Assessing treatment progress of individual patients using expected treatment response models.

The dosage model provides a normative estimate of the overall pattern of patient improvement in psychotherapy. The phase model further specifies patterns of change in the domains of subjective well-being, symptom remediation, and functioning. The expected treatment response (ETR) approach uses patient characteristics to predict an expected path of progress for each patient. With repeated measures of mental health status, the treatment progress of an individual patient can be assessed against the patient's ETR to support decisions that would enhance the quality of a clinical service while it is being delivered.

The predicted and observed course of psychotherapy for anxiety and mood disorders.

By applying hierarchical linear modeling (HLM) techniques, patient clinical characteristics at the beginning of treatment were used to predict individual patient responses (N = 160) to psychotherapy. Four diagnostic groups (mood, anxiety, other, and no diagnosis) were formed among the patients based on intake-administered Structured Diagnostic Interview for the Diagnosis of DSM-III-R axis I Disorders. Patients with mood and anxiety disorders had predicted courses of response to psychotherapy that were similar but different from patients with other disorders and no diagnosis. Predicted and observed courses of response to psychotherapy in a subsample (N = 75) who had provided enough data to model the actual course of treatment showed high levels of congruence, thus supporting the validity of predicting course of response. HLM predictive profiling offers a new approach for assessing treatment effectiveness of psychotherapy with patients having axis I diagnostic conditions by considering an individual patient's clinical characteristics.

Individual psychotherapy outcome and process research: challenges leading to greater turmoil or a positive transition?

Psychotherapy is facing challenges that relate to the emergence of managed health care, the possibility of a national health care system, and advances in biological psychiatry. These situations have created pressure to achieve a more accurate assessment of psychotherapeutic effectiveness. Psychotherapy has been proven to be generally effective; however, there is uncertainty as to why. The field is currently experiencing apparent turmoil in three areas: (a) theory development for psychotherapeutic effectiveness, (b) research design, and (c) treatment technique. This chapter reviews the dynamics within each of the areas and highlights the progress made in treating mental disorders. We conclude that recent advances in research design may provide a transition that will bring psychotherapy closer to becoming a unified paradigm with an acceptable theory of effectiveness.

Using feedback on patient progress to predict the outcome of psychotherapy.

The Dose-Response and Phase Models are useful for informing quality assurance research on the expected patterns for separate categories of outcomes in psychotherapy. Moreover, these models predict the sequence of change for outcomes that may be differentially valued by patients, therapists, stakeholders, and cost managers. Valid feedback on the progress of treatment is critical because patients, therapists, and cost managers make decisions about continuation and focus of treatment while psychotherapy is in progress. In this study, the focus is on the validity of feedback data for therapist appraisal of patient progress. Feedback at patient intake, in early sessions of psychotherapy, and at later sessions of psychotherapy is considered. Among the variables examined are patient and therapist agreement on severity, level of severity, evidence of remoralization, and evidence of symptomatic remission. Data are drawn from archived records of 243 psychotherapy cases conducted in several managed care service delivery settings. The implications of a therapist's use of feedback to adjust the therapeutic process in an individual case are discussed.

Readability of self-report clinical outcome measures.

Because the validity of data obtained from self-report clinical outcome measures depends upon the ability of the client to comprehend the inventories, readability was assessed for five frequently employed measures: Beck Depression Inventory, Integra Outpatient Tracking Assessment, MOS 36-Item Short-Form Health Survey, Social Adjustment Scale-Self Report, and Symptoms Checklist-90-Revised. The Flesch Reading Ease (RE) formula and a Flesch abstraction formula were applied. The measures are generally shown to be useful for patients with an eighth or ninth grade education, suggesting that outcome researchers must choose only those measures appropriate to the educational background of their clients.

Patterns of mental health service utilization.

How many and which individuals, with which psychiatric disorders, receive (and do not receive) mental health services from which professionals in what settings? This question falls within the purview of mental health services research, which is a multidisciplinary field that brings together the methodologies of epidemiology, econometrics, and clinical research. First, in this article, we present an explication of what is known about those individuals in need of psychotherapy and how they access services. Next, we describe the numbers, professional affiliations, and service sites of professionals who are engaged in the practice of psychotherapy. We summarize our current knowledge about the actual utilization of psychotherapy services relative to the needs of patients and the professional background of therapists. Finally, we identify aspects of psychotherapy service utilization that are, as yet, unaddressed.

The clinician's illusion and the psychotherapy practice: an application of stochastic modeling.

The caseload of practicing clinicians tends to be unrepresentative of the population of psychotherapy patients. This results from the fact that, although the majority of patients use relatively few treatment sessions, the majority of a clinician's time is spent with longer term cases--a minority of patients consume the majority of services. Here, a stochastic model is used to describe the development of caseloads under 4 different treatment regimens. It is shown that a psychotherapy practice will reach a steady state (a stable case mix) in relatively short time and at that this will limit the open appointment slots available each week to serve new patients. Implications for training and clinic staffing are discussed.

A phase model of psychotherapy outcome: causal mediation of change.

A 3-phase model of psychotherapy outcome is proposed that entails progressive improvement of subjectively experienced well-being, reduction in symptomatology, and enhancement of life functioning. The model also predicts that movement into a later phase of treatment depends on whether progress has been made in an earlier phase. Thus, clinical improvement in subjective well-being potentiates symptomatic improvement, and clinical reduction in symptomatic distress potentiates life-functioning improvement. A large sample of psychotherapy patients provided self-reports of subjective well-being, symptomatic distress, and life functioning before beginning individual psychotherapy and after Sessions 2, 4, and 17 when possible. Changes in well-being, symptomatic distress, and life functioning means over this period were consistent with the 3-phase model. Measures of patient status on these 3 variables were converted into dichotomous improvement-nonimprovement scores between intake and each of Sessions 2, 4, and 17. An analysis of 2 x 2 cross-classification tables generated from these dichotomous measures suggested that improvement in well-being precedes and is a probabilistically necessary condition for reduction in symptomatic distress and that symptomatic improvement precedes and is a probabilistically necessary condition for improvement in life functioning.

Frontal-lobe cognitive dysfunction in conduct disorder adolescents.

Behavioral similarities between antisocial behavior disorders and frontal-lobe cerebral impairment have led to suggestions that conduct disorders are attributable to disinhibition deficit associated with frontal-lobe cerebral functions. This study compared the performance of 21 conduct disorder adolescents on measures of cognitive processes associated with frontal-lobe functions with that of a matched comparison sample. Conduct disorder adolescents performed more poorly on measures sensitive to frontal-lobe dysfunction (conceptual perseveration, poorly sustained attention, impaired sequencing on memory and motor tasks), but not on non-frontal-lobe specific cognitive measures. Although the findings support a neurobehavioral explanation of antisocial behavior as a product of cerebral disinhibition, caution is urged in overinterpreting causal relationships through neurobehavioral data.

Neuropsychological and academic achievement correlates of abnormal WISC-R verbal-performance discrepancies.

This study examined neuropsychological and academic achievement correlates of statistically abnormal VIQ less than PIQ discrepancies on the WISC-R in a sample of 53 hospitalized children. Of 17 neuropsychological measures, only aphasia errors was associated with VIQ. Academic achievement measures of reading, spelling, and arithmetic were associated with abnormal VIQ less than PIQ discrepancies. The results indicate that statistically abnormal VIQ less than PIQ discrepancies reflect specific aphasia deficits rather than generalized neuropsychological dysfunction and that academic achievement deficiencies of a general nature ensue.

Use of the MMPI to identify subtypes of delinquent adolescents.

Assessed the utility of the MMPI to identify and distinguish among subtypes of delinquent adolescents (N = 50). Behavior ratings were used as the criterion of classification into three delinquent subtypes--conduct problem, anxious-withdrawn, and a group with neither of those features. Only the Hs scale differed significantly between the first two groups. Results were disappointing in that they failed to support a previous study that had found differences, but that had used less rigorous classification criteria.

The use of the MMPI-168 with delinquent adolescents.

Compared the standard MMPI and the MMPI-168 scores of 90 male delinquent adolescents. Raw score and T-score correlations were generally high and within acceptable limits, which indicates that MMPI-168 scores are useful with delinquent adolescents. However, two-point codetypes derived from standard MMPIs and MMPI-168s were in agreement less than half of the time. Caution should be exercised in the interpretation of two-point codetypes from MMPI-168 raw scores.

Variables associated with recidivism and program-termination of delinquent adolescents.

Reexamined variables--parental status, age at first court contact, amount of pretreatment delinquency, age at admission, diagnosis and intelligence estimates--that have been associated with recidivism of delinquent adolescents (N = 89). Groups of recidivating and nonrecidivating delinquents and a third comparison group of prematurely program-terminated delinquents were compared across all variables. The results provided additional support for the association of age and cognitive variables with premature treatment termination and recidivism and generally supported previous research findings.

Mental health workers' ratings of the importance of the goals of a cooperative CMHC-state hospital screening-aftercare program.

Ratings of the importance of the goals of a pilot community mental health center (CMHC)-state psychiatric hospital cooperative program aimed at providing screening and aftercare were obtained from 214 mental health professionals. Respondents were employed at state hospitals, at CMHCs that were participating in the program, and at CMHCs that were not participating in the pilot cooperative program. Ratings of importance were found to differ across goals, between mental health workers of state hospitals and CMHCs, between participating and nonparticipating CMHCs, between professions, and as a function of distance between CMHCs and state hospitals. Implications of the findings for the evaluation of the success of a cooperative screening-aftercare pilot program are discussed.

Emotional expressivity and sex-role perceptions of repressors and sensitizers.

Two studies were conducted examining the contributions of repression-sensitization (R-S) status, sex-role perceptions, and sex of the target of expressivity to assess the expression of emotional discomfort by males, in Experiment I verbal and nonverbal measures of emotional expressiveness were obtained for male repressors and sensitizers exposed to neutral or moderately negative arousal situations with sex of the target of the expressiveness controlled. In Experiment 2 repressors were found to be sex-typed masculine and male sensitizers sex-reversed in their sex-role perceptions. The usefulness of R-S status and sex, role perceptions to predicting emotional expressivity by males is discussed.