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

Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104-1696, USA.
Journal of Consulting and Clinical Psychology (Impact Factor: 4.85). 04/2010; 78(2):200-11. DOI: 10.1037/a0018912
Source: PubMed


The authors conducted a meta-analytic review of adherence-outcome and competence-outcome findings, and examined plausible moderators of these relations.
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.
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.
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.

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Available from: Jacques P. Barber, Sep 29, 2015
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    • "Best practices involve ratings by therapists who have expertise in the intervention protocol and training in the rating system (Perepletchikova and Kazdin 2005). Although ratings of adherence to a protocol are typically reliable, ratings of competence have shown consistently low reliability across treatment modalities within individual therapy (Muse and McManus 2013; Webb et al. 2010) as well as family-centered intervention (Cross and West 2011). Although there are only a handful of studies, the reliability of observationally rated adherence is typically higher (r≥.80 Brody et al. 2004; ICC=.64 to .79 "
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    ABSTRACT: The valid and reliable assessment of fidelity is critical at all stages of intervention research and is particularly germane to interpreting the results of efficacy and implementation trials. Ratings of protocol adherence typically are reliable, but ratings of therapist competence are plagued by low reliability. Because family context and case conceptualization guide the therapist’s delivery of interventions, the reliability of fidelity ratings might be improved if the coder is privy to client context in the form of an ecological assessment. We conducted a randomized experiment to test this hypothesis. A subsample of 46 families with 5-year-old children from a multisite randomized trial who participated in the feedback session of the Family Check-Up (FCU) intervention were selected. We randomly assigned FCU feedback sessions to be rated for fidelity to the protocol using the COACH rating system either after the coder reviewed the results of a recent ecological assessment or had not. Inter-rater reliability estimates of fidelity ratings were meaningfully higher for the assessment information condition compared to the no-information condition. Importantly, the reliability of the COACH mean score was found to be statistically significantly higher in the information condition. These findings suggest that the reliability of observational ratings of fidelity, particularly when the competence or quality of delivery is considered, could be improved by providing assessment data to the coders. Our findings might be most applicable to assessment-driven interventions, where assessment data explicitly guides therapist’s selection of intervention strategies tailored to the family’s context and needs, but they could also apply to other intervention programs and observational coding of context-dependent therapy processes, such as the working alliance.
    Prevention Science 08/2015; DOI:10.1007/s11121-015-0589-0 · 2.63 Impact Factor
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    • "Die therapeutische Adhärenz oder Manualtreue ist im Vergleich zur therapeutischen Allianz und Kompetenz ein methodischer Aspekt, der den Grad der Umsetzung eines Therapiekonzepts bezeichnet . Obwohl die Adhärenz selbst zumeist keinen unmittelbaren Effekt auf das Behandlungsergebnis hat (Webb et al. 2010) "
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    ABSTRACT: Psychotherapie ist in der Behandlung einer Vielzahl von psychischen Störungen wirksam. Dies wurde in zahlreichen Studien und Metaanalysen nachgewiesen. Die Behandlungserfolge sind beträchtlich: Durchschnittlich kann die Hauptsymptomatik mit großem Effekt verbessert werden (d = 0,80). Auf der Grundlage solcher Daten empfehlen aktuelle Leitlinien in vielen Ländern und auch im deutschen Sprachraum zunehmend „Goldstandards“ der evidenzbasierten Psychotherapie für einzelne psychische Störungen. Über Standards von Psychotherapie hinaus stellt sich jedoch zusätzlich die Frage nach den tatsächlich wirksamen Faktoren, die zumeist in den Leitlinien nicht beleuchtet werden.Verwoben mit der Frage nach Wirkfaktoren in der Psychotherapie ist die bis heute andauernde Diskussion, ob und zu welchem Anteil therapeutische Effekte durch allgemeine Wirkfaktoren (z. B. therapeutische Beziehung) oder spezifische Techniken (z. B. Exposition) erzielt werden (Norcross und Lambert 2011). Spätestens seit der Einf ...
    Psychotherapeut 05/2015; 60(3). DOI:10.1007/s00278-015-0017-8 · 0.78 Impact Factor
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    • "The authors found a significant effect of therapy on amount of substance used per substance using day which was maintained over two year follow-ups; although the therapy had no effect on hospital admissions or symptoms. Identifying factors which contribute to these outcomes has important treatment implications as it can help future researchers and therapists to modify therapies to maximise benefit (Webb et al., 2010). One process factor that is frequently investigated to help explain outcomes is therapeutic alliance. "
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    ABSTRACT: This study aimed to explore factors associated with outcomes in a randomised controlled trial of integrated motivational interviewing and cognitive behavioural therapy for psychosis and substance misuse. Clients and therapists completed self-report measures of alliance and clients completed a self-report measure of adult attachment. Trial therapists were also asked to identify challenges in therapy, client strengths and reasons for client making and not making changes in relation to substance misuse. Neither therapist-rated nor client-rated alliance was significantly related to objective outcomes. Client insecure attachment avoidance was associated with poorer symptoms and functioning at 12 and 24 months; although not changes in substance misuse. Therapists' perceptions of therapeutic processes (e.g., challenges to therapy, client strengths, client reasons for change and alliance) were consistent with previous literature. Therapists' perceptions of client improvement were associated with reductions in substance use at the end of treatment and their ratings of therapeutic alliance. Insecure adult attachment styles may be a potentially important predictor of symptom outcomes for people with psychosis and substance misuse. Trial therapists may also provide an important source of information about therapeutic processes and factors associated with outcome. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Drug and alcohol dependence 04/2015; 152. DOI:10.1016/j.drugalcdep.2015.04.006 · 3.42 Impact Factor
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