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Listening to our clients: a dangerous proposal.

Although therapeutic thinking and practice have entered their second century, most practitioners remain largely uncertain as to what data to trust, including "what works" and, "why it works." If anything, practitioners' reliance on ever-increasing numbers of theoretical models and either vague or contradictory research findings as primary guidelines to their practice has added to the confusion. What can the practitioner trust? This paper puts forward the "dangerous proposal" that it is of primary value for clinical professionals to place their trust on an often overlooked variable: the clients' statements about their therapy and their relationship to and with their therapist. It is argued that through the clarification of this variable will emerge a better understanding of the nonspecific variables of the therapeutic relationship itself and, as significantly, of the encompassing interrelational realms of discourse evident in all therapeutic models.

Humans↗

Improving the diagnosis related grouping model's ability to explain length of stay of elderly medical inpatients by incorporating function-linked variables.

INTRODUCTION: This study first aimed to determine the adequacy of the Diagnosis Related Grouping (DRG) model's ability to explain (1) the variance in the actual length of stay (LOS) of elderly medical inpatients and (2) the LOS difference in the same cohort between the departments of Geriatric Medicine (GRM) and General Medicine (GM). We then looked at how these explanatory abilities of the DRG changed when patients' function-linked variables (ignored by DRG) were incorporated into the model. MATERIALS AND METHODS: Basic demographic data of a consecutively hospitalised cohort of elderly medical inpatients from GRM and GM, as well as their actual LOS, discharge DRG codes [with their corresponding trimmed average length of stay (ALOS)] and selected function-linked variables (including premorbid functional status, change in functional profile during hospitalisation and number of therapists seen) were recorded. Beginning with ALOS, function-linked variables that were significantly associated with LOS were then added into two multiple liner regression models so as to quantify how the functional dimension improved the DRGs' abilities to explain LOS variances and interdepartmental LOS differences. Forward selection procedure was employed to determine the final models. For the interdepartmental analysis, the study sample was restricted to patients who shared common DRG codes. RESULTS: 114 GRM and 118 GM patients were studied. Trimmed ALOS alone explained 8% of the actual LOS variance. With the addition of function-linked variables, the adjusted R2 of the final model increased to 28%. Due to common code restrictions, the data of 79 GRM and 78 GM patients were available for the analysis of interdepartmental LOS differences. At the unadjusted stage, the median stay of GRM patients was 4.3 days longer than GM's and with adjustments made for the DRGs, this difference was reduced to 3.9 days. Additionally adjusting for the patients' functional features diminished the interdepartmental LOS discrepancy even further, to 2.1 days. CONCLUSION: This study demonstrates that for elderly medical inpatients, the incorporation of patients' functional status significantly improves the DRG model's ability to predict the patients' actual LOS as well as to explain interdepartmental LOS differences between GRM and GM.

Age Factors↗

Suitability for insight-oriented psychotherapy as a prognostic factor in treatment of phobic women.

Suitability for insight-oriented psychotherapy comprises many factors that may have a positive relation to outcome in individual psychotherapy. We wanted to test the hypothesis that patients suitable for insight-oriented psychotherapy (I patients) improve more than not-suitable patients (NI patients) in non-dynamic therapies. Pairs of phobic female NI and I patients were formed with age, type of phobia, global rating of severity, therapist and type of therapy as matching variables. All women received a simple basal therapy in the form of standardized information, self-exposure instructions and anxiolytic medication. Six pairs received this treatment only, six pairs in addition received relaxation therapy and nine pairs in addition received therapist-directed prolonged exposure in vivo. The patients were rated with regard to symptoms and functions at the start of the treatment, at the termination of treatment 3 months later, and at a 1 year follow up. NI patients were less often married, had a longer duration of their phobias, and had higher initial ratings on aspects of indirect as well as direct manifestations of anxiety, ego restriction, and global severity. I patients improved more than NI patients with regard to aspects of the target phobia, both at the termination of the treatment and at the follow up. Otherwise the outcome was similar. There was no indication of a greater amount of conflict solution in the I patients. The result might be explained by supposed differences in the amount of self-exposure. The hypothesis was supported, but the results cannot be applied to other types of neuroses.

Adult↗

Aptitude-treatment interaction as a framework for research on individual differences in psychotherapy.

Aptitude-treatment interaction (ATI) methods are designed to take individual differences into account systematically in treatment evaluation. This article reviews the general concepts of aptitude and ATI and summarizes lesions learned in ATI research on educational treatments that should help ATI research on psychotherapeutic treatments. Recommendations for research design and data analysis address problems of aptitude distributions, multivariate aptitude complexes, detective work with scatterplots, disattenuation, treatment and therapist characteristics, therapist-client matching, ecological validity, outcome variables, statistical power, aggregation, and person independence. Example studies and hypotheses about the nature of ATI processes are also included.

Aptitude↗

Social behavior of students who are seriously emotionally disturbed. A quantitative analysis of intervention studies.

The social behavior of students who are seriously emotionally disturbed sets them apart from their normative classroom peers. This article provides a quantitative analysis of intervention studies dealing with the social behavior of seriously emotionally disturbed students. Social behavior was broadly defined as including social skills deficits, behavior under inadequate stimulus control, and inappropriate behavior in the classroom. Of the 28 studies located, 11 dealt with some aspect of social skills and 17 with inappropriate classroom behavior. Each study was analyzed with respect to (a) the age, gender, and classification of the subjects; (b) the setting, referral source, and therapist; (c) the dependent and independent variables; (d) type of evaluation design used; (e) reliability of the dependent and independent variable; (f) social validation; (g) programmed generalization, maintenance, and follow-up; (h) measurement of collateral behaviors; (i) functional analysis of the target behavior; and (j) efficacy rating of the results on a 3-point scale. The results are presented and discussed in terms of current status and implications for future research.

Adolescent↗

Risk factors for homelessness among schizophrenic men: a case-control study.

OBJECTIVES: To identify risk factors for homelessness among the severely mentally ill, we conducted a case-control study of 100 indigent schizophrenic men meeting criteria for literal homelessness and 100 such men with no homeless history. METHODS: Subjects were recruited from shelter, clinic, and inpatient psychiatric programs in Upper Manhattan. Clinical interviewers employed standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. RESULTS: Homeless subjects showed significantly higher levels of positive symptoms, higher rates of a concurrent diagnosis of drug abuse, and higher rates of antisocial personality disorder. Homeless subjects experienced greater disorganization in family settings from birth to 18 years and less adequate current family support. Fewer homeless subjects than subjects in the never-homeless comparison group had a long-term therapist. These differences remained when demographic variables were adjusted statistically. CONCLUSIONS: Homeless schizophrenic men differed from their domiciled counterparts in all three domains we investigated; family background, nature of illness, and service use history. Findings are discussed in relation to policy and programs for the severely mentally ill.

Adolescent↗

The interaction of wearing multifocal lenses with head posture and pain.

Chronic placement of the head anterior to the body's center of gravity can be a component in the development of neurovascular and musculoskeletal dysfunction. In order to evaluate and treat dysfunction and pain, physical therapists need to be aware of variables that can affect head position. The objectives of this study were to investigate the interaction between wearing multifocal lenses and head posture; to determine the interaction of forward head posture and upper quarter pain; and to determine the intratester reliability of a head posture gauge. Head posture and self-reported pain were collected on 25 randomly chosen multifocal lens wearers between the ages of 40 and 50 and compared with a similar group of nonmultifocal lens wearers. The mean forward head posture in the two groups were significantly different (t = 2.06, one-tailed, p = 0.023). Subjects wearing multifocal lenses had a greater degree of forward head posture when compared with nonmultifocal lens wearers. A one-way analysis of variance was used to compare forward head posture with pain. In this sample, mean forward head posture levels did not differ significantly according to level of pain (p = 0.15). Intratester reliability of the head posture gauge was demonstrated to be high through the use of the intraclass correlation coefficient (ICC = 0.99). Wearing multifocal lenses may influence a person to hold his/her head in a position more forward than the ideal postural alignment.

Adult↗

Matching client and therapist ethnicity, language, and gender: a review of research.

The purpose of this article is to examine whether therapy process and outcome are influenced by a client-therapist ethnicity, language, or gender match. A review of research in this area does not demonstrate support for a client-therapist match on any of these variables. The methodological problems and unresolved conceptual issues involved in this research may limit the findings. The ethical and political context of the research and the implications for mental health nursing are explored.

Cultural Characteristics↗

A survey of aphasia services in the United Kingdom.

A survey of the service available, in speech and language therapy departments, to adults with aphasia revealed that many districts in the United Kingdom are unable to fulfil the professional recommendations for the care of aphasic clients. Although individual 'good practice' criteria could be satisfied, only a minority of districts were able to provide a comprehensive service. Levels of staffing for the adult neurological caseload are variable and even, at best, hinder therapists in delivering the recommended standard of management to aphasic clients and their carers.

Aphasia↗

A descriptive study of the clinical practice patterns of occupational therapists working with infants and young children.

This investigation was designed to gather descriptive data on the clinical practice patterns of occupational therapists working with infants and young children. One hundred nineteen therapists entered the study, and 118 completed the interview, yielding a response rate of 99.4%. The therapists were highly experienced, with a mean of 9.47 years working in pediatrics. The school setting was the most common type of facility in which therapists served infants and young children and accounted for 37.3% of the sample. The majority of the respondents (67.8%) were members of formally identified teams. Although 80.5% of the therapists served very young children (aged birth to 12 months), no therapists served this population exclusively. Considerable variability in models of service provision, team structures, and assessment and treatment practices were found. Additionally, there was a lack of consensus on the unique contributions of occupational therapy and diverse opinions regarding the importance of selected frames of reference. Implications of the findings on professional initiatives to enhance practice are discussed.

Child Health Services↗

Slot machines: their use in rehabilitation after stroke.

A comparative study of a novel and entertaining motor function exercise and traditional motor function exercise was conducted in the therapy of stroke patients. Therapists rated patients in five dependent variables, including range of motion, muscle strength, fine motor coordination, gross motor coordination, and degree of depression in control and experimental groups. Multivariate analysis of the results showed significantly greater progress in the five dependent variables among patients in the experimental group. Follow-up procedures using stepwise discriminant function analysis produced a rank ordering of the impact of each of the five dependent variables. Demographic variables of age, sex, education level, and marital status showed no effect. Correlations between the dependent variables were performed.

Adult↗

Interpretation and power of a pooled index.

OBJECTIVE: To describe, illustrate, provide statistical rationale and give clinical examples of the concept of a pooled index. METHODS: No explicit design. Randomized control trials of patients diagnosed with rheumatoid arthritis from Rheumatic disease clinics, tertiary care hospitals and communities are used as examples to illustrate the pooled index technique. Interventions in rheumatic disease unit inpatient and outpatient care, occupational therapy and physiotherapy provided by Arthritis Society Therapists in the community were compared. Variables included active joint count, morning stiffness in min, mean of right and left grip strength in mm Hg, erythrocyte sedimentation rate in mm/h, a functional change score, and a pooled index. RESULTS: The pooled index in each study detected a clinically important effect while individual measures were generally not able to declare the effect statistically significant. CONCLUSIONS: The pooled index is a more powerful clinical outcome than any individual measure provided it is computed from at least 2 relevant clinical outcome measures that have low correlation with each other.

Arthritis, Rheumatoid↗

[The prognostic significance of the therapeutic working alliance from the perspective of the patient and therapist].

In general, the prognostic relevance of a working alliance for both the course and the outcome of psychotherapy is no longer a matter of dispute. Since a working alliance is conceived as an interactional variable, the results must be interpreted on the basis of several important dimensions: the perspective of the investigator and the time structure during the course of therapy. Using the data available from the Berlin Psychotherapy Study (Rudolf 1991), we investigated for the 238 patients (inpatients and outpatients who received psychoanalytically oriented therapy in the study) the prognostic relevance of diagnostic and therapy-related working alliance variables for the various outcomes investigated. A complex correlation-statistical method (latent-trait-model) was used to consider the investigator perspective with regard to the working alliance and the outcome as well as the time structure and the diagnostic variables. Our results emphasize the relevance of the therapist's perspective beginning with the diagnostic indication, the working alliance and finally the outcome. The patient's perspective, however, seems to be less relevant. The results are presented and discussed in relation to the relevant literature. One result we have found as a further important dimension is that the kind of therapy carried out must be taken into consideration. This implies that as in our study for all phases of the investigation therapy specific instruments must be applied. In this regard our results also contribute to the validation of the instrument used to measure the working alliance TAB.

Adult↗

Therapists and quasi-therapists in a therapy analogue situation.

Evaluated an assumption from previous psychotherapy analogue studies, namely, that trained psychotherapists and untrained quasi-therapists with personality similarities will respond similarly to patient presentations. Ss were 24 male psychotherapists and 24 male undergraduate students, chosen partially on the basis of their responses to an A-B personality scale derived from the work of Whitehorn and Betz (1954). The three-factor experimental design included S personality type (A or B), S professional status (psychotherapist vs. student), and videotaped patient simulations (neurotic vs. schizoid), with all Ss exposed to both patient prototypes. Therapists demonstrated a higher degree of accurate empathy, were less active, made shorter responses, and used more declarative sentences (p less than .01 for each variable). Second-order interaction effects indicated that therapist personality type X patient type pairings produced opposite results for quasi-therapists when compared to professional therapists.

Empathy↗

[Research on psychotherapies. Methodology].

"Assessment" (of outcome and of factors of outcome) and "psychotherapy" are first defined. Although the aims of these surveys are deeply varying depending on their initiators (therapists or administrations), they share the same objects and the same methodological problems. This common problematic is specific, different from those prevailing for epidemiology or therapeutic trials; it also varies depending on the psychiatric and cultural background (for instance, depending on the side of the ocean). The choice of variables is discussed for objects (patients, families, therapists, institutions), sources (self and hetero-questionnaires) and exploratory levels (from symptoms to subjective quality of life). This leads to the choice of instruments, the interest of open ended questions and specific modalities of responses being emphasized. After a discussion of several methods of outcome assessment, the study of factors of change includes a comparison of the naturalistic and experimental approaches. Although these studies encounter some risks and limitations, they have an obvious clinical interest.

Evaluation Studies as Topic↗

Attitudes of consumers of physical therapy in California toward the professional image of physical therapists.

The purpose of this study was to identify attitudes of California physical therapy consumers toward the professional image of physical therapists. Attitudes toward the professional image of physicians were elicited for comparative purposes. Independent variables were selected to determine their influence on the perceived professional images. The results indicated that consumers viewed physical therapists as possessing four of the five criteria of professionalism; the exception was autonomy of judgment. No significant difference existed between the consumer views of the professional image of physical therapists and the professional image of physicians. A significant relationship existed between the variable of age and the criteria of perceived autonomy of judgment of physical therapists and physicians. Older consumers believed physical therapists and physicians possess less autonomy of judgment than younger consumers believed. The majority of physical therapy consumers perceived physical therapists and physicians as having equally high professional status.

Age Factors↗

A survey of suctioning practices among physical therapists, respiratory therapists and nurses.

OBJECTIVE: To assess the current tracheal and oropharyngeal suctioning practice variability within and among the professions of physical therapy, respiratory therapy and nursing. DESIGN: A mail survey of physical therapists, respiratory therapists and registered nurses who perform suctioning. The survey instrument consisted of questions about professional characteristics, clinical suctioning practice and sociodemographics. SETTING: The survey was restricted to professionals practising within the province of Ontario. PARTICIPANTS: Random samples (n=448) were drawn from membership of the regulatory boards of all three professions. MAIN RESULTS: Fifty-eight per cent of respondents returned completed questionnaires. There was large variation in reports of gloving procedure (eg, double clean: 26% for physical therapists, 5% for respiratory therapists, 55% for registered nurses, P<0.0001) and technique of catheter use (sterile, inline or clean, P<0.01). There was also discrepancy in the techniques used to minimize harmful effects, ie, prelubrication with gel (83% for physical therapists, 54% for respiratory therapists, 17% for registered nurses, P<0.0001), use of hyperinflation (12% of physical therapists, 25% of respiratory therapists, 39% of registered nurses never hyperinflate) and use of instillation (7% of physical therapists, 0% of respiratory therapists, 19% of registered nurses never instill). However, there was agreement about the routine application of hyperoxygenation (74% or more) and there was almost perfect agreement (99% or more) within and across the three professions that secretion removal was the main indication for suctioning. CONCLUSIONS: The results of this study indicate a wide variation in suctioning techniques among physical therapists, respiratory therapists and registered nurses. Comparisons among professions revealed inconsistencies in some areas, such as the use of in-line catheters, gloving procedures, prelubrication and hyperinflation.

Cross-Sectional Studies↗

[Dimensions of experience in encounter groups. Empirical studies on client-centered group activities].

The experiencing of participants of client-centered encounter groups served to demonstrate possibilities and limits of current models of the group process. This was done by analyzing the correlations between 5 dimensions of experiencing and aims of group participation, personality variables, modus of participation i.e. patient, student, therapist, time of participation, and group setting. The experiencing dimensions included 1. sympathy, trust, understanding, and help between members, 2. freedom from anxiety and stress, 3. openness, controversy and feedback, 4. momentary strong and basic feelings in one's self and others, 5. understanding, help and closeness of the group facilitator. The results show: Successful group participation was to the extent of maximal 50% determined by the experiences immanent in the client centered group process concept. Personality variables measured by tests determined the experiencing in the group to an extent of maximal 10%, supposedly less than the group experiencing was influenced by special characteristics of the group development for example the initial phase of group formation, member characteristics like age, attitudes concerning group work, and conventions of social behaviour. Even less relevant as determinants of group experiencing were differences of group setting and social pressure in the direction of uniform experiences at least within the first 20 hours of group participation.

Evaluation Studies as Topic↗