William C. Follette

Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance.

The purpose of this article is to suggest some new directions for the presentation and reporting of data in psychotherapy outcome research. Statistical comparisons based on group means provide no information on the variability of treatment outcome, and statistical significance tests do not address clinical significance. Although psychotherapy research has begun to address these issues, it has done so unsystematically. New standards and conventions are needed to serve as criteria for classifying therapy subjects into categories of improved, unimproved, and deteriorated based on response to treatment. A two-fold criterion for determining improvement in a client is recommended, based on both statistical reliability and clinical significance. Statistical procedures for determining whether or not these criteria have been met are discussed.

Less Dialysis-Induced Morbidity and Vascular Instability with Bicarbonate in Dialysate

We devised three protocols to test the postulate that increased morbidity during high-efficiency dialysis with large-surface-area units (LS) might be due in part to the increased flux of bicarbonate out and acetate into the patient inherent is LS dialysis. The first protocol showed that with LS-acetate dialysis there was a marked fall in plasma bicarbonate and Pco2 during the first 3 to 4 h, followed by a rapid rise in bicarbonate above normal and return to control in Pco2. With LS-bicarbonate dialysis, these oscillations were largely eliminated. A second double-blind protocol showed that central nervous system-type symptoms noted during and after LS-acetate dialysis were reduced significantly by switching to LS-bicarbonate dialysis. The third protocol showed that with LS-carbonate the tolerable rate of ultrafiltration could be increased 67% compared with LS-acetate dialysis.

Models of Scientific Progress and the Role of Theory in Taxonomy Development: A Case Study of the DSM

The proliferation of categories in recent editions of the Diagnostic and Statistical Manual of Mental Disorders (e.g., 4th ed.; DSM; American Psychiatric Association, 1994) is discussed as an indication that the underlying classification scheme is inadequate and unlikely to produce the scientific progress originally envisioned. In any nosological system, it eventually becomes necessary to reduce the number of categories by an organizing theory that describes the fundamental principles underlying the taxonomy. The DSM has put itself in an awkward position by claiming to be atheoretical. Although taking such a tack had historical advantages to promote the acceptability of the 3rd edition of the DSM, it now limits the progression of science. It is argued that the DSM should not be used as the basis for guiding scientific research programs because it emphasizes primarily behavioral topography rather than providing an explicit theory that would allow for an evaluation of scientific progress. Theoretically driven taxonomies should be allowed to compete on the basis of how successful they are at achieving their specified goals that might include illuminating etiology, course, and response to treatment. Such systems are not likely to attend primarily to behavioral topography alone and would probably organize behavior differently than the current categorical syndromes seen in the 4th edition of the DSM.

Spontaneous Retroperitoneal Bleeding in Patients on Chronic Hemodialysis

Six patients developed spontaneous retroperitoneal bleeding while on maintenance dialysis (3% of all patients so treated). At the time of the bleeding episode, four patients were receiving Coumadin for prevention of recurrent clotting problems in external shunts. In three patients, including two who had not received Coumadin, bleeding developed while on dialysis. The presenting common symptoms and signs of retroperitoneal bleeding included sudden and progressive abdominal pain with blood pressure drop and subsequent development of an abdominal mass. These symptoms were associated with a falling hematocrit without any documented external blood loss and with suggestive X-ray changes, including absence of psoas shadow with soft tissue density. All six patients recovered. Treatment included blood transfusions, temporary regional heparinization, withdrawal of Coumadin, and bed rest. Surgical exploration was undertaken in two patients, but no obvious bleeding source was found. Anticoagulation therapy and functional platelet abnormalities may be contributory causes.

A radical behavioral understanding of the therapeutic relationship in effecting change

This paper presents a behavior analytic understanding of the functional components of the therapeutic relationship. Whereas other models of understanding therapy have offered interpretations of the importance of the client-therapist alliance, few have specified mechanisms responsible for mediating change that have a foundation in experimental psychology. Consistent with the radical behaviorally based Functional Analytic Psychotherapy (FAP), we describe, using a contemporary understanding of verbal behavior, how the therapist establishes him or herself as a provider of social reinforcement in order to shape change using contingent and noncontingent responding. We propose a reason why a limited amount of client-therapist contact can produce large changes in behavior. The paper closes with a description of a research strategy for evaluating the proposed model of effecting client change as a function of the therapeutic relationship.

Individual Predictors of Outcome in Group Treatment for Incest Survivors.

Sixty-five abused women who participated in time-limited group therapy were evaluated before treatment on demographic variables, sexual abuse history, characteristics of the family of origin, and initial levels of depression and distress. Hierarchical regression analyses were conducted to determine the impact of these variables on response to treatment. Results suggest that education, marital status, type of sexual contact, and initial levels of depression and distress predicted response to treatment. In addition, a history of previous therapy showed a tendency to interact with type of group format to predict outcome. Implications for therapy and further research are considered.

A Guide to Functional Analytic Psychotherapy

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Do As I Do, Not As I Say: A Behavior-Analytic Approach to Supervision

There is a limited amount of empirical data on how to train therapists. This article first presents limitations in commonly used training procedures. It then describes a training methodology based on contingent shaping, using video feedback to increase responsiveness to the ongoing client-therapist interactions. The approach attempts to overcome some of the problems encountered when teaching therapy by using primarily rule-governed or direct instruction. The authors describe the therapeutic approach used in this research, provide a clinical illustration of the training procedure, and discuss the role direct instruction plays in this training model. A methodology for determining whether the therapists behavior changes as a result of training is described, as well as a method for identifying the relationship between the therapists behavior and subsequent changes in client responding. This methodology is broadly applicable and can be empirically tested and compared with other approaches for its utility in training therapist effectiveness and changing client behavior.

Clinical significance of improvement resulting from two behavioral marital therapy components

This study compared the effectiveness of behavioral marital therapy (BMT) to that of its major components—behavior exchange (BE) and communication/problem solving training (CPT)—each presented in isolation. In a previous manuscript, Jacobson (1984) reported the results for thirty-six couples. This manuscript presents data from an additional twenty-four couples and presents a thorough analysis of clinical significance of the results at both posttest and a 6-month follow-up. Between-groups comparisons were based on the proportions of couples improved in each condition. Criteria for improvement included both the clinical significance of the changes and whether or not the changes were statistically reliable. In terms of marital satisfaction, differences between groups began to emerge at the 6-month follow-up. BE couples deteriorated at very high rates, while couples receiving the complete treatment (CO) in particular tended to either maintain or enhance their progress. On a measure tapping desire for behavior change, the differences between groups were much less striking, although there remained a tendency for CO couples to show lower deterioration rates at follow-up time. Overall, the CO treatment produced the most enduring as well as the most consistent changes.

USEFUL CONSTRUCTIONS OF THE CLIENT- THERAPIST RELATIONSHIP

Although different theories of psychotherapy emphasize the importance of the therapeutic relationship, these perspectives diverge when considering why this relationship matters clinically. This article proposes that different verbal constructions or definitions of the therapeutic relationship result in very different approaches to treatment and affect the way the client and therapist interact. An understanding of this relationship using a contemporary radical behavioral therapy, Functional Analytic Psychotherapy (FAP), is discussed and is contrasted with different conceptualizations of this relationship. This discussion emphasizes how specific constructions provide advantages to therapists that facilitate treatment and offers a distinction between the therapeutic relationship and a friendship. A discussion of why it is important for the therapist to understand and convey this definition to the client during treatment is included along with a brief description of how supervision helps the therapist gain an understanding of this relationship.