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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden Gains in Cognitive Therapy for Depression: A Replication and Extension.

Of 76 clients receiving 8-20 sessions of cognitive therapy (CT) in a joint university and a national health service clinic, 31 experienced sudden gains that appeared very similar to those first reported in clinical trials of CT by T. Z. Tang and R. J. DeRubeis (1999) and subsequently replicated in other studies. The sudden gains appeared less stable in the present study's more routine clinical practice settings than they were in the clinical trials. Life events did not appear to account for sudden gains. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden gains and critical sessions in cognitive-behavioral therapy for depression.

In this study of cognitive-behavioral therapy for depression, many patients experienced large symptom improvements in a single between-sessions interval. These sudden gains' average magnitude was 11 Beck Depression Inventory points, accounting for 50% of these patients' total improvement. Patients who experienced sudden gains were less depressed than the other patients at posttreatment, and they remained so 18 months later. Substantial cognitive changes were observed in the therapy sessions preceding sudden gains, but few cognitive changes were observed in control sessions, suggesting that cognitive change in the pregain sessions triggered the sudden gains. Improved therapeutic alliances were also observed in the therapy sessions immediately after the sudden gains, as were additional cognitive changes, suggesting a three-stage model for these patients' recovery: preparation?→?critical session/sudden gain?→?upward spiral. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does a continuous feedback system improve psychotherapy outcome?

Using outcome data on a continual basis to monitor treatment progress has been identified as a way to enhance psychotherapy outcome. The purpose of this study was to investigate the use of a continuous feedback assessment system, the Partners for Change Outcome Management System (PCOMS; Miller & Duncan, 2004). Findings from 2 client samples that attended individual therapy at a university counseling center (N = 74) or a graduate training clinic (N = 74) indicated that clients who used PCOMS with their therapists (feedback condition) demonstrated statistically significant treatment gains when compared to clients receiving treatment as usual (no-feedback condition). Clients using PCOMS were also more likely to experience reliable change and in fewer sessions. A survival analysis demonstrated that approximately 50% of the clients in the feedback condition demonstrated reliable change after the 7th (graduate training clinic) or 9th session (university counseling center). Further findings, limitations of the study and ideas for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of therapist-facilitated and self-guided dream interpretation sessions.

Twenty-five volunteer clients participated in both a therapist-facilitated and a self-guided dream interpretation session; sessions were randomly ordered and separated by approximately 1 week. Observer and therapist ratings indicated that therapists adhered to the C. E. Hill (1996) model during therapist-facilitated sessions. Clients reported achieving greater depth, mastery, and insight, as well as more dream exploration-insight gains and more action-related gains, from therapist-facilitated sessions than from self-guided sessions. In addition, 88% of the clients preferred therapist-facilitated over self-guided sessions. Implications for using both types of sessions are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Termination, appointment use, and outcome patterns associated with intake therapist discontinuity.

Psychotherapy clients often experience intake therapist discontinuity: meeting first with an intake therapist, then entering therapy with a different treating therapist. The authors compared such discontinuity clients at a university’s counseling center (55.6% of 15,137 clients) with continuity clients, who continued therapy with their intake therapists. Discontinuity clients were twice as likely as continuity clients to terminate by missing the appointment after intake. Improvement among discontinuity clients lagged behind improvement among continuity clients at Sessions 2 and 3. Though more likely to terminate by missing Session 2, discontinuity clients attended 2 sessions more than continuity clients, on average, making treatment of discontinuity clients 19% more expensive than treatment of continuity clients in terms of sessions attended. The extra sessions attended by discontinuity clients did not yield overall better outcomes. Intake therapist discontinuity appeared to disrupt the beginning of psychotherapy, dissuading some clients from returning after intake, slowing early improvement among those who did return, and unproductively lengthening their treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcomes of time-limited psychotherapy in applied settings: Replicating the Second Sheffield Psychotherapy Project.

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N?=?36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP clients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethical knowledge exhibited by clients and nonclients.

Two studies were conducted to explore the relation between (a) experience in counseling and psychotherapy and (b) ethical knowledge. In Study 1, 77 college students reported their experience as clients in a variety of settings and then completed a questionnaire concerning their knowledge of ethical issues. The hypothesis that clients (subjects who had counseling experience) would demonstrate ethical knowledge superior to that of nonclients (those with no such experience) was not supported. Ethical knowledge did not differ as a function of counseling experience, the setting in which counseling was received, or the number of sessions. However, though overall ethical knowledge was high across groups, knowledge with respect to each ethical issue was incomplete. In Study 2, following the same procedure, we compared 17 current psychotherapy clients at a Veterans Administration medical center with 15 nonclients, patients in the hypertension clinic who had never received psychological services. These clients demonstrated superior ethical knowledge on specific issues (.008?ps?     

Correlations of male college students' verbal response mode use in psychotherapy with measures of psychological disturbance and psychotherapy outcome.

Compared verbal response mode use by 31 male college student clients in 3 sessions of time-limited psychotherapy (selected from an average of 17.2 sessions) with measures of clients' psychological distress, disturbance, and change, which were gathered at intake, termination, and 1-yr follow-up as part of the Vanderbilt Psychotherapy Project. Results show that (a) clients who were more distressed tended to use a higher percentage of Disclosures (revealing subjective information) and a lower percentage of Edifications (conveying objective information), perhaps reflecting greater preoccupation with inner troubles; and (b) clients who improved more were those who participated more, as measured by their estimated total number of utterances, a product of talking more in each session and remaining in therapy for more sessions; but (c) there was no relationship between clients' percentage of Disclosures and their improvement in psychotherapy, as hypothesized, even though percentage of Disclosures was correlated with process ratings of intrapsychic exploration. (58 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Responsive regulation of treatment duration in routine practice in United Kingdom primary care settings: Replication in a larger sample.

Replicating a previous study (M. Barkham et al., 2006), the authors examined rates of improvement in psychotherapy in United Kingdom primary care settings as a function of the number of sessions attended. Included in the study were adult clients who returned valid assessments at the beginning and the end of their treatment, had planned endings, began treatment above the clinical cutoff score, and were seen for 20 or fewer sessions (N = 9,703; 72.4% female; 87.7% Caucasian; average age = 40.9 years). Clients' average assessment scores improved substantially across treatment, with a pretreatment-posttreatment effect size of 1.96; 62.0% achieved reliable and clinically significant improvement (RCSI). Clients' mean pretreatment-posttreatment change was approximately constant regardless of treatment duration (in the range of 0 to 20 sessions); the RCSI rate decreased slightly with treatment duration, as fewer clients fell below the cutoff at longer durations. Results were interpreted as suggesting that therapists and clients tend to make appropriately responsive decisions about treatment duration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client introversion and counseling session impact.

Tested the hypothesis that insofar as personal counseling is a social encounter, introverted clients may be expected to experience greater distress in sessions than extraverted clients. This expectation was confirmed in a total of 83 clients (aged 17–39 yrs) in a university clinic who completed the Minnesota Multiphasic Personality Inventory (MMPI) during their treatment and completed a session evaluation questionnaire immediately after their sessions. With differences among counselors statistically controlled, relatively introverted (higher MMPI Social Introversion) clients rated their sessions as relatively uncomfortable, unpleasant, tense, rough, and difficult and rated their postsession mood as relatively unfriendly, uncertain, sad, angry, and afraid. Conversely, relatively gregarious, overactive, extraverted (higher MMPI Hypomania scores) clients rated their sessions as relatively comfortable, pleasant, relaxed, smooth, and easy. It is suggested that client introversion should be incorporated explicitly into counseling theories and should be measured as a possible mediating variable in process and outcome research. (40 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder.

Objective: Our objective was to examine sudden gains during developmentally adjusted prolonged exposure for posttraumatic stress disorder (PTSD) among children and adolescents. We hypothesized that sudden gains would be detected and would be predictive of treatment outcome and follow-up. Method: Sixty-three youngsters (ages 8–17) completed a developmentally adjusted protocol for the treatment of pediatric PTSD (Foa, Chrestman, & Gilboa-Schechtman, 2008). Participants' posttraumatic and depressive symptoms were assessed before each treatment session, as well as at approximately 3 and 12 months after treatment termination. We measured posttraumatic symptoms with the Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001) and measured depressive symptoms with the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the Children's Depression Inventory (Kovacs, 1981, 1982). Results: Sudden gains were found among 49.2% of participants and constituted 48.6% of the total reduction in posttraumatic symptoms. Compared to individuals who did not experience sudden gains, individuals who experienced sudden gains reported lower levels of posttraumatic symptoms, F(1, 61) = 14.4, p     

Predicting counseling center clients' response to counseling: A 1-year follow-up.

A follow-up survey mailed 10 months after termination to 542 clients who received counseling at a university counseling center resulted in 207 (43%) returned surveys. Of the 158 clients who received 1 or more sessions, 32% showed reliable improvement. Of the 106 who began in the dysfunctional range of scores on a computerized intake assessment (CASPER), 31% showed clinically significant (CS) change. Likelihood of CS change depended on the number of sessions received but not in a linear, "more is always better" fashion. Survival analysis indicated that 25% of clients who achieved CS change did so after receiving 8 sessions and that 50% did so after receiving 16 sessions. Likelihood of eventual reliable change within a given number of sessions depended on the precounseling configuration of some CASPER symptom dimensions, with higher Hyperactivated Attachment interpersonal problems associated with fewer sessions needed to achieve reliable change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Counselor and client personality as determinants of counselor expectancy effects.

78 students enrolled in summer-session college courses were randomly assigned to serve either as counselors or as clients for a 20-min, role-played peer counseling session. Ss completed a battery of standardized personality measures, including the Personality Research Form. Each counselor interacted with 2 clients. Prior to the sessions, the counselor was led to believe that one of the clients was especially introverted and that the other client was especially extraverted. Dependent measures were based on clients' change scores on a mood adjective rating scale administered before and after the peer counseling sessions. Analyses showed that counselors who were more successful at biasing their clients in the direction of their expectancies (a) scored higher on measures of dogmatism, nurturance, and social recognition; (b) scored lower on impulsivity; and (c) were more likely to be female. Clients who were more susceptible to counselor bias scored higher on the Self-Monitoring Scale, its Other-Directedness subscale, and social recognition. (32 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Validity of Sudden Gains in Acute Phase Treatment of Depression.

The authors examined the validity of sudden gains identified with T. Z. Tang and R. J. DeRubeis's (1999) method in 2 clinical data sets that involved treatment of major depressive disorder (N=227). Sudden gains replicated among self- and clinician reports of depressive symptoms and predicted better psychosocial functioning at the acute phase treatment end point, in support of their validity. However, sudden gains occurred with roughly the same moderate frequency in pill placebo and pharmacotherapy with clinical management as in cognitive therapy. Furthermore, sudden gains predicted more depressive symptoms and negative failure attributions in longitudinal follow-up of responders to acute phase cognitive therapy. On the basis of these findings, the authors conceptualize sudden gains as one of several possible patterns of acute phase treatment response. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client and therapist variability in clients' perceptions of their therapists' multicultural competencies.

This study examined therapist differences in their clients' ratings of their therapists' multicultural competencies (MCCs) as well as tested whether therapists' who were rated as exhibiting more MCCs also had clients who had better therapy outcomes (N = 143 clients and 31 therapists). All clients completed at least 3 sessions. Results demonstrated that therapists accounted for less than 1% of the variance in their clients' Cross-Cultural Counseling Inventory–Revised (CCCI-R; T. D. LaFromboise, H. L. K. Coleman, & A. Hernandez, 1991) scores, suggesting that therapists did not differ in terms of how clients rated their MCCs. Therapists accounted for approximately 8.5% of the variance in therapy outcomes. For each therapist, their clients' CCCI-R scores were aggregated to provide an estimate of therapists' MCCs. Therapists' MCCs, based on aggregate CCCI-R scores, did not account for the variability in therapy outcomes that were attributed to them. Additionally, clients' race/ethnicity, therapists' race/ethnicity, or the interaction of clients'–therapists' race/ethnicity were not significantly associated with clients' perceptions of their therapists' MCCs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of counselor identification of client problem description to continuance in a behavioral weight loss program.

I investigated the relation of counselor ability to articulate salient information to continuance in a weight loss program in two studies. In the first, clients (N?=?39) were asked questions regarding their weight loss problems, and counselors were asked to predict client responses. A higher proportion of accurate predictions occurred for clients who later completed the program than for those who dropped out. Within the completer group, there was greater weight loss in cases that had been accurately predicted than in those that had not. The second study was identical to the first except for program duration, which was eight sessions for the first and six sessions for the second (N?=?41 clients). The results of the second study replicated those of the first with regard to continuance but not outcome. I discuss the relevance of the results to similar research done with different client populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist interventions and client emotional experiencing in expert psychodynamic–interpersonal and cognitive–behavioral therapies.

Eighteen sessions of cognitive–behavioral (CB) and 13 sessions of psychodynamic–interpersonal therapy obtained from experienced clinicians in a naturalistic setting were investigated to determine the various therapeutic interventions associated with high and low emotional experiencing (EXP). Clients receiving reflections and acknowledgments, affiliative and noncontrolling interventions, or interventions highlighting nonspecific client content were associated with maintained high EXP. Lengthier interventions and interventions rated as affiliative but moderately controlling were associated with shifts to low EXP. For clients of CB therapists, questions, interventions rated affiliative but controlling, and highlighting minimal emotional content were also associated with shifts to low EXP. Male therapists were associated with clients who maintained high EXP and female therapists were associated with clients who shifted to low EXP. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The prevalence and impact of large sudden improvements during adolescent therapy for depression: A comparison across cognitive-behavioral, family, and supportive therapy.

This study assessed the treatment specificity and impact on outcome of large, abrupt symptomatic improvements occurring prior to and during cognitive- behavioral, family, and supportive therapy. Eighty-seven depressed adolescents receiving at least 8 therapy sessions were included. Abrupt large decreases in depressive symptoms were identified by changes in weekly Beck Depression Inventory scores. Overall, 28% experienced a pretreatment gain and 39% a sudden within-treatment gain. Both types of gains were associated with superior outcome on self-report and interviewer ratings of depression. Among those participants failing to experience a pretreatment or sudden within-treatment gain, cognitive-behavioral therapy produced the superior outcomes. These findings suggest pretreatment and sudden within-treatment gains are important therapeutic events worthy of further investigation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden gains during therapy of social phobia.

The present study investigated the phenomenon of sudden gains in 107 participants with social phobia (social anxiety disorder) who received either cognitive-behavioral group therapy or exposure group therapy without explicit cognitive interventions, which primarily used public speaking situations as exposure tasks. Twenty-two out of 967 session-to-session intervals met criteria for sudden gains, which most frequently occurred in Session 5. Individuals with sudden gains showed similar improvements in the 2 treatment groups. Although cognitive-behavioral therapy was associated with more cognitive changes than exposure therapy, cognitive changes did not precede sudden gains. In general, the results of this study question the clinical significance of sudden gains in social phobia treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)