We have seen that in addition to technique factors such as the type of therapy practiced by the clinician, researchers must consider client and therapist factors and the tone or quality of the therapeutic relationship. Table 17-6 summarizes the research and clinical questions raised by these factors. The design of therapy research will improve as these questions stimulate methodological advances.
A number of clues are already available to permit the strengthening of research designs. These pertain to sample size, patient specificity, treatment specificity, and outcome measures.
Questions Raised by Client, Therapist, and Relationship Factors- 1. Client factors 2. Therapist factors 3. The therapeutic relationship
What role do the personal characteristics of clients play in the outcome of therapy? Among the factors that often play important roles are the attitudes of clients toward therapy, their educational and socioeconomic levels, their levels of psychological distress, the social supports available to them in their environment, and the nature of the problem for which they are seeking help. What contributions do the characteristics of the therapist make to the process of therapy and its outcome? Among the important therapist variables are training, experience, clinical orientation, and personal qualities. The therapist's sex, age, ethnicity, and cultural background may also play important roll.
Does the therapist-client relationship make a difference? Available evidence suggests that the psychological chemistry that takes place when a therapist with a particular personality meets a client with a particular personality is an important factor in several types of therapy. Although the rapist client relationships have been explored more deeply in psychotherapy, there is evidence that they are also very important in other forms of therapy.
1. Sample size. Because of the need to incorporate a large number of factors in the design of therapy research, large enough sample sizes are needed to allow for appropriate statistical analyses and justifiable inferences from results. 2. Patient specificity. Firm conclusions are more likely if subjects are relatively homogeneous in terms of factors that are not the target of the treatment intervention. So many factors may influence outcome that it is important to control as many extraneous variables as possible. 3. Treatment specificity. The more clearly defined the treatment or treatments, the more likely it is that reasonable inferences can be drawn from the research. This requires careful specification of the therapeutic techniques used in the research. 4. Outcome measures. The more relevant the outcome measures are to the type of case being treated, the more useful the study will be. For example, since obsessive- compulsives rarely hallucinate, there would be little value in using the frequency of hallucinations as an outcome variable. A more useful variable would be the frequency of obsessive thoughts and compulsive behaviors.
Control and Comparison Groups Control and comparison groups are needed in therapy studies because many influences beyond those that are of special interest to the researcher may be at work during the period covered by therapeutic intervention. Without adequate control or comparison groups, researchers cannot rule out the possibility of alternative explanations such as spontaneous remission.
No single control group is appropriate for testing all hypotheses. The control group or groups for a particular study must be chosen on the basis of the particular question under investigation. Table 17-7 describes some types of control groups that have been used in therapy outcome research. The type of control group or groups used in a given study depends on the number of subjects available and on the nature of the setting in which the research is carried out.
Biological Therapies In another paper we discussed the biological orientation to maladaptive behavior and the therapies that have been generated by this point of view. The most widely used biological therapies today are electro-convulsive therapy (ECT) and a growing variety of drugs that influence psychological functioning.
Electro-Convulsive Therapy Although ECT is still an important biological therapy, its use has declined in the past 20 years. ECT is particularly effective in treating cases of severe depression in which rapid recovery is essential (for example, where a suicide attempt seems likely). It is also effective in treating acute mania and, to a lesser extent, catatonic states and some forms of schizophrenia. Available evidence suggests that ECT is a relatively safe procedure, particularly when used with anesthetics and muscle relaxants that substantially lessen the traumatic effects of the treatment. Risks are further reduced by applying the electric current to only one side of the head. However, there is concern about the cognitive consequences of passing an electric current through a person's head. The major risk is memory loss, although this can be reduced by using ECT on the non-dominant side of the brain and in the lowest possible dose.
Even though it has been used for many years, the mechanism by which ECT works is not yet clear.
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