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A survival analysis of clinically significant change in outpatient psychotherapy

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Abstract

The number of sessions required to produce meaningful change has not been assessed adequately, in spite of its relevance to current clinical practice. Seventy-five clients attending outpatient therapy at a university-affiliated clinic were tracked on a weekly basis using the Outcome Questionnaire (Lambert et al., 1996) in order to determine the number of sessions required to attain clinically significant change (CS). Survival analysis indicated that the median time required to attain CS was 11 sessions. When current data were combined with those from an earlier investigation (Kadera, Lambert, and Andrews, 1996), it was found that clients with higher levels of distress took 8 more sessions to reach a 50% CS recovery level than clients entering with lower levels of distress. At a six-month follow-up, CS gains appeared to have been maintained. Other indices of change also were examined (reliable change, average change per session). The implications of these results for allocating mental-health benefits, such as the number of sessions provided through insurance, are discussed. © 2001 John Wiley & Sons, Inc. J Clin Psychol 57: 875–888, 2001.
... İlgili literatür incelendiğinde Clement (2008) çalışmasında danışanların katılmış olduğu ortalama oturum sayısı 17.43 olarak hesaplanmış ve oturum sayısı ile psikoterapi sonucu arasında anlamlı ve olumlu yönde bir ilişki bulunmuştur. Literatürde psikolojik danışma yardımının etkililiğinin oturum etkisini araştırma yolu ile ölçüldüğü görülmektedir (Kadera, Lambert ve Andrews, 1996;Anderson ve Lambert, 2001;Wolgast ve diğ., 2003). Bu çalışmalar incelendiğinde Kadera vd. ...
... Bu çalışmalar incelendiğinde Kadera vd. (1996) danışanların anlamlı değişimi için 14 oturuma, Anderson ve Lambert (2001) 11 oturuma, Wolgast vd. (2003) 16 oturuma, ihtiyaç duyulduğunu ortaya koymuştur. ...
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Abstract. Purpose of this study was to examine client’s experience and behavior change levels according to perceived social support, gender, number of the sessions they attended and problem solving styles. This study is a descriptive field research. The sample of this study consisted of 200 clients who had counseling from counselor trainees, attending Guidance and Counseling Undergratuade Program at different 12 state universities in 2011-2012 and 2012-2013 academic years. Multidimensional Scale of Perceived Social Support, Problem Solving Inventory, The Change in Experiences and Behaviors Scale were used in order to collecting data. Also informed consent form and inform letters developed by the researcher were used to inform clients and counselor trainees. Multiple linear hierarchical regression was used to analyze whether clients’ experience and behavior change levels predicted by clients’ attended session numbers, gender, perceived social support and problem solving styles. The result of this study indicated that clients’ experience and behavior change levels were not predicted by clients’ gender, perceived social support, problem solving styles and session number. Quick-tempered problem solving, avoidant problem solving, evaluator problem solving, self-confident problem solving, planned problem solving did not predict clients’ experience and behavior change level. The relationship between these problem solving styles with experience and behavior change level was also found insignificant. The only problem solving style is thinking style which has a relationship in a negative and significant way with clients’ experience and behavior change levels. Keywords: Counseling outcome, Problem solving style, Perceived social support, Client variables in counseling. Öz. Bu araştırmanın amacı, psikolojik danışma süreci sonunda danışanların göstermiş oldukları yaşantı ve davranış değişim düzeyinin danışanların algıladıkları sosyal destek düzeyi, cinsiyeti, katılmış oldukları oturum sayısı ve problem çözme tarzlarına göre incelenmesidir. Araştırma betimsel bir alan araştırmasıdır. Araştırmanın örneklemi orta ve büyük ölçekteki 12 devlet üniversitesinde RPD lisans programında öğrenim gören psikolojik danışman adaylarının psikolojik yardım sunduğu 200 danışandan oluşmuştur. Araştırmada veri toplama aracı olarak Çok Boyutlu Algılanan Sosyal Destek Ölçeği (ÇBASDÖ), Problem Çözme Envanteri (PÇE), Yaşantı ve Davranışlarda Değişim Ölçeği (YADA) ve araştırmacı tarafından hazırlanan Bilgilendirilmiş Onay Formu ile bilgilendirme mektupları kullanılmıştır. Danışanların yaşantı ve davranışlardaki değişim düzeylerinin danışanların katılmış oldukları oturum sayısı, cinsiyeti, algılanan sosyal destek ve problem çözme becerisi değişkenlerine göre yordanıp yordanmadığını incelemek için çoklu doğrusal hiyerarşik regresyon analizi yapılmıştır. Araştırmanın bulgularına bakıldığında, danışanların cinsiyetinin, algıladıkları sosyal destek düzeylerinin ve katılmış oldukları oturum sayısının psikolojik danışma sürecinde algıladıkları yaşantı ve davranış değişim düzeyini yordamada anlamsız bulunduğu görülmüştür. Danışanların aceleci problem çözme, kaçıngan problem çözme, değerlendirici problem çözme, kendine güvenli problem çözme, planlı problem çözme tarzı puanları, yaşantı ve davranışlarda değişim düzeyi puanlarını yordamada istatistiksel olarak anlamsız bulunmuştur. Bu problem çözme tarzları ile danışanların algıladıkları yaşantı ve davranış değişim düzeyi arasında anlamlı bir ilişki bulunamamıştır. Sadece danışanların düşünen tarz problem becerisi ile algıladıkları yaşantı ve davranış değişimi düzeyi arasında anlamlı ve olumsuz bir ilişki olduğu ortaya konmuştur. Anahtar Kelimeler: Psikolojik danışma sonucu, Problem çözme tarzı, Algılanan sosyal destek, Psikolojik danışmada danışan değişkenleri.
... This measure consists of 45 items, evaluating three primary dimensions: 1) symptom distress, 2) interpersonal relationships, and 3) social role performance. While the total score range is 0-180, the cutoff score between clinical and nonclinical populations is 63 [15]. This scale is broadly used, showing good validity, internal consistency (0.93), and test-retest reliability (r = 0.84) [16]. ...
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Objectives: Studies assessing the effect of the COVID-19 pandemic on psychiatric patients have mostly focused on cross-sectional evaluations of differences in levels of distress. In this study, we aimed to assess changes in distress and well-being following the COVID-19 pandemic outbreak as compared with pre-pandemic levels, as well as potential predictors of symptomatic deterioration, among psychiatric outpatients treated in a public mental health hospital in Israel. Methods: Patients evaluated for distress and well-being before the pandemic ( n = 55) were re-evaluated at the end of the first lockdown in Israel. Results: Analyses revealed a significant decrease in the patients’ sense of personal growth. Increases in distress were significantly associated with fear of COVID-19 beyond patient characteristics. Conclusion: These results suggest that the pandemic has a short-term effect on patients’ well-being, and that fear of the pandemic is associated with elevations in distress.
... Studies describing mental health service dose and response are limited and inconsistent. For example, whereas one study with adults found that a minimum of four therapy sessions were necessary to achieve more than 50% reliable and clinically significant improvement (Delgadillo et al., 2014), Anderson et al. (2001) found that somewhere between 11 and 16 therapy sessions resulted in 50% clinically significant improvement. From the children's mental health services literature, there is some evidence that the type of treatment moderates the dose-response relation. ...
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The current study (1) characterizes patterns of mental health service utilization over 8 years among youth who received psychotherapy in the context of a community implementation of multiple evidence-based practices (EBPs), and (2) examined youth-, provider- and service-level predictors of service use patterns. Latent profile analyses were performed on 5,663,930 administrative claims data furnished by the county department of mental health. Multinomial logistic regression with Vermunt’s method was used to examine predictors of care patterns. Based on frequency, course, cost, and type of services, three distinct patterns of care were identified: (1) Standard EBP Care (86.3%), (2) Less EBP Care (8.5%), and (3) Repeated/Chronic Care (5.2%). Youth age, ethnicity, primary language, primary diagnosis and secondary diagnosis, provider language and provider type, and caregiver involvement and service setting were significant predictors of utilization patterns. Although the majority of youth received care aligned with common child EBP protocols, a significant portion of youth (13.7%) received no evidence-based care or repeated, costly episodes of care. Findings highlight opportunities to improve and optimize services, particularly for youth who are adolescents or transition-aged, Asian-American/Pacific Islander, Spanish-speaking, or presenting with comorbidities.
... Although not always ending therapy earlier is synonymous with poor-outcome, there is a scarce of research exploring the relationship between dropout and therapeutic outcomes (Zieve et al., 2019). Considering that 12 to 21 sessions are necessary to achieve recovery for at least 50% of clients (Anderson & Lambert, 2001;Hansen et al., 2002;Lambert, 2007Lambert, , 2013, more effort should be devoted to understanding therapy dropout and reducing its occurrence when it is associated with poor-outcomes (Swift & Greenberg, 2015). Therefore, knowing more about the processes associated with different outcomes in dropout cases will help therapists handling with the patients in risk of dropping out from therapy when they are still experiencing clinically significant distress. ...
Article
Ambivalence toward change is an expected, recurrent process in psychological change. However, the prolonged experience of ambivalence in psychotherapy contributes to client disengagement, which could result in treatment dropout. Considering the negative effects of premature termination of therapy and the convenience of the identification of clients who are at risk of dropping out before achieving good-outcome, the current study explored the predictive power of ambivalence for premature therapy termination using a multilevel time backwards model (i.e., considering the session of the dropout as session zero and then modeling what occurred from the dropout until session 1). Participants included a total of 96 psychotherapy clients (38 dropouts) treated in a university-based clinic following the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Multilevel modeling using a time-backwards model to analyze dropout data provided evidence of the predictive power of ambivalence evolution throughout treatment on the decision to prematurely discontinue treatment (p < .0001; R2adj = .29). Specifically, good-outcome dropouts presented a decreasing ambivalence trend throughout treatment, whereas poor-outcome dropouts tended to experience the same levels of ambivalence before deciding to drop out (time x dropout; B 11 = .64, p = .014). Additionally, poor-outcome dropouts presented higher levels of ambivalence (B 01 = 9.92, p < .0001) in the last session. The results suggest that the pattern of client ambivalence toward change is a predictor of premature termination of therapy. Implications for clinical and research contexts are discussed.
... Also, some studies (37)(38)(39) have documented the effectiveness of brief time-limited therapy (eight to 16 sessions or five sessions of CBT) (30,37). It has been suggested that about 50% of treated patients in routine care might recover if they received about 18 to 21 sessions of psychotherapy (40), although about 50% of clients will show reliable improvement after only seven sessions. However, it is also known that deterioration rates for patients in routine practice settings can be as high as 14% (41), whereas the response rate (recovered and improved patients) for patients with clinical symptoms participating in 20 sessions of therapy is around 40% (31). ...
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Objective: The aim of this article was to explore the effectiveness of rational emotive and cognitive-behavioral therapy (REBT) in a clinical setting. Methods: This study included 349 patients of the Albert Ellis Institute who sought psychotherapy from 2007 to 2016. Analyses were conducted by using the intent-to-treat principle, and outcomes were measured after three sessions of therapy (to measure early response) and at the end of 20 sessions. Outcome Questionnaire-45 was used to measure patient functioning. Results: Patients reported significant improvements in their functioning after participating in REBT, with a medium effect size for early response after three sessions of psychotherapy and at the end of the 20 sessions. Conclusions: The authors' findings documented that REBT can be effectively transported from a research setting to clinical practice.
... According to previous clinical outcome studies, the number of sessions at which clients achieve clinically significant improvement is between 11 and 21 sessions (E. M. Anderson & Lambert, 2001;Hansen et al., 2002;Wolgast et al., 2003). This finding has significant implications for RCT studies on therapeutic outcomes and therapist effects. ...
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... The median effective dose is utilized as one of multiple criteria that can determine whether to continue or change a medication and can be identified from dose-response curves. Others have extensively applied these pharmacotherapy concepts to psychotherapy broadly (e.g., Anderson & Lambert, 2001;Hansen, Lambert, & Forman, 2002;Harnett, O'Donovan, & Lambert, 2010;Howard et al., 1986;Robinson, Delgadillo, & Kellett, 2020). However, only recently have researchers begun to apply these concepts to specific treatments (e.g., Byllesby, Dickstein, & Chard, 2019). ...
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Prolonged exposure therapy (PE) is an effective treatment for posttraumatic stress disorder (PTSD). Identifying metrics of treatment response can guide treatment delivery. The median effective dose represents the number of sessions at which there is a 50% probability of clinically meaningful improvement (i.e., 10-point reduction in PTSD checklist). The goal of the current study was to investigate the median effective dose of PE. We identified a cohort of Iraq and Afghanistan war veterans who received psychotherapy for PTSD in the Veterans Health Administration between 2001 and 2017. From this cohort, 10,234 veterans who received PE (as identified using natural language processing) and had ≥2 PTSD symptom measures were included in analyses. To determine how the number of PE sessions and covariates affected clinically meaningful improvement, we utilized a Cox proportional hazards regression, followed by Kaplan-Meier curves to determine the median effective dose. The median effective dose of PE was four sessions. Although some covariates were found to be statistically significant predictors of clinically meaningful improvement (e.g., age, gender, PTSD medications, and depressive disorder comorbidity), these effects were small. Clinicians and patients should consider evaluating treatment response after four sessions to determine preliminary effectiveness of PE.
Thesis
Im Rahmen des patientenzentrierten Forschungsansatzes wurden Monitoringsysteme entwickelt, die die Beeinträchtigung und den Symptomverlauf von Patienten durch psychometrische Instrumente im Therapieverlauf erfassen und an die Behandler zurückmelden. Während die ersten Studien überzeugende Effekte dieses Verlaufsfeedbacks, -insbesondere für Patienten mit initial ungünstigem Behandlungsverlauf-, berichteten, werden die empirischen Befunde mittlerweile zurückhaltender beurteilt. Für das hiesige Versorgungssystem liegen nur wenige Studien mit heterogenen Ergebnissen vor. Eine systematische Untersuchung der Effektivität von Feedbackinhalten, die sich neben der Symptomatik auch auf Prozessmaße wie die therapeutische Beziehung beziehen, steht noch aus. In dieser Studie wurden die Praktikabilität, Akzeptanz und Effektivität symptombezogener Rückmeldungen im frühen Behandlungsverlauf sowie mögliche differenzielle Effekte einer zusätzlichen Rückmeldung der therapeutischen Beziehung untersucht. In einem cluster-randomisierten Design wurden 21 Therapeuten einer Fachklinik für Psychiatrie und Psychotherapie einer von drei Untersuchungsgruppen (G1, G2, G3) zugeteilt: G1: symptombezogenes Verlaufsfeedback 6 Wochen nach Aufnahme, G2: symptombezogenes Verlaufsfeedback bei Aufnahme, 2 Wochen und 6 Wochen nach Aufnahme, G3: prozess- und symptombezogenes Verlaufsfeedback bei Aufnahme, 2 Wochen und 6 Wochen nach Aufnahme. Das symptombezogene Feedback basierte auf der Symptom-Checkliste (SCL-90-R) und dem Inventar Interpersoneller Probleme (IIP-C), das Prozessfeedback auf der Beziehungsskala des Helping Alliance Questionnaire (HAQ). Daten von 537 Patienten (Intent-to-treat-Stichprobe) wurden mittels gemischter linearer Modelle und gemischter logistischer Regressionsmodelle analysiert. Der Globale Schwereindex GSI, die reliable Veränderung des GSI („Reliable Change Index“) und das nach dem Stuttgart-Heidelberger Modell der Qualitätssicherung bestimmte Auffälligkeitssignal wurden als Outcome-Maße verwendet. Die Praktikabilität des computergestützten Monitoring- und Feedbacksystems erwies sich als sehr gut. Die Behandler zeigten eine hohe Adhärenz bezüglich der Intervention, beurteilten die inhaltliche Relevanz des Feedbacks und dessen Nutzen jedoch als eher gering. Therapeuten, die zusätzlich Feedback über die therapeutische Beziehung erhalten hatten (G3), beurteilten die Rückmeldungen positiver als Therapeuten der Gruppen G1 und G2. Signifikante Gruppenunterschiede für Patienten mit einem frühen auffälligen Verlauf waren auf zwei der drei Outcome-Maße (GSI bei Entlassung, Auffälligkeitssignal) festzustellen. In Einzelvergleichen zeigte sich, dass initial auffällige Patienten in G2 einen niedrigeren GSI-Wert bei Entlassung und ein geringeres Risiko für einen auffälligen Gesamtverlauf aufwiesen als initial auffällige Patienten in G1. Entgegen der Hypothese zeigte sich kein signifikanter Unterschied bezüglich der Outcome-Maße zwischen initial auffälligen Patienten der Gruppen G3 und G1. Das zusätzliche Feedback im frühen Behandlungsverlauf (G2, G3) hatte keinen Effekt bezüglich einer Steigerung der Effizienz: In allen drei Gruppen wurden Patienten mit einem frühen auffälligen Verlauf etwas länger und Patienten, deren GSI bei der ersten Zwischenerhebung im Normbereich lag, etwas kürzer behandelt. Das zusätzliche Prozessfeedback in G3 hatte weder einen Effekt auf die Werte der HAQ-Beziehungsskala bei Entlassung noch auf die reliable Veränderung der therapeutischen Beziehung. Symptombezogenes Feedback im frühen Therapieverlauf erhöht bei Patienten mit einem initial auffälligen Verlauf die Wahrscheinlichkeit für ein positives Therapie-Outcome. Da sich der Effekt bei lediglich zwei zusätzlichen Rückmeldungen zeigte, kann Verlaufsfeedback auch empfohlen werden, wenn keine sehr engmaschigen Erhebungen möglich sind. Als Wirkfaktor wird das Alarmsignal, das die Bewertung „auffälliger Verlauf“ erzeugt, angenommen. Die mit durchschnittlich 97 Tagen sehr lange Behandlungsdauer bei gleichzeitig begrenzter Flexibilität des stationären Settings werden als Gründe angenommen, warum das zusätzliche Verlaufsfeedback in G2 und G3 nicht zu einer höheren Effizienz i.S. einer stärkeren Orientierung der Behandlungsdauer an Symptomschwere und Gesundungsverlauf geführt hat, wie dies für Settings mit sehr kurzen Behandlungsdauern berichtet wurde. In der vorliegenden Studie hatte die zusätzliche Rückmeldung der therapeutischen Beziehung weder positive Effekte auf Prozess- noch auf Symptommaße. Um eindeutige Empfehlungen zu geben, sollte die empirische Basis bezüglich der Effekte prozessorientierter Verlaufsrückmeldungen erweitert werden.
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Given the perceived importance of supervision and the obvious diversity in the conceptualization, roles, functions, and goals of supervision, there is considerable variability in the purposes and methods of research on supervision. Although there are many ways in which we might focus a review of research on supervision, we have tried to keep central our interest in patient outcome. We emphasize research that has implications for the practice of supervision on the trainee rather than focusing on the experience of the supervisor. We divide research on supervision into 3 sections: (a) research on therapist interviewing and interpersonal skills; (b) research on therapist technical skills, including the use of treatment manuals to enhance technical skills; and (c) measurement strategies for assessing supervision outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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• We investigated the effectiveness of two brief psychotherapies, interpersonal psychotherapy and cognitive behavior therapy, for the treatment of outpatients with major depressive disorder diagnosed by Research Diagnostic Criteria. Two hundred fifty patients were randomly assigned to one of four 16-week treatment conditions: interpersonal psychotherapy, cognitive behavior therapy, imipramine hydrochloride plus clinical management (as a standard reference treatment), and placebo plus clinical management. Patients in all treatments showed signifi-cant reduction in depressive symptoms and improvement in functioning over the course of treatment. There was a consistent ordering of treatments at termination, with imipramine plus clinical management generally doing best, placebo plus clinical management worst, and the two psychotherapies in between but generally closer to imipramine plus clinical management. In analyses carried out on the total samples without regard to initial severity of illness (the primary analyses), there was no evidence of greater effectiveness of one of the psychotherapies as compared with the other and no evidence that either of the psychotherapies was significantly less effective than the standard reference treatment, imipramine plus clinical management. Comparing each of the psychotherapies with the placebo plus clinical management condition, there was limited evidence of the specific effectiveness of interpersonal psychotherapy and none for cognitive behavior therapy. Superior recovery rates were found for both interpersonal psychotherapy and imipramine plus clinical management, as compared with placebo plus clinical management. On mean scores, however, there were few significant differences in effectiveness among the four treatments in the primary analyses. Secondary analyses, in which patients were dichotomized on intial level of severity of depressive symptoms and impairment of functioning, helped to explain the relative lack of significant findings in the primary analyses. Significant differences among treatments were present only for the subgroup of patients who were more severely depressed and functionally impaired; here, there was some evidence of the effectiveness of interpersonal psychotherapy with these patients and strong evidence of the effectiveness of imipramine plus clinical management. In contrast, there were no significant differences among treatments, including placebo plus clinical management, for the less severely depressed and functionally impaired patients.
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