Outcome effects of receiving a preferred, randomly assigned, or nonpreferred therapy

Clinical hypnosis as a nondeceptive placebo: empirically derived techniques

Many psychological problems are maintained, in part, by dysfunctional response expectancies, and changing those expectations is an essential part of treatment. Hypnotic inductions alter response expectancies and have been shown empirically to substantially enhance the effects of psychotherapy. Therefore, hypnosis can be used therapeutically as a nondeceptive placebo. Expectancy plays a major role in hypnotic inductions and their effects. Clinical procedures suggested by these data are explored.

Integrating Clinical Hypnosis and Neurofeedback

Hypnosis and neurofeedback each provide unique therapeutic strengths and opportunities. This article provides an overview of some of the research on neurofeedback and hypnosis. The author's perspective and recommendations are provided on the relative clinical utility of using either neurofeedback or hypnosis as the initial treatment of choice with various clinical conditions.

Marathon Versus Weekly Encounter-Group Treatment on Self-Actualization: Two Years Later

This study investigates the comparative ability of a marathon and a weekly encounter group to produce gains in self-actualization. The sub jects were twenty-three undergraduates who volunteered for each of the experiences. The marathon group was conducted for sixteen relatively continuous hours. The weekly group met for two hours, twice weekly, for four weeks-a total of sixteen hours. Both treatment groups, conducted by the same leader, received the same sequence of group exercises. A signifi cant group effect indicated that both groups increased their self- actualization scores from the pretest. No significant differences were found between the two experimental groups on self-actualization or per ceived adjustment to life events over the two-year follow-up. No signifi cant group differences were found on participants' retrospective ratings of short-term and long-term group effects. Among other issues, the possi bility that certain treatment goals may be selectively influenced by one time format over the other is discussed.

A brief, multidimensional measure of clients' therapy preferences: The Cooper-Norcross Inventory of Preferences (C-NIP)

Addressing and accommodating client preferences in psychotherapy have been consistently associated with improved treatment outcomes; however, few clinically useful and psychometrically acceptable measures are available for this purpose. The aim of this study was to develop a brief, multidimensional clinical tool to help clients articulate the therapist style they desire in psychotherapy or counseling. An online survey composed of 40 therapy preference items was completed by 860 respondents, primarily female (n = 699), British (n = 650), White (n = 761), and mental health professionals themselves (n = 615). Principal components analysis resulted in four scales that accounted for 39% of the total variance: Therapist Directiveness vs. Client Directiveness, Emotional Intensity vs. Emotional Reserve, Past Orientation vs. Present Orientation, and Warm Support vs. Focused Challenge. These scales map well onto dimensions of therapist activity and cover most of the major preference dimensions identified in the research literature. Internal consistency coefficients ranged between .60 and .85 (M = .71). Tentative cutoff points for strong preferences on each dimension were established. The 18-item Cooper-Norcross Inventory of Preferences (C-NIP) is a multidimensional measure with clinical utility, but additional validity data are needed.

Implementation and effectiveness of integrated trauma and addiction treatment for incarcerated men

A controlled trial of Seeking Safety (SS) and Male-Trauma Recovery Empowerment Model (M-TREM) examined implementation and effectiveness of integrated group therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) on PTSD and mental health symptoms plus self-esteem and efficacy for incarcerated men. The study sample (n=230) was male inmates 18 years or older who were primarily non-white, high school graduates or equivalents, had childhood trauma histories, committed violent crimes, had serious mental illnesses, and resided in a maximum security prison. Incarcerated men, who screened positive for PTSD and SUD, were assigned randomly (n=142) or by preference (n=88) to receive SS or M-TREM, with a waitlist group of (n=93). Manualized interventions were group-administered for 14 weeks. Primary outcomes were PTSD and other mental health symptoms. Secondary outcomes were self-esteem, coping, and self-efficacy. SUD outcomes cannot be measured in a correctional setting. Implementation feasibility was exhibited by the ability to recruit, screen, assign, and retain participants. Effectiveness findings depended on sample, design, and method for analysis. Using a waitlist control group and no follow-up period, we found no aggregate effect of treatment on PTSD symptoms, although, when disaggregated, M-TREM was found to improve PTSD severity and SS improved general mental health symptoms and psychological functioning. Using intent-to-treat and completer analyses, no significant differences were found in the relative performance between SS and M-TREM on primary or secondary outcomes. When longitudinal data were maximized and modeled in ways that reflect the hierarchical nature of the data, we found that SS and M-TREM performed better than no treatment on PTSD severity and secondary outcomes, and that treatment benefits endured. Findings cautiously support implementing either Seeking Safety or M-TREM to treat incarcerated men with co-morbid PTSD and addiction problems.

Psychotherapy for depression: a randomized clinical trial comparing schema therapy and cognitive behavior therapy

BACKGROUND

The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression.

METHODS

In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders.

RESULTS

ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders.

LIMITATIONS

This study needs replication.

CONCLUSIONS

This preliminary research indicates that ST may provide an effective alternative therapy for depression.

Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults

BACKGROUND

Anxiety disorders are the most common mental health problems. They are chronic and unremitting. Effective treatments are available, but access to services is limited. Media-delivered behavioural and cognitive behavioural interventions (self-help) aim to deliver treatment with less input from professionals compared with traditional therapies.

OBJECTIVES

To assess the effects of media-delivered behavioural and cognitive behavioural therapies for anxiety disorders in adults.

SEARCH METHODS

Published and unpublished studies were considered without restriction by language or date. The Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR) was searched all years to 1 January 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Complementary searches were carried out on Ovid MEDLINE (1950 to 23 February 2013) and PsycINFO (1987 to February, Week 2, 2013), together with International trial registries (the trials portal of the World Health Organization (ICTRP) and ClinicalTrials.gov). Reference lists from previous meta-analyses and reports of randomised controlled trials were checked, and authors were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials of media-delivered behavioural or cognitive behavioural therapy in adults with anxiety disorders (other than post-traumatic stress disorder) compared with no intervention (including attention/relaxation controls) or compared with face-to-face therapy.

DATA COLLECTION AND ANALYSIS

Both review authors independently screened titles and abstracts. Study characteristics and outcomes were extracted in duplicate. Outcomes were combined using random-effects models, and tests for heterogeneity and for small study bias were conducted. We examined subgroup differences by type of disorder, type of intervention provided, type of media, and recruitment methods used.

MAIN RESULTS

One hundred and one studies with 8403 participants were included; 92 studies were included in the quantitative synthesis. These trials compared several types of media-delivered interventions (with varying levels of support) with no treatment and with face-to-face interventions. Inconsistency and risk of bias reduced our confidence in the overall results. For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants). The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice. Evidence suggested benefit for secondary outcome measures (depression, mental-health related disability, quality of life and dropout), but this evidence was of low to moderate quality. Evidence regarding harm was lacking.

AUTHORS' CONCLUSIONS

Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior. Economic analyses were beyond the scope of this review.Important heterogeneity was noted across trials. Recent interventions for specific problems that incorporate clinician support may be more effective than transdiagnostic interventions (i.e. interventions for multiple disorders) provided with no guidance, but these issues are confounded in the available trials.Although many small trials have been conducted, the generalisability of their findings is limited. Most interventions tested are not available to consumers. Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established. Large, pragmatic trials are needed to evaluate and to maximise the benefits of self-help interventions.

Credibility clusters, preferences, and helpfulness beliefs for specific forms of psychotherapy

BACKGROUND

There is some evidence that the perceived credibility of specific forms of psychotherapy, beliefs about helpful and not-so-helpful interventions, and differential treatment preferences may influence both therapeutic alliance and outcome, at least in the short term. The present study explored whether distinct clusters exist, based on credibility ratings, and how these may be related to treatment preferences and beliefs about the helpfulness of specific interventions.

METHOD

Written descriptions of psychodynamic, cognitive, and cognitive-behavioural psychotherapy were rated by a random community sample with the 'normal' level of psychiatric treatment (n= 121), psychiatric outpatients with limited previous experience of psychiatric care (n= 118), and a group of psychiatric 'veterans' with long experience of psychiatric care (n= 48). Participants completed a questionnaire focusing on beliefs about the helpfulness of specific therapy components, rated the credibility of each form of psychotherapy, and ranked the alternatives in terms of preferences.

RESULTS

Using cluster analysis, six distinct groups of participants were delineated. Some approached psychotherapy in an undifferentiated manner, tending to either embrace all or reject all of the methods examined. Others had differentiated ideas about the credibility of specific therapeutic approaches. These clusters were strongly associated with differential treatment preferences. They were also associated with helpfulness beliefs, type of psychological problems, previous experiences with psychotherapy, and gender. Analysis of the interactions among these factors revealed that the distribution across clusters was almost entirely accounted for by the helpfulness beliefs.

CONCLUSIONS

For clinicians, it may be important to investigate the differential appeal of specific components of psychotherapy as well as entire therapy packages in individual cases prior to commencing therapy. For researchers, it may be important to consider whether outcome studies would become more informative by taking patients' beliefs and preferences into account.

Clinical decision making and outcome in routine care for people with severe mental illness (CEDAR): study protocol

BACKGROUND

A considerable amount of research has been conducted on clinical decision making (CDM) in short-term physical conditions. However, there is a lack of knowledge on CDM and its outcome in long-term illnesses, especially in care for people with severe mental illness.

METHODS/DESIGN

The study entitled "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR) is carried out in six European countries (Denmark, Germany, Hungary, Italy, Switzerland and UK). First, CEDAR establishes a methodology to assess CDM in people with severe mental illness. Specific instruments are developed (and psychometric properties established) to measure CDM style, key elements of CDM in routine care, as well as CDM involvement and satisfaction from patient and therapist perspectives. Second, these instruments are being put to use in a multi-national prospective observational study (bimonthly assessments during a one-year observation period; N = 560). This study investigates the immediate, short- and long-term effect of CDM on crucial dimensions of clinical outcome (symptom level, quality of life, needs) by taking into account significant variables moderating the relationship between CDM and outcome.

DISCUSSION

The results of this study will make possible to delineate quality indicators of CDM, as well as to specify prime areas for further improvement. Ingredients of best practice in CDM in the routine care for people with severe mental illness will be extracted and recommendations formulated. With its explicit focus on the patient role in CDM, CEDAR will also contribute to strengthening the service user perspective. This project will substantially add to improving the practice of CDM in mental health care across Europe.

TRIAL REGISTER

ISRCTN75841675.

The impact of client treatment preferences on outcome: a meta-analysis

An important part of evidence-based practice is to include client preferences in the treatment decision-making process. However, based on previous reviews of the literature there is some question as to whether including client preferences actually has an effect on treatment outcome. This meta-analytic review summarized data from over 2,300 clients across 26 studies comparing the treatment outcome differences between clients matched to a preferred treatment and clients not matched to a preferred treatment. The findings indicate a small significant effect (r=.15, CI(.95): .09 to .21) in favor of clients who received a preferred treatment. The binomial effect size indicated that matched clients have a 58% chance of showing greater improvement, and further analysis indicate that they are about half as likely to drop-out of treatment when compared with clients not receiving a preferred treatment. Study design was seen to be a moderating variable in that partially randomized preference trials may underestimate the treatment preference effect. Implications for best practice standards are discussed.

Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate

BACKGROUND

Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up-to-date physicians and treatments. This is an updated version of the original Cochrane review published in Issue 1, 2005.

OBJECTIVES

To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. We aimed to compare similar patients receiving similar treatment inside and outside of RCTs.

SEARCH STRATEGY

In March 2007, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded 7586 new references. In addition, we reviewed the reference lists of relevant articles.

SELECTION CRITERIA

Randomized studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies for inclusion, assessed study quality and extracted data.

MAIN RESULTS

We identified 30 new non-randomized cohort studies (45 comparisons): no new RCTs were found. This update now includes five RCTs (yielding 6 comparisons) and 80 non-randomized cohort studies (130 comparisons), with 86,640 patients treated in RCTs and 57,205 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. When the results of RCTs and non-randomized cohorts that reported dichotomous outcomes were combined, there were 98 comparisons; there was also heterogeneity (P < 0.00001, I(2) = 42.2%) between studies. No statistical significant differences were found for 85 of the 98 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. There was significant heterogeneity (P < 0.00001, I(2) = 58.2%) among the 38 continuous outcome comparisons. No statistically significant differences were found for 30 of the 38 comparisons. Three comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs.

AUTHORS' CONCLUSIONS

This review indicates that participation in RCTs is associated with similar outcomes to receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.

The relation of patients' treatment preferences to outcome in a randomized clinical trial

Randomization procedures are performed in order to maximize the internal validity of treatment outcome studies. Objections have been made that this practice undermines the external validity of these studies because it ignores patients' treatment preferences, thereby precluding the self-selection of treatment that can occur in the community. This study used data from a multisite, double-blind, randomized, placebo-controlled trial comparing antidepressant medication to cognitive therapy for moderately to severely depressed outpatients. It compared the treatment outcomes of patients who, via randomization, received their preferred treatment versus those who did not. Although the majority of patients stated a preference for one treatment over the other, there was no significant difference in the magnitude of reduction in symptoms of depression between those who received their treatment of choice versus those who did not. These results do not provide support for the claim that the external validity of randomized controlled trials suffers from this aspect of the randomization procedure.

Outcomes of patients who participate in randomised controlled trials compared to similar patients receiving similar interventions who do not participate

BACKGROUND

Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up to date physicians and treatments.

OBJECTIVES

To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not.

SEARCH STRATEGY

In May 2001, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded over 10,000 references. In addition, we reviewed the reference lists of relevant articles and wrote to over 250 investigators to try to obtain further information.

SELECTION CRITERIA

Randomised studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed studies for inclusion, assessed study quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We included five randomised studies (yielding 6 comparisons) and 50 non-randomised cohort studies (85 comparisons), with 31,140 patients treated in RCTs and 20,380 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. There was statistically significant heterogeneity (P < 0.002, I(2) = 36.2%) among the 73 dichotomous outcome comparisons; none of the potential explanatory factors we investigated helped to explain this heterogeneity. No statistically significant differences were found for 63 of the 73 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and two comparisons reported statistically significant worse outcomes for patients treated within RCTs. There were no statistically significant differences in heterogeneity (P = 0.53, I(2) = 0%) or in outcomes (SMD 0.01, 95% CI -0.10 to 0.12) of patients treated within and outside RCTs in the 18 comparisons which had used continuous outcomes.

AUTHORS' CONCLUSIONS

This review indicates that participation in RCTs is not associated with greater risks than receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.

Trust, choice and power in mental health: a literature review

Trust, choice and empowerment of patients are emerging as important issues in mental health care. This may be due to an increasingly consumerist attitude amongst patients and as a consequence of postmodern cultural changes in society. This study aimed to find evidence for the influence of trust, patient choice and patient empowerment in mental health care. A literature review was undertaken. Six searches of PubMed were made using the key terms trust, patient choice and power combined separately with psychiatry and mental health. The literature search found substantial research evidence in the areas of trust, choice and power including validated scales measuring these concepts and evidence that they are important to patients. Trust in general health clinicians was found to be high and continuity of care increases patients' trust in their clinician. However, only qualitative research has been found on trust in mental health settings and further quantitative studies are needed. Patient choice is important to patients and improves engagement with services, although studies on outcome show varying results. Empowerment has impacted more at an organisational level than on individual care. Innovative research methodologies are needed to expand on the present significant body of research, utilising qualitative and quantitative techniques.

Patient-centered communication: do patients really prefer it?

OBJECTIVE

To investigate patient preferences for a patient-centered or a biomedical communication style.

DESIGN

Randomized study.

SETTING

Urgent care and ambulatory medicine clinics in an academic medical center.

PARTICIPANTS

We recruited 250 English-speaking adult patients, excluding patients whose medical illnesses prevented evaluation of the study intervention.

INTERVENTION

Participants watched one of three videotaped scenarios of simulated patient-physician discussions of complementary and alternative medicine (CAM). Each participant watched two versions of the scenario (biomedical vs. patient-centered communication style) and completed written and oral questionnaires to assess outcome measurements.

MEASUREMENTS AND MAIN RESULTS

Main outcome measures were 1) preferences for a patient-centered versus a biomedical communication style; and 2) predictors of communication style preference. Participants who preferred the patient-centered style (69%; 95% confidence interval [CI], 63 to 75) tended to be younger (82% [51/62] for age < 30; 68% [100/148] for ages 30-59; 55% [21/38] for age > 59; P < .03), more educated (76% [54/71] for postcollege education; 73% [94/128] for some college; 49% [23/47] for high school only; P= .003), use CAM (75% [140/188] vs. 55% [33/60] for nonusers; P= .006), and have a patient-centered physician (88% [74/84] vs. 30% [16/54] for those with a biomedical physician; P < .0001). On multivariate analysis, factors independently associated with preferring the patient-centered style included younger age, use of herbal CAM, having a patient-centered physician, and rating a "doctor's interest in you as a person" as "very important."

CONCLUSIONS

Given that a significant proportion of patients prefer a biomedical communication style, practicing physicians and medical educators should strive for flexible approaches to physician-patient communication.

Do consumers who have a choice of treatment have better outcomes?

This study used a non-equivalent control group design to investigate the effect of consumer choice of treatment on both process and outcome variables. All study participants suffered from severe mental illness, were homeless at baseline, and were enrolled in a modified Assertive Community Treatment (ACT) program. Consumers in the choice condition had selected the ACT program from a menu of five treatment programs; clients in the no-choice condition were simply assigned to the ACT program by an intake worker. Results found that consumers in the choice condition visited the ACT staff at their offices more than consumers in the no-choice condition, but there were no significant differences between groups on the other treatment process variables. Although consumers in the choice condition increased their income more than consumers in the no-choice condition, there were no significant differences between groups on the other outcome variables (stable housing, psychotic symptoms, depression, and substance abuse).

Does preference for type of treatment matter? A study of exposure in vivo with or without hypnosis in the treatment of panic disorder with agoraphobia

There is evidence that preference for a given therapy may influence results. Literature also suggests that hypnotizability may be elevated in agoraphobic patients, making hypnosis a potentially powerful method for treatment. Agoraphobic patients (N = 64) were treated with either exposure in vivo or exposure combined with hypnosis in a crossover design. Half of the patients started with the treatment they preferred and the other half received the other treatment first. Although patients' preference clearly shifted in favor of the combined therapy in the course of the study, no effect of preference on outcome was evident. Although hypnotizability clearly correlated to outcome in the combined therapy, no difference in effect between the two therapies was found on behavioral, self-report, and observer measures. No additional effect of hypnosis could be shown and preference was not found to be a powerful mediator of effect.

Clinical hypnosis as a nondeceptive placebo: empirically derived techniques

Many psychological problems are maintained, in part, by dysfunctional response expectancies, and changing those expectations is an essential part of treatment. Hypnotic inductions alter response expectancies and have been shown empirically to substantially enhance the effects of psychotherapy. Therefore, hypnosis can be used therapeutically as a nondeceptive placebo. Expectancy plays a major role in hypnotic inductions and their effects. Clinical procedures suggested by these data are explored.

Matching pain coping strategies to the individual: a prospective validation of the cognitive coping strategy inventory

The validity of the Cognitive Coping Strategy Inventory (CCSI; Butler et al., 1989) was tested in a prospective fashion. Subjects were randomly assigned to one of three conditions. Some were "matched" to a strategy for which they received a high CCSI score, some were "mismatched" to a strategy for which they received a low CCSI score, and some were given a choice of strategies. Those subjects using a matched strategy obtained better threshold and tolerance times on the cold pressor than subjects who used a mismatched strategy. Despite clear differences in exposure to the cold pressor these conditions did not differ from each other in self-reported levels of pain. It was concluded that the CCSI appears to be a valid and useful tool for selecting a coping strategy to help particular individuals manage acute pain. Though the CCSI is relatively easy to administer and score, the comparative costs and benefits of using it must be weighed against the somewhat more efficient approach of simply offering the subject a choice of treatments. Subjects given a choice of strategies performed as well as subjects matched to a strategy on the basis of CCSI scores.

When does a choice of coping strategies help? The interaction of choice and locus of control

Undergraduate student volunteers either were given a choice of coping strategies or were assigned to a coping strategy which was used to help them tolerate the cold pressor. Subjects who were given a choice of coping strategies reported their strategy to be more credible and perceived a greater sense of control than subjects who were not given a choice. Improved pain tolerance, however, did not result directly from being given a choice. Increases in pain tolerance depended on locus of control. Subjects who had a high internal health locus of control reported a greater strength of self-efficacy and demonstrated increased pain tolerance following a choice of strategies. In comparison, subjects who reported a more external health locus of control did not benefit from receiving a choice. This study has implications for our understanding of the role of choice in therapy and for improving the effectiveness of our interventions with individuals.

Balancing the right to habilitation with the right to personal liberties: the rights of people with developmental disabilities to eat too many doughnuts and take a nap

In the pursuit of efficient habilitation, many service providers exercise a great deal of control over the lives of clients with developmental disabilities. For example, service providers often choose the client's habilitative goals, determine the daily schedule, and regulate access to preferred activities. This paper examines the advantages and disadvantages of allowing clients to exercise personal liberties, such as the right to choose and refuse daily activities. On one hand, poor choices on the part of the client could hinder habilitation. On the other hand, moral and legal issues arise when the client's right to choice is abridged. Recommendations are offered to protect both the right to habilitation and the freedom to choose.

The effect of previous experience on preference of approach for effective counseling

Students in a general psychology class viewed four videotapes of initial vocational-educational and initial personal concern counseling sessions. The sessions were presented from a client-centered approach and from a behavioral approach, and employed the same client and counselor. After viewing the tapes, the students were asked to indicate which approach they thought would be more effective in helping a client. Results showed that students who had previously experienced counseling preferred a behavioral approach for both the vocational-educational concern and the personal concern. Students with no experience of counseling did not exhibit a preference.

Preference for counseling and psychotherapy as related to preoedipal fixation

Preference for a particular mode of psychotherapy was hypothesized to relate to psychoanalytically derived characterological attributes of the potential client. Specifically, psychoanalysis was seen as a mode which enhances dependency within the client and fosters an air of intimacy in the treatment, while behavior therapy was seen as consonant with a more aloof stance between client and therapist, involving concrete and rigid procedures. It was hypothesized that oral fixation within clients would correlate with a preference for psychoanalysis while anal fixation would correlate with a preference for behavior therapy. 87 students took the Rorschach (which was content-scored for fixation) and also indicated preferences for psychoanalysis, behavior therapy, and client-centered therapy. Results confirmed the hypothesized relationships, but these accounted only for a small proportion of the variance. An unhypothesized relationship emerged between sadistic fixation and a bias against behavior therapy. Conceptual suggestions are offered to interpret these findings, and an unexpected sex difference in the correlations, within the context of psychosexual theory.

Prognostic factors with four treatment methods for phobic disorders

The associations between prognostic factors and outcome with four treatment methods for phobic disorders were studied in 103 women. The prognostic factors were sociodemographic, intelligence, personality, early interpersonal relations, aspects of previous and current mental disorder, and intensity of symptoms at start of treatment. All patients received basal therapy, which implied information, advice on exposure in vivo, and anxiolytics. One group received this treatment only (B), while others received supplementary treatment, with therapist-directed prolonged exposure in vivo (PE), supportive therapy (ST) of dynamic type, or relaxation (R). The patients were treated for 3 months, with a 9-month follow-up period. Factors associated with a better outcome were: PE: greater needs for succourance and lower avoidance; ST: higher social class, better relations between parents and with father during childhood, inner conflicts as cause, and lower levels of free anxiety; R: satisfaction with contact when aged 15, bereavement as a cause, and lower levels of several symptoms; B: greater needs for order, stress at the onset, shorter duration and satisfaction with work. There were thus interactions between prognostic factors and type of treatment. The prognostic factors should be taken into account in the choice and design of treatment.

The effect of client choice of therapist on therapy outcome

This study compared the therapeutic progress of three randomly assigned groups (n = 14 in each group) of community mental health center clients: (a) clients who viewed a slide/sound presentation about all available therapists and chose their own therapist; (b) clients who viewed the presentation and were assigned to a therapist by the center's clinical director; (c) clients who were assigned to a therapist by the clinical director without seeing the presentation. There were no significant differences among the three groups in their initial reaction to the clinic, number of therapy sessions, type of termination, severity of presenting problems, General Well-Being Schedule scores, Current Adjustment Rating Scale scores, or therapist's satisfaction with therapy. Further analysis revealed that three out of four clients had improved significantly as a result of therapy. It was concluded that in the absence of research evidence demonstrating the efficacy of client choice on therapy outcome, support for the notion of client choice must be based solely on social, ethical, and legal considerations.

Attraction to therapy and therapist credibility as a function of therapy orientation

Exposed male and female Ss (N = 96) to psychoanalytic, behavioral, client-centered, or gestalt therapy, in the form of a brief written description and a 5-minute videotaped simulation. Attraction to therapy and various dimensions of therapist credibility were measured. The psychoanalytic presentation generated the greatest attraction and the greatest perceived total credibility. The gestalt presentation was next highest on these variables, followed by the behavioral and client-centered presentation. No significant effects for sex of S or sex by therapy approach interaction were reported. Explanations for and implications of these findings are discussed.

Relationships between certain MMPI factors and psychotherapeutic preferences

50 undergraduate students completed the MMPI, described a personal problem, then indicated their preferences for one of five psychotherapeutic approaches. Subjects with relatively more neurotic profiles chose therapist-directed therapies, and those with more characterological profiles preferred patient-directed approaches, as predicted. Subjects provided illuminating reasons for their choices and rejections.

Incentive effects of choosing a therapist

Investigated the effects of offering clients (N = 55) a choice of therapeutic style on show rate and reactions to the initial interview. Individuals who called for an appointment were assigned randomly to Choice and Attention-Control conditions. Choice Ss were informed that they would be assigned to a therapist who identified with one of two descriptions of therapy styles from which they could choose. Based on this choice, these persons were scheduled with the next therapist in line who had identified him/herself with the selected style. Attention-Control clients were informed about the range of services available at the clinic and paired with a therapist regardless of style on the usual rotating basis. A significantly higher proportion of Choice than Attention-Control Ss kept their schedules appointments. However, no significant differences were found on client and therapist evaluations of the initial interview.

Malleability of preference for therapists' response style

Studies of clients' preferences, primarily descriptive in nature, are being reported at an increasing rate. The resources given to this sort of collecting and summarizing of clients' and nonclients' preferences are justified only if preference is an important variable to be reckoned with in group and individual psychotherapy. While a number, of authors have indeed postulated that clients' preferences constitute a critical variable in psychotherapy, not much experimental work has been done. To estimate the importance of clients' preferences for therapists' directiveness, the strength with which such preference is held was investigated. Sixty-six undergraduates were randomly assigned to six groups in a Solomon design. The four experimental groups were subsequently shown one of two taped demonstrations of high and low directive therapists' response styles, respectively. Posttests determined preference regarding therapists' directiveness. Results suggested preference was not impervious to shaping procedures and can be modified prior to therapy. It was hypothesized that if preference proved to be a such weakly held attitude, then it might well prove similarly weak in actual therapy.

Preferred versus nonpreferred treatment and self-control training versus determination raising as treatments of obesity: a pilot study

Of 12 overweight women half received 10 wk. of self-control training and the rest received an equal period aimed at increasing determination to lose weight. Half of each treatment group had expressed a preference for the type of treatment they received and half for the other type of treatment. Both groups lost a statistically significant amount of weight, and at a 3-mo. follow-up there was still a significant weight loss. Follow-up at 6 mo. on 9 of the 12 original subjects indicated both groups regained much of their lost weight. There was no evidence that either type of treatment or receiving one's preferred type of treatment was related to weight loss.

A research strategy for evaluating the effectiveness of psychotherapy

A classification scheme is proposed that integrates previous outcome studies in psychotherapy. Studies are classified into one of three frameworks according to the question addressed, the assumptions made, and the experimental designs used. Strengths and weaknesses of the three frameworks are examined within the context of specific studies of outcome. Evidence from the three frameworks suggests an alternative formulation of the question about outcome and a new experimental design. Specifically, the design involves evaluating the effectiveness of psychotherapy with respect to a population of patients deemed appropriate for psychotherapy. This design avoids random assignment of patient to psychotherapist and permits the investigator to address the question of whether psychotherapists are effective with patients whom they regard as appropriate for their particular type of therapeutic intervention.