the normal in shape. Clinical and research applications of the scale are suggested.

ASSIMILATION OF PROBLEMATIC EXPERIENCES BY CLIENTS IN PSYCHOTHERAPY

DAVID A. SHAPIRO AND GILLIAN HARDYMRC/ESRC Social and Applied Psychology UnitUniversity of SheffieldIn successful psychotherapy,problematic experiences (threatening orpainful thoughts, feelings, memories,etc.) are gradually assimilated intoschemata that are introduced by thetherapist or developed in the therapist-client interaction by modification of oldschemata. As it is assimilated, aproblematic experience passes throughpredictable stages. The client movesfrom being oblivious, to experiencingthe content as acutely painful, then asless distressing, merely puzzling, thenunderstood, and finally as confidentlymastered.

Interaction Exchange Structure and Patient Satisfaction with Medical Interviews

The verbal interaction between patients and physicians in 52 initial interviews in a university hospital screening clinic was studied using a new discourse coding system. Factor analysis of category frequencies showed that each interview segment, medical history, physical examination, and conclusion, consisted mainly of two or three types of verbal exchange. Patient satisfaction with the interviews, assessed with a questionnaire that yields separate scores for satisfaction with cognitive and affective aspects, was found to be associated with exchanges involving the transmission of information in particular interview segments. Affective satisfaction was associated with transmission of information from patient to physician in “exposition” exchanges during the medical history, in which patients told their story in their own words. Cognitive satisfaction was associated with transmission of information from physician to patient in “feedback” exchanges during the conclusion segment, in which physician gave patients information about illness and treatment.

Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped?

The authors attempted to replicate and extend D. M. Kivlighan and P. Shaughnessys (2000) findings of (a) 3 distinctive patterns of alliance development across sessions and (b) a differential association of one of these, a U-shaped quadratic growth pattern, with positive treatment outcome. In data drawn from a clinical trial of brief psychotherapies for depression (N = 79 clients), the authors distinguished 4 patterns of alliance development. These matched 2 of Kivlighan and Shaughnessys patterns, but not the U-shaped pattern, and none was differentially associated with outcome. However, further examination of the data identified a subset of clients (n = 17) who experienced rupture-repair sequences-brief V-shaped deflections rather than U-shaped profiles. These clients tended to make greater gains in treatment than did the other clients.

Therapist effects in outpatient psychotherapy: A three-level growth curve approach

Evidence suggests that a moderate amount of variance in patient outcomes is attributable to therapist differences. However, explained variance estimates vary widely, perhaps because some therapists achieve greater success with certain kinds of patients. This study assessed the amount of variance in across-session change in symptom intensity scores explained by therapist differences in a large naturalistic data set (1,198 patients and 60 therapists, who each treated 10–77 of the patients). Results indicated that approximately 8% of the total variance and approximately 17% of the variance in rates of patient improvement could be attributed to the therapists. Cross-validation and extreme group analyses validated the existence of these therapist effects.

Dose-Effect Relations and Responsive Regulation of Treatment Duration: The Good Enough Level

This study examined rates of improvement in psychotherapy as a function of the number of sessions attended. The clients (N=1,868; 73.1% female; 92.4% White; average age=40), who were seen for a variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had planned endings, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and clinically significant improvement (RCSI) on the CORE-OM did not increase with number of sessions attended. Among clients who began treatment above the CORE-OM clinical cutoff (n=1,472), the RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12 sessions (r=-.91). Previously reported negatively accelerating aggregate curves may reflect progressive ending of treatment by clients who had achieved a good enough level of improvement.

Early sudden gains in psychotherapy under Routine clinic conditions: Practice-based evidence

Sudden gains--large, enduring reductions in symptom intensity from one session to the next--were identified by T. Z. Tang and R. J. DeRubeis (1999b) on the basis of data from 2 manualized clinical trials of cognitive therapy for depression. The authors found similar sudden gains among clients with a variety of disorders treated with a variety of approaches in routine clinic settings. Clients (N = 135 who met inclusion criteria) completed short forms of the Clinical Outcomes in Routine Evaluation (CORE-SF) preceding 7 to 74 individual sessions. Those who experienced sudden gains within their first 16 sessions (n = 23) had significantly lower CORE-SF scores in their final 3 sessions than did the other clients.

Disabuse of the drug metaphor: Psychotherapy process-outcome correlations.

The drug metaphor suggests that if a process component (e.g., interpretation) is an active ingredient of a successful psychotherapy, then administering a relatively high level of it should yield a relatively positive outcome, and levels of the process component and the outcome should be correlated across clients. Measures of 5 theoretically relevant, reliably measured verbal process components were compared with the rate of change in 3 standard symptom intensity measures across the brief treatments of 39 (mainly depressed) psychotherapy clients. The expected significant process-outcome correlations were not found. These results are discussed as they illuminate some misleading assumptions that underlie many conventional studies of psychotherapy process and outcome.

Dialogical Sequence Analysis and the Zone of Proximal Development as Conceptual Enhancements to the Assimilation Model: The Case of Jan Revisited

The assimilation model has proposed a set of developmental stages through which a clients problematic experiences pass in successful psychotherapy. We present 2 conceptual additions to the model. First, we examine the clients problematic experiences using dialogical sequence analysis, an intensive method for studying the moment-to-moment process. Second, we extend the developmental stages to describe the intersubjective exchange between client and therapist by introducing Vygotskys concept of the zone of proximal development. We illustrate the application of the new conceptual tools by presenting 3 excerpts from the 1st session with Jan, a 42-year-old woman whose therapy has been studied previously. Our analysis suggested that, during the 1st session, Jans problems reached higher developmental stages in the joint exchange with her therapist (i.e., in the zone of proximal development) than in her internal assimilation.