Toward a more clinically valid approach to therapy research

Matching substance abuse aftercare treatments to client characteristics

This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Substance use outcomes were assessed 3 and 6 months posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

Behavioral and pharmacologic treatment of transformed migraine with analgesic overuse: outcome at 3 years

OBJECTIVE

To determine whether combined treatment using medication and biofeedback would be more effective than drug treatment alone for treating transformed migraine complicated by analgesic overuse.

BACKGROUND

Headaches that are chronic, daily, and aggravated by medication overuse are particularly difficult to treat.

METHODS

Sixty-one consecutive patients with transformed migraine and analgesic overuse were treated with inpatient pharmacologic therapy alone or with inpatient pharmacologic therapy combined with biofeedback-assisted relaxation. All patients then were followed prospectively for 3 years.

RESULTS

Both treatment groups exhibited similar levels of improvement immediately following treatment and for 1 year thereafter. At year 3, participants receiving combined treatment showed greater sustained improvement on two of three outcome measures assessed (ie, fewer days of headache and reduced consumption of analgesic medication). In addition, a greater number of patients assigned to pharmacologic treatment alone relapsed (ie, resumed overuse of analgesics) compared to patients receiving combined treatment.

CONCLUSIONS

These results suggest that a combination of pharmacologic and behavioral treatment is more effective than drug therapy alone in the long-term management of transformed migraine with analgesic overuse. Confirmation of these findings, as well as extension to other forms of behavioral and cognitive-behavioral treatment, is required.

Treatment of behavior problems in preschoolers: a review of parent training programs

The literature for parent training interventions with conduct-problem preschool-aged children is reviewed. Although previous reviews have identified the preschool years as a critical point for intervention [J. Clin. Psychol. 21 (1992) 306; School Psychol. Rev. 22 (1993) 437], there still remains a paucity of well-designed outcome studies that have focused exclusively on preschoolers. Interventions that utilize parents as active sources of change remain predominant. The review reveals the need for further research to improve accessibility and delivery of interventions. Treatments that have undergone modification in their delivery format (e.g., use of telephone and videotape) were also identified and critically evaluated. Results of the review indicate that many studies are still accompanied by methodological limitations. Although promising interventions exist for young conduct-problem children, it is recommended that treatment effectiveness for preschoolers be evaluated more rigorously.

Prediction of dose-response relations based on patient characteristics

The recent discussion of evidence-based, adaptive treatment planning highlights the need for models for the prediction of courses of treatment response. We combine a dose-response model with growth curve modeling to determine dose-response relations for well-being, symptoms, and functioning. Hierarchical linear modeling was used to model each patient's expected course of improvement. The resulting predictions were cross-validated on two samples of psychotherapy outpatients. The results give further empirical support for the dose-response model and the phase model of psychotherapy as well as for the usefulness of patient treatment response profiling for individual treatment management.

Vorhersage individueller Psychotherapieverläufe

Zusammenfassung.Theoretischer Hintergrund: Patienten/Klienten, Kostenträger sowie Berufsorganisationen von Psychotherapeuten und die Gesundheitsgesetzgebung beschäftigen sich mehr und mehr mit der Integration von psychometrischen Erhebungen in die therapeutische Routine sowie dem Monitoring des therapeutischen Fortschrittes. Neben den traditionellen Evaluations- und Kosten-Nutzen Studien werden Entscheidungsregeln zur selektiven und adaptiven Indikation benötigt, die unmittelbar angewendet werden können, um den individuellen Behandlungsfortschritt zu dokumentieren sowie negative Entwicklungen frühzeitig im Behandlungsverlauf zu erkennen. Fragestellung: Es wird der theoretische Hintergrund sowie die Operationalisierung eines Systems vorgestellt, welches dem Psychotherapeuten solche systematische Informationen über den Fortschritt eines Patienten in der Psychotherapie liefern kann. Methode: Dazu wurden Methoden der Wachstumsanalyse eingesetzt, um den Einfluss von Patientenausgangscharakteristika und Verlaufsindikatoren auf den individuellen Therapieverlauf zu identifizieren. Die Untersuchung basiert auf Längsschnittdaten von 890 Patienten (bzw. einer Substichprobe von 75 Patienten für die Analyse der Verlaufsindikatoren), welche kontinuierlich über ihre Behandlung hinweg psychometrisch untersucht wurden. Ergebnisse: Die Ergebnisse dieser Wachstumsanalysen ermöglichen eine Vorhersage des individuellen therapeutischen Verlaufs auf der Grundlage spezifischer Patientenausgangscharakteristika sowie eine kontinuierliche Adaptation dieser Vorhersagen auf der Grundlage des konkreten therapeutischen Prozesses. Schlussfolgerung: Diese Ergebnisse werden im Kontext ihrer Anwendbarkeit und der Implikationen für die Entwicklung von Entscheidungsregeln zur Unterstützung der adaptiven und selektiven Indikation erörtert.

Research on psychotherapy efficacy and effectiveness: between Scylla and Charybdis?

Clinical researchers have recently begun to explore differences between psychotherapy outcome studies that focus on efficacy and those that focus on effectiveness. The authors provide concise descriptions of these research models, followed by more extended consideration of the most important conceptual and empirical distinctions between the two. Research on the efficacy/effectiveness distinction is then put into context: The common treatment variables that also influence treatment outcomes are reviewed. Fifty years of research on psychotherapy outcomes are next considered; contemporary research on the efficacy and effectiveness research models is emphasized. A description and evaluation of current efforts to heighten the value of technique-focused research to clinicians follow. The authors conclude by anticipating some promising future directions in this research domain.

Psychotherapy for patients with complex disorders and chronic symptoms. The need for a new research paradigm

BACKGROUND

A clear distinction has been made between efficacy and effectiveness in relation to the methods of evaluation of new psychological treatments in psychiatry. Efficacy trials target patients with relatively pure conditions, who may not be representative of the patients who are usually referred for psychological treatment in a clinical setting. Few studies have explored the benefits of psychotherapy in patients with complex disorders and enduring symptoms.

AIMS

To explore the rationale for the distinction between efficacy and effectiveness, particularly in relation to outcome studies of patients with complex and enduring disorders.

METHOD

A narrative review with examples drawn from the literature, and an illustration of a recent naturalistic outcome study which combines features of both efficacy and effectiveness.

RESULTS

Studies of patients with complex and mixed disorders can be designed so that they retain internal validity, but also have external validity and are relevant to clinical practice.

CONCLUSION

Studies which evaluate psychological interventions should be carried out in populations of patients clinically representative of those who are likely to receive the intervention, should it be shown to be of benefit.

Effectiveness of psychotherapeutic treatment of personality disorder

BACKGROUND

Psychiatrists have been criticised for failing to develop adequate treatment for personality disorder. Psychotherapeutic treatments are promising, but their effectiveness is uncertain.

AIMS

To investigate the evidence for effectiveness of psychotherapeutic treatment for personality disorder.

METHOD

Systematic literature review.

RESULTS

There is evidence for the effectiveness of psychotherapy for personality disorder. Problems of case identification, comorbidity, randomisation, specificity of treatment and outcome measurement are inadequately addressed. Authors mainly relied on cohort studies. Evidence neither suggests superiority of one type of therapy over another nor indicates which subgroups of patients should be offered psychotherapy as in-patient, day patient, or out-patient.

CONCLUSIONS

New research strategies are needed to show that personality change is both measurable and clinically meaningful. Effectiveness studies using randomised controlled designs are required. The literature suggests that effective treatment should be long-term, integrated, theoretically coherent and focused on compliance.

Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context

This study investigated the clinical significance of previously reported statistically significant mean reductions in drinking and related problems among college students in a randomized trial of a brief indicated preventive intervention (G. A. Marlatt et al., 1998). Data were analyzed over a 2-year follow-up for participants from a high-risk intervention group (n = 153), a high-risk control group (n = 160), and a functional comparison group (n = 77). A risk cutpoint for each dependent measure was based on the functional comparison group distribution. Compared with the high-risk controls, more individuals in the high-risk intervention group improved and fewer worsened, especially on alcohol-related problems and, to a lesser extent, on drinking pattern variables. These data from a prevention context clarify the magnitude and direction of individual change obscured by group means.

A national survey of practicing psychologists' attitudes toward psychotherapy treatment manuals

There has been considerable debate and little empirical data on the role of psychotherapy treatment manuals in clinical practice. Attitudes toward treatment manuals are a potentially important determinant of how likely practitioners are to use manual-based treatments in clinical practice. A total of 891 practicing psychologists nationwide were surveyed about their attitudes toward treatment manuals and their ideas about the content of manuals. Practitioners held widely varying attitudes toward treatment manuals, and ideas about what constitutes a manual were associated with attitudes in a predictable way. Recommendations are made for how to gather more useful information about practitioners' attitudes toward the many changes affecting current models of clinical practice.

Training the scientist-practitioner for the 21st century: putting the bloom back on the rose

The field of clinical psychology has been characterized over the past five decades as shaped by social, economic, and political forces outside of it. Even before the Boulder Conference, meetings and writings evidenced the underpinnings of the scientist-practitioner model that was to be developed in a welcoming climate (Dosier, 1947; Kubie, 1949; Luchins, 1949). Difficulties in implementation, however, produced a schism between the scientist and practitioner aspects. Our thesis is that the current environment dictated by managed care necessitates a reaffirmation of the scientist-practitioner model. We believe that clinical psychologists are in an unparalleled position to intercede among forces in the current climate because of their sensitivity to clinical and research issues, and we offer suggestions for how clinicians, researchers, and training programs can close the gap between research and practice.

Solution-focused brief therapy: a review of the outcome research

Solution-focused brief therapy (SFBT) is a new and increasingly used therapeutic approach that focuses on helping clients construct solutions rather than solve problems. The approach evolved in a clinical context amid many anecdotal reports of success from both therapists and clients, but it has not been subjected to controlled empirical testing until very recently. In this article we critically review all of the controlled outcome studies of SFBT to date (N = 15) to assess the extent to which SFBT has received empirical support. Five studies were well-controlled and all showed positive outcomes--four found SFBT to be better than no treatment or standard institutional services, and one found SFBT to be comparable to a known intervention: Interpersonal Psychotherapy for Depression (IPT). Findings from the remaining 10 studies, which we consider moderately or poorly controlled, were consistent with a hypothesis of SFBT effectiveness. We conclude that the 15 studies provide preliminary support for the efficacy of SFBT but do not permit a definitive conclusion. Our critique highlights areas where methodology in future studies can be strengthened to provide more conclusive evidence of SFBT efficacy.

Patient Impairment Lexicon: a validation study

Growth of managed behavioral health organizations (MBHOs) has increased the need for a standardized diagnostic language. The Patient Impairment Lexicon (PIL; Goodman, Brown, & Deitz, 1992, 1996) is intended to address this need. Augmenting previous psychometric assessment (Klewicki, Bjorck, Leucht, & Goodman, 1998), the current study evaluated the PIL's construct validity. Sixteen raters completed impairment inventories; diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R; American Psychiatric Association, 1987); and independent measures of psychiatric functioning for patients in 20 vignettes. Overall rater accuracy was significantly higher for PIL impairments than for diagnoses. As predicted, there were positive correlations between PIL impairments and psychiatric functioning for all 20 vignettes, 11 of which were significant. Results remained significant after controlling variance due to: (a) raters' past experience with similar patients and (b) vignette imaginability. Findings are discussed in terms of MBHO applications and future PIL research.

Patient Impairment Lexicon: a psychometric analysis

Growth in managed care has magnified the needs for assessment of treatment efficacies and standardized communication regarding treatment needs. Addressing both needs requires a common terminology describing the scope of treatable mental health impairments. The Diagnostic and Statistical Manual of Mental Disorders-IV provides a common categorical language for describing clinical disorders, but its categories are not discrete and do little to facilitate communication regarding specific treatment needs. Goodman, Brown, and Deitz developed a Patient Impairment Lexicon intended to address these limitations. The current vignette study provided initial psychometric assessment of this nomenclature, specifically examining interrater reliability, temporal stability, and content validity. Findings are discussed with respect to both applications in managed care and psychometric research.