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Background

Rewarding provider performance has been recommended by the Institute of Medicine as an approach to improve the quality of treatment, yet little empirical research currently exists that has examined the effectiveness and cost-effectiveness of such approaches. The aim of this study is to test the effectiveness and cost-effectiveness of providing monetary incentives directly to therapists as a method to improve substance abuse treatment service delivery and subsequent client treatment outcomes.

Design

Using a cluster randomized design, substance abuse treatment therapists from across 29 sites were assigned by site to either an implementation as usual (IAU) or pay-for-performance (P4P) condition.

Participants

Substance abuse treatment therapists participating in a large dissemination and implementation initiative funded by the Center for Substance Abuse Treatment.

Intervention

Therapists in both conditions received comprehensive training and ongoing monitoring, coaching, and feedback. However, those in the P4P condition also were given the opportunity to earn monetary incentives for achieving two sets of measurable behaviors related to quality implementation of the treatment.

Outcomes

Effectiveness outcomes will focus on the impact of the monetary incentives to increase the proportion of adolescents who receive a targeted threshold level of treatment, months that therapists demonstrate monthly competency, and adolescents who are in recovery following treatment. Similarly, cost-effectiveness outcomes will focus on cost per adolescent receiving targeted threshold level of treatment, cost per month of demonstrated competence, and cost per adolescent in recovery.

Trial Registration

Trial Registration Number: NCT01016704

Objective

The purpose of this investigation was to compare three types of treatment for binge eating disorder to determine the relative efficacy of self-help group treatment compared to therapist-led and therapist-assisted group cognitive-behavioral therapy.

Method

A total of 259 adults diagnosed with binge eating disorder were randomized to wait-list or 20 week group treatment that was therapist-led, therapist-assisted, or self-help. Binge eating as measured by the Eating Disorder Examination was assessed at baseline, post-treatment, 6- and 12 month follow-up and outcome was determined using logistic regression and analysis of covariance (intention-to-treat).

Results

At end of treatment, the therapist-led (51.7%) and the therapist-assisted (33.3%) conditions had higher binge eating abstinence rates than the self-help (17.9%) and wait-list (10.1%) conditions. No differences in abstinence rates were observed at either follow-up assessment. The therapist-led condition also showed more reductions in binge eating at post-treatment and follow-up compared to the self-help condition, and treatment completion rates were higher in the therapist-led (88.3%) and wait-list (81.2%) conditions than the therapist-assisted (68.3%) and the self-help (59.7%) conditions.

Conclusions

Therapist-led group cognitive-behavioral treatment for binge eating disorder led to higher binge eating abstinence rates, greater reductions in binge eating frequency, and lower attrition at the end of treatment compared to group self-help treatment. Although these findings indicate that therapist delivery of group treatment is associated with better short-term outcome and less attrition than self-help treatment, the lack of group differences at follow-up suggests that self-help group treatment may be a viable alternative to therapist-led interventions. (Clinical Trials Registration: Treatment of Binge Eating Disorder, #NCT00041743; http://www.clinicaltrials.gov/ct2/show/NCT00041743?term=00041743&rank=1)

The effects of therapeutic punishment delivered following inappropriate behavior on the academic responding and eye-to-face contact of 2 persons with developmental handicaps was examined using a counterbalanced alternating treatment design. Each subject was sequentially taught by two therapists each day. While one of the therapists taught the subject, the second therapist stood in close proximity directly behind the subject. During baseline, neither therapist delivered punishment following inappropriate behavior. During the treatment condition, one of the therapists delivered all punishment regardless of whether she was teaching or standing behind the subject. The therapist who delivered all punishment for 1 subject did not deliver any punishment for the other subject. During the last condition, the therapist delivering all punishment was reversed for 1 of the subjects. The results indicated that the task being taught was mastered by each subject only when the therapist delivering punishment was teaching. Data collected also indicated that each subject made more eye-to-face contact when the therapist delivering all punishment was teaching. Although neither therapist had to deliver punishers often, punishment had to be administered less often when the therapist teaching the subject was also the therapist delivering punishment.

This study was a crosscultural replication of a study that investigated therapist adherence to behavioral interventions as a result of an intensive quality assurance system which was integrated into Multisystemic Therapy. Thirty-three therapists and eight supervisors participated in the study and were block randomized to either an Intensive Quality Assurance or a Workshop Only condition. Twenty-one of these therapists treated 41 cannabis-abusing adolescents and their families. Therapist adherence and youth drug screens were collected during a five-month baseline period prior to the workshop on contingency management and during 12 months post workshop. The results replicated the previous finding that therapist adherence to the cognitive-behavioral interventions, but not to contingency management, showed a strong positive difference in trend in favor of the intensive quality assurance condition. While the clinical impact of such quality assurance may be delayed and remains to be demonstrated, cannabis abstinence increased as a function of time in therapy, and was more likely with stronger therapy adherence to contingency management, but did not differ across quality assurance interventions.

Despite the fact that the number of Hispanic individuals in need of treatment for substance use problems is increasing internationally, no studies have investigated the extent to which therapists can provide empirically supported treatments to Spanish-speaking clients with adequate fidelity. Twenty-three bilingual Hispanic therapists from five community outpatient treatment programs in the United States were randomly assigned to deliver either three sessions of motivational enhancement therapy (MET) or an equivalent number of drug counseling-as-usual sessions (CAU) in Spanish to 405 Spanish-speaking clients randomly assigned to these conditions. Independent ratings of 325 sessions indicated the adherence/competence rating system had good to excellent interrater reliability and indicated strong support for an a priori defined fundamental MET skill factor. Support for an advanced MET skill factor was relatively weaker. The rating scale indicated significant differences in therapists’ MET adherence and competence across conditions. These findings indicate that the rating system has promise for assessing the performance of therapists who deliver MET in Spanish and suggest that bilingual Spanish-speaking therapists from the community can be trained to implement MET with adequate fidelity and skill using an intensive multisite training and supervision model.

Contextual variables potentially influencing premature termination were examined. Clients (n = 83) and therapists (n = 35) provided parallel data on early working alliance, psychotherapy termination decision (unilateral vs. mutual), clients’ reasons for termination, and barriers to treatment participation. When clients unilaterally ended therapy, therapists were only partially aware of either the extent of clients’ perceived improvements or their dissatisfaction. When termination was mutually determined, there were no differences between client and therapist ratings of termination reasons. Although working alliance and barriers to treatment participation were rated as lower in the context of unilateral termination by clients and therapists, all clients rated the early alliance and barriers to treatment more highly than did therapists. Results have implications for understanding premature termination and suggest future research examining the utility of therapist feedback regarding contextual variables in terms of retaining clients in therapy.

The success of psychotherapy depends on the nature of the therapeutic relationship between a therapist and a client. We use dynamical systems theory to model the dynamics of the emotional interaction between a therapist and client. We determine how the therapeutic endpoint and the dynamics of getting there depend on the parameters of the model. Previously Gottman et al. used a very similar approach (physical-sciences paradigm) for modeling and making predictions about husband–wife relationships. Given that this novel approach shed light on the dyadic interaction between couples, we have applied it to the study of the relationship between therapist and client. The results of our computations provide a new perspective on the therapeutic relationship and a number of useful insights. Our goal is to create a model that is capable of making solid predictions about the dynamics of psychotherapy with the ultimate intention of using it to better train therapists.

The success of psychotherapy depends on the nature of the therapeutic relationship between a therapist and a client. We use dynamical systems theory to model the dynamics of the emotional interaction between a therapist and client. We determine how the therapeutic endpoint and the dynamics of getting there depend on the parameters of the model. Previously Gottman et al. used a very similar approach (physical-sciences paradigm) for modeling and making predictions about husband–wife relationships. Given that this novel approach shed light on the dyadic interaction between couples, we have applied it to the study of the relationship between therapist and client. The results of our computations provide a new perspective on the therapeutic relationship and a number of useful insights. Our goal is to create a model that is capable of making solid predictions about the dynamics of psychotherapy with the ultimate intention of using it to better train therapists.

Background:

Clinical reasoning has long been a valuable tool for health care practitioners, but it has been under-researched in the field of massage therapy. Case reports have been a useful method for exploring the clinical reasoning process in various fields of manual therapy and can provide a model for similar research in the field of massage therapy. A diagnostically challenging case concerning a client with low back pain serves as a guideline for examining the clinical reasoning process of a massage therapist.

Methods:

A two-part methodology was employed: Client profileReflective inquiry

The inquiry included questions pertaining to beliefs about health problems; beliefs about the mechanisms of pain; medical conditions that could explain the client’s symptoms; knowledge of the client’s anatomy, assessment, and treatment choices; observations made during treatment; extent of experience in treating similar problems; and ability to recognize clinical patterns.

Results:

The clinical reasoning process of a massage therapist contributed to a differential diagnosis, which provided an explanation for the client’s symptoms and led to a satisfactory treatment resolution.

Conclusion:

The present report serves as an example of the value of clinical reasoning in the field of massage therapy, and the need for expanded research into its methods and applications. The results of such research could be beneficial in teaching the clinical reasoning process at both the introductory and the advanced levels of massage therapy education.

Objectives

The authors examine if some of the reason clients from racial and ethnic minority groups experience outcome disparities is explained by their therapists.

Method

Data from 98 clients (19% minority) and 14 therapists at two community mental health agencies where clients from racial and ethnic minority groups were experiencing outcome disparities were analyzed using hierarchical linear modeling with treatment outcomes at Level 1, client factors at Level 2, and therapists at Level 3.

Results

There were substantial therapist effects that moderated the relationship between clients’ race and treatment outcomes (outcome disparities). Therapists accounted for 28.7% of the variability in outcome disparities.

Conclusions

Therapists are linked to outcome disparities and appear to play a substantial role in why disparities occur.

Parent involvement in the treatment of childhood disruptive behavior problems is a critical component of effective care. Yet little is known about the amount of time therapists are involving parents in treatment and factors that predict therapists’ efforts to involve parents in routine care. The purpose of this study is to examine therapists’ within-session involvement of parents in community-based outpatient mental health treatment. The data are from a larger longitudinal observational study of psychotherapy for children ages 4–13 with disruptive behavior problems and include videotaped psychotherapy sessions coded for the therapeutic strategies delivered as well as measures of child, parent/family, and therapist characteristics at baseline. Parent involvement is defined as the proportion of time in the session that therapists direct treatment strategies towards parents. Results indicated that therapists directed treatment strategies towards parents an average of 44% of the time within a session. Multilevel modeling was used to examine client-level (child, parent, and family functioning) and provider-level (therapist experience and background) predictors of parent involvement. Therapists involved parents more when the child had higher levels of behavior problems, when the parent reported higher levels of internalized caregiver strain, and when the therapist was more experienced. The results highlight potential areas to target in efforts to increase parent involvement, including training less experienced therapists to increase their focus on directing strategies towards parents.

Sustained treatment attendance has been reported to be poor in publicly-funded community-based clinic settings serving children and families. Several child and family characteristics have been shown to predict attendance in community-based care, but virtually no research has been conducted to examine how experiences in care, including psychotherapists’ within-session practices, influence client attendance. The goal of this exploratory study was to examine how observed practice within sessions, in particular the extent to which therapists delivered elements consistent with evidence-based practices, impacts total number of sessions attended, while accounting for an array of other potential predictors. Participants include 181 children ages 4–13 and their parents entering a new episode of care for disruptive behavior problems in publicly-funded clinics. Data sources include administrative billing records on treatment attendance, coded videotaped treatment sessions, and self-reports from children, parents, and therapists. Results indicate that parent education, service funding source, parent alliance with therapist, and therapist experience predicted number of sessions attended; intensity of evidence-based treatment techniques delivered to children was marginally associated with attendance (p=.059). Implications for improving engagement in community-based care are discussed.

This study is the first to examine within-session therapist and client language/process predictors of a client’s decision to complete a written Change Plan in an alcohol-focused motivational interview (MI). Data were from an ongoing hospital-based clinical trial (N = 291). Trained raters coded audio-recorded MI sessions using the Motivational Interviewing Skill Code. Logistic regression analyses found that therapist MI-consistent behaviors (b = .023, p < .001) and client change talk (b = .063, p < .001) were positive predictors, and client counter change talk (b = −.093, p < .001) was a negative predictor of the decision to complete a Change Plan regarding alcohol use. Mean comparisons showed that compared to non-completion, Change Plan completion did not result in significantly greater changes in client motivational readiness. Completion of a Change Plan is a proximal outcome in MI that is associated with client intention to change (change talk), and may predict follow-up alcohol outcomes. Analyses of such theory-driven proximal client mechanisms provide a more complete model of MI process and may inform MI providers of necessary treatment ingredients.

Background

Although numerous efficacy studies in recent years have found internet-based interventions for depression to be effective, there has been scant consideration of therapeutic process factors in the online setting. In face-to face therapy, the quality of the working alliance explains variance in treatment outcome. However, little is yet known about the impact of the working alliance in internet-based interventions, particularly as compared with face-to-face therapy.

Methods

This study explored the working alliance between client and therapist in the middle and at the end of a cognitive-behavioral intervention for depression. The participants were randomized to an internet-based treatment group (n = 25) or face-to-face group (n = 28). Both groups received the same cognitive behavioral therapy over an 8-week timeframe. Participants completed the Beck Depression Inventory (BDI) post-treatment and the Working Alliance Inventory at mid- and post- treatment. Therapists completed the therapist version of the Working Alliance Inventory at post-treatment.

Results

With the exception of therapists' ratings of the tasks subscale, which were significantly higher in the online group, the two groups' ratings of the working alliance did not differ significantly. Further, significant correlations were found between clients' ratings of the working alliance and therapy outcome at post-treatment in the online group and at both mid- and post-treatment in the face-to-face group. Correlation analysis revealed that the working alliance ratings did not significantly predict the BDI residual gain score in either group.

Conclusions

Contrary to what might have been expected, the working alliance in the online group was comparable to that in the face-to-face group. However, the results showed no significant relations between the BDI residual gain score and the working alliance ratings in either group.

Trial registration

ACTRN12611000563965

Two studies were conducted to assess the train clinical interviewing skills. In Experiment 1, eight university practicum students ("therapists") and either role played or volunteer "clients" were audiotaped during simulated interviews. Following the collection of baseline data on both therapist and client responses, training was provided by way of written materials, classroom instruction and practice, and quizzes. Results of a multiple baseline design across subjects showed improvements in therapists' interviewing skills and subsequent increases in client responding. Experiment 2 replicated and extended the research to a hospital outpatient clinic, in which therapists interviewed the parents of children with behavior problems. In addition, four months following the completion of Experiment 2, follow-up data collected during a maintenance condition showed continued high levels of therapist and client behavior. Finally, a panel of expert peers indicated that each response category was judged highly relevant to the behavioral assessment process.

The purpose of this study was to gain an understanding of how therapists providing usual care (UC) psychotherapy are using elements of treatment common to evidence-based practices (EBPs) for children with disruptive behavior disorders (DBPs) and to identify client and therapist characteristics that may be associated with EBP strategies directed toward children and those directed to their caregivers. Results indicate that certain child, family, and therapist characteristics are associated with use of EBP strategies; however, much of the variability in practice was not explained by the variables examined. These findings highlight the complexity of UC psychotherapy and provide directions for future research on implementation of EBPs in UC.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.

Views differ concerning the importance of therapist-client similarity, but the theory underlying multimodal therapy suggests that similarity would be most advantageous for treatment outcome and client satisfaction. To explore this question, 43 therapist-client pairs were evaluated with the Session Evaluation Questionnaire (SEQ) after the second psychotherapy session. Similarity was determined by computing D"2 statistics from the Structural Profile Inventory, administered to both therapist and client. Regression analyses indicated therapist- client similarity was significantly predictive of client session rating on the SEQ. The more similar the dyad, the more "positive" and "arousing" (versus "still" or "dull") clients rated early sessions. Although there were several nonsignificant analyses, none of the results suggested that dissimilarity was positively associated with higher levels of client satisfaction and rapport.

This study implemented and evaluated a training program (a written manual, videotaped models, rehearsal, role plays, and performance feedback) designed to teach five subjects the skills to become effective family therapists. The study examined the therapists' use of three target behaviors: instructing, informing, and praising. The therapists, each paired with a parent and a preschool-aged child (2 1/2-4 1/2 yr old), were trained in the clinic to use, and to teach to the parents, several behavioral skills (e.g., praising, planned ignoring, and time-out) relevant to teaching children compliance to parental instructions. A multiple-baseline design across triads (therapist/parent/child) demonstrated that after the training program was instituted, the therapists increased their rates of instructing, praising, and informing the parents; all parents increased attention to compliance, decreased attention to noncompliance, and increased rates of praise to their children; and all children increased their compliance and decreased their noncompliance.

Maitland's construct of musculoskeletal pain irritability is widely used by physical therapists for making decisions about the vigor of examination and treatment, but this construct has not been defined to the extent that its measurement properties can be tested. The purposes of this study were to 1) determine if physical therapists utilize low back pain (LBP) irritability judgments to make treatment decisions, 2) identify LBP characteristics appropriate for an LBP irritability construct, and 3) develop a measurement construct of LBP irritability. Physical therapists evaluated and treated 183 subjects with LBP. The therapists judged the subjects' LBP as irritable or non-irritable, and recorded treatments provided at the initial visit. A principal-components analysis (PCA) was performed on 14 patient-reported LBP characteristics to identify potential components of a measurement construct of LBP irritability. The therapists' irritability judgments were found to be associated with the types of treatments prescribed. Five dimensions of LBP irritability were identified by the PCA from the 14 LBP characteristics considered. Four of these dimensions were associated with the therapists' LBP irritability judgments. The Roland-Morris Disability Questionnaire, presence of distal symptoms, and forward bending tolerance were found to have a stronger association with the irritability judgments than the dimensions of irritability identified in this study. Validated measures of LBP characteristics in current clinical use may adequately capture Maitland's concept of irritability.

Four hundred and thirty-two public sector therapists attended a workshop in contingency management and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of contingency management to treat substance abusing adolescent clients. Results showed that 58% of the practitioners (n = 131) with at least one substance abusing adolescent client (n = 225) adopted contingency management. Rates of adoption varied with therapist service sector (mental health versus substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting contingency management, whereas unfavorable attitudes toward and difficulty in implementing contingency management were rarely cited as barriers. The fidelity of initial contingency management implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted.

This study investigated whether withdrawn adults living in a residential center for psychotic and mentally handicapped persons could serve as peer therapists to increase the social interaction of other withdrawn residents. Two pairs of residents served as participants. Treatments were introduced and evaluated within a multiple baseline with reversal design. After baseline, the peer therapist was instructed to increase the social interactions of a target peer through engagement in social interactions. The results demonstrated that the peer therapist increased the social interactions of target peers. However, these increases did not generalize to other residents until the introduction of a multiple peer therapist condition. The percentage of time the peer therapists interacted with other nontarget residents also increased throughout the study. These results were maintained during a 4-month follow-up condition.

This paper proposes a historical excursus of studies that have investigated the therapeutic alliance and the relationship between this dimension and outcome in psychotherapy. A summary of how the concept of alliance has evolved over time and the more popular alliance measures used in literature to assess the level of alliance are presented. The proposal of a therapeutic alliance characterized by a variable pattern over the course of treatment is also examined. The emerging picture suggests that the quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. In our opinion, with regard to the relationship between the therapeutic alliance and outcome of psychotherapy, future research should pay special attention to the comparison between patients’ and therapists’ assessments of the therapeutic alliance. This topic, along with a detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects.

Objective. To measure the impact of medication therapy management (MTM) learning activities on students’ confidence and intention to provide MTM using the Theory of Planned Behavior.

Design. An MTM curriculum combining lecture instruction and active-learning strategies was incorporated into a required pharmacotherapy laboratory course.

Assessment. A validated survey instrument was developed to evaluate student confidence and intent to engage in MTM services using the domains comprising the Theory of Planned Behavior. Confidence scores improved significantly from baseline for all items (p < 0.00), including identification of billable services, documentation, and electronic billing. Mean scores improved significantly for all Theory of Planned Behavior items within the constructs of perceived behavioral control and subjective norms (p < 0.05). At baseline, 42% of students agreed or strongly agreed that they had knowledge and skills to provide MTM. This percentage increased to 82% following completion of the laboratory activities.

Conclusion. Implementation of simulated MTM activities in a pharmacotherapy laboratory significantly increased knowledge scores, confidence measures, and scores on Theory of Planned Behavior constructs related to perceived behavioral control and subjective norms. Despite these improvements, intention to engage in future MTM services remained unchanged.

The widely-disseminated clinical method of motivational interviewing (MI) arose through a convergence of science and practice. Beyond a large base of clinical trials, advances have been made toward “looking under the hood” of MI to understand the underlying mechanisms by which it affects behavior change. Such specification of outcome-relevant aspects of practice is vital to theory development, and can inform both treatment delivery and clinical training. An emergent theory of MI is proposed, emphasizing two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk A resulting causal chain model links therapist training, therapist and client responses during treatment sessions, and post-treatment outcomes.