Synopses of Psychotherapy Outcome Research
compiled by James W. Kreider, LSCSW
UTILIZATION PATTERNS AND EXPECTATIONS
"In 1949...with a VA outpatient clinic...Much to my surprise, I noted that some patients improved rather quickly without acquiring deep insights, and many terminated after a relatively small number of sessions, with or without the consent of their therapists."
Garfield, S. (1989). The Practice of Brief Psychotherapy. NY: Pergamon Press.
Reported most frequent length of outpatient stay was less than 10 sessions.
Alexander, F. & French, T. (1940). Psychoanalytic therapy. Principles and applications. NY: Ronald Press.
2/3 of post W.W.II patients (including war related PTSD) seen in a long-term psychoanalytic oriented VA outpatient clinic came less than 10 sessions.
Garfield & Kurtz. (1952). Evaluation of treatment and related procedures in 1216 cases referred to a mental hygiene clinic. Psychiatric Quarterly, 26, 414-424.
80% of outpatient clients come less than 6 times, and most frequently come 1 time.
NIMH (1981). Provisional CMHC Data. Washington, DC: US Government Printing Office.
At least 2/3 of clients in outpatient settings are seen 6 sessions or less. The majority of clients anticipate and desire 10 or fewer sessions.
Garfield. (1986). Research on client variables in psychotherapy in Handbook of psychotherapy and behavior change. NY: Wiley.
87% of clients studied expected to be seen 12 or fewer sessions, with 3 as the mode.
Gelso & Johnson. (1983) Explorations in time-limited therapy and psychotherapy. NY: Teachers College Press.
Client expectation of length of treatment is a key predictor of actual duration.
Pekarik & Wierzbicki. (1986). The relationship between clients' expected and actual treatment duration. Psychotherapy, 23, 532a-534.
50% of client terminations are unilaterally decided by clients without telling their therapist.
Wierzbicki & Pekarik. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190-195.
Meta-analysis of research found could not reliably predict dropout rate from demographics, type or severity or duration of problem. Mis-matching stage of readiness for change to intervention acurately predicted dropout 93% of the time.
Medeiros & Prochaska. (1994). Predicting premature termination from psychotherapy.
submitted manuscript, cited in Clinical Psychology: Science & Research, v2 n1, pp.101-105.
When clients knew therapy would be brief, dropout rates decreased significantly.
Sledge, Moras, Hartley & Levine. (1990). Effect of time-limited psychotherapy on patient dropout rates. American J. of Psychiatry, 147, 1341-1347.
Review of 260 cases at Kaiser-Permanente found it not possible to reliably predict length of stay or treatment outcome from diagnosis, history, or symptom severity or longevity.
Tolman, M. (1991). Single-Session Therapy workshop. Kansas City, KS.
[note: same findings in studies done by BFTC in Milwaukee (1988 workshop)]
Therapists are typically unfamiliar with their own client utilization patterns, overestimating length of stay by 3 times and underestimating dropout rate by 2 times. Pekarik & Finney-Owen. (1987). Psychotheripists' attitudes and beliefs relevant to client dropout. Community Mental Health Journal.
DURATION AND OUTCOME
"Recently many psychoanalysts (have become)... puzzled by the great discrepancy between the length of treatment, frequency of interviews and therapeutic results...I have seen more than one patient who, under the influence of a few interviews, become sufficiently free to undertake tasks in life and to enter experiences which he never could before: and the new experiences influenced his personality as much as a long analysis...."
Alexander, F. (1944). Proceedings of the Second Brief Psychotherapy Council, p. 3.
Review of eight studies. One revealed superior results for time-unlimited therapy, two superior results for time-limited therapy, and five found no difference in outcomes.
Luborsky, Singer, & Luborsky. (1975). Comparative Studies of Psychotherapy in Archives of General Psychiatry. 32, 995-1008.
Extensive meta-analysis of research observed only a weak relationship between treatment effect and the duration of therapy, with outcome at its peak at 8 sessions and again (but more weakly) at around 20 sessions. Little difference found between various approaches.
Smith, Glass, Miller. (1980). The Benefits of Psychotherapy. John Hopkins U. Press.
Meta-analysis of 143 outcome studies found no significant positive relationship between duration and effect, but found some negative effect with increased duration. Behavior therapies were more effective for phobias, cognitive therapies for anxiety & depression.
Shapiro & Shapiro. (1982). Meta-analysis of comparative therapy outcome studies: in Psychological Bulletin, 92, 581-604.
Meta-analysis of outcomes in cognitive, behavioral and dynamic therapies found cognitive and behavioral therapies "significantly superior" up to twelve sessions, then dynamic therapy showed superior outcomes. One year follow-up showed those who remained improved to be 33% with dynamic therapy and 67% with cognitive or behavior therapy.
Svartberg & Stiles. ((1991). Comparative effects of short-term psychodynamic psychotherapy in .J. of Consulting and Clinical Psychology., 59, 704-714.
Review of 40 years of studies found planned short term therapies are as effective as time-unlimited therapies regardless of diagnosis or duration.
Koss & Butcher. (1986). Research on brief psychotherapy in Bergen & Garfield (Eds.) Handbook of psychotherapy and behavior change: An Empirical Analysis. NY: Wiley.
Review of 36 studies found 89% of therapists associate outcome with duration but only
50% of clients did so.
Gelso & Johnson. (1983) Explorations in time-limited therapy and psychotherapy. NY: Teachers College Press.
At 4 year follow-up of over 1700 families treated with brief therapy the re-admission rate compared favorably (10%) with other forms of long-term treatment previously used.
Leventhal & Weinberger. (1975). Evaluation of a large scale brief therapy program for children. American J. of Orthopsychiatry, 45, 119-133.
25% of clients returned to therapy with 16 sessions and 23% with time-unlimited therapy.
Gelso & Johnson. (1983).
Numerous studies of individual, marital, and family therapy show positive results of 2/3 to 3/4 of those treated. Kiser found 85% of 164 Brief Family Therapy Center (using SFBT) clients reporting successful outcome of brief therapy at 18 month follow-up.
Wylie. (March/April, 1990). Brief therapy on the couch. Networker, pp. 26-35.
88% of single-session clients reported they met or exceeded goals, and they reported greater progress toward goals and satisfaction with therapy than those in time-unlimited therapy.
Tolman, M. (1991). Single-Session Therapy. SF: Jossey-Bass.
FACTORS TO CONSIDER
"In brief psychotherpy, the therapist does not have time for insight to develop: he must foster insight. He does not have time for working through: he must stimulate working through. when not forthcoming, he must invent alternatives."
Bellak & Small. (1965). Emergency Psychotherapy and Brief Psychotherapy. NY: Grune and Stratton.
A limited number of sessions spread over time showed greater change than the same number of sessions all at one time.
Lorr, McNair, Michaux & Raskin. (1962). Frequency of treatment and change in psychotherapy. J. of Abnormal and Social Psychology, 64, 281-292.
Found length of analysis could be shortened considerably and patient independence fostered when the therapist actively prescribed between-session tasks for patients.
Herzberg. (1946). Active Psychotherapy. NY: Grune & Stratton.
Favorable outcomes increased with between-session task assignment.
Burns & Nolen-Hoeksema. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: J. of Consulting and Clinical Psychology, 60, 441-449.
Skill at maintaining a therapeutic alliance is a strong predictor of outcome.
Luborsky, Crits-Christoph, Mintz, & Auerbach. (1988). Who will benefit from psychotherapy. NY: Basic Books.
Positive outcomes are more likely the more active the therapist is in maintaining a focus on the concerns that brought the client to therapy.
Harris, Kalis, & Freeman. (1963). Precipitating stress: and approach to brief therapy in American J. of Psychotherapy, 17, 465-471.
Greatest distinction between group that reported improvement and that which did not of unilateral terminations was whether or not client perceived that the therapist understood what he/she wanted to discuss.
Presley. (December, 1987). the clinical Dropout: a view from the client's perspective. Social Casework, pp. 603-608.
Positive outcome was more likely when therapist directed rather than followed topics. High levels of therapist topic-focusing correlated with treatment continuance, and therapist topic-following was predictive of dropout.
Tracy. (1986). Interactional correlates of premature termination. J. of Counseling Psychology, 31, 13-17.
Client satisfaction level is directly and significantly linked to attainment of goals.
Ankuta & Abeles. (1993). Client satisfaction, clinical significance and meaningful change in psychotherapy. Professional Psychology: Research and Practice, 24, 70-74.
[note: most clients reported liking their therapists whether or not they reported improvement. (Presley, 1987)]
Factors that were predictive of "unsuccessful" cases as rated by therapists were less frequent discussion of the end of therapy, less review of course of therapy, therapist less active in bringing closure to client-therapist relationship, and less discussion of client's feelings about termination.
Quintana, S. & Holahan, W. (1992). Termination in Short-Term Counseling: Comparison of Successful and Unsuccessful Cases. J. of Counseling Psychology, 39, pp. 299-305.
Some Solution-Oriented & Related Research
Study found that typically more than 95% of clients' descriptions of (criteria for) successful outcome of therapy were not clearly related to their presenting problem descriptions.
deShazer, S. (1982). Unpublished study. Brief Family Therapy Center, Milwaukee.
50 out of 56 clients given the vague assignment of "pay attention to what is worth continuing" (FFST) noticed things they wanted to continue to have happen in their lives. 46 of these 50 described at least one of the things noticed as "new" or "different."
deShazer, et al. (June 1986). Brief Therapy: Focused Solution Development in Family Process, 25, pp. 249-263.
Study found therapist-client interaction significantly influences client's focus on change. .067 probability client will initially talk about making changes; increases to .417 when therapist introduces questions about desired changes; increases to .741 when therapist elicits more details and clarifies information about desired changes.
deShazer, S. (1988). SFBT workshop, Milwaukee, Wi.
67% of clients studied reported positive changes between the time they called for an appointment and their initial appointment.
Weiner-Davis, et al. (1987). Building on Pretreatment Change to Construct the Therapeutic Solution: An Exploratory Study in Journal of Marital and Family Therapy, 13, pp. 358-363.
With time limit of 12 sessions, most clients waited until session 10 to "work." With 6 session limit, most waited until session 5 to "work." Found no difference in outcome, so added time-unlimited to project, resulting in shorter stays and slightly better outcomes than either 6 or 12 session limits. (Similar findings by Fisher, '80 & '84, Family Process, 19 & 23.)
deShazer, Unpublished Study, cited in Hoyt, Ed. (1995). Constructive Therapies 2.
70-85% of ACOA do not abuse alcohol and lead "healthy," well adjusted lives. Those most likely to do so focused more on what kind of lives they wanted to have than on their past lives with their troubled families, took deliberate and active steps to make their lives be what they wanted, repeated the positive family rituals they observed and rejected chaotic or troublesome rituals, distanced themselves physically and emotionally from their families of origin (saw less than 2x/year, lived more than 200 miles away).
Wolin, S.& S. (1994). The Resilient Self: How Survivors of Troubled Families Rise Above Adversity. NY: Villard Books.
Facilitating a "pivital moment" or turning point where client was ready do something about their concern was greatest predictor of treatment outcome, regardless of history, diagnosis, symptomatology, or therapists theoretical orientation.
Tolman, M. (1991). Single Session Therapy. San Francisco: Josey Bass
Addiction & Research Institute of Toronto found 1/2 of those seriously addicted to alcohol, heroin, crack cocaine, and other substances had successfully stopped using without professional help. deShazer estimates the number is closer to 2/3 based on his clinical experience at BFTC (Hoyt, 1995, Constructive Therapies 2, p. 37-38.)
Those who were able to describe their desired outcome felt more able to do something about what their problem, which doubled the likelihood of achieving a successful therapeutic outcome. (Beyebach, Marejon, Palenuela, & Rodrigues-Arias, 1996)
A meta-analysis of 40 years of psychotherapy outcome research found that 40% of positive outcome was due to extra-therapeutic factors, 30% due to relationship factors, and 15% due to hope/expectance and 15% due to model or technique. (Miller, Hubble, Duncan. Family Therapy Networker, Mar/Apr, 1995)