Generic change indicators in therapeutic processes with different outcomes

Abstract

Objectives: This paper analyzes the relationship between ongoing change and final outcome in therapies carried out in natural settings with 39 clients. Method: Ongoing change was assessed through generic change indicators (GCIs), an observational method designed to label the content of change moments by selecting one specific GCI from the sequence of 19 that covers from more rudimentary and low complexity to more elaborated and complex changes. These GCIs can also be grouped into three broad stages of change, according to their level of complexity. Productivity indicators were generated to account for the number of GCIs (total and grouped by stage) adjusted by the length of therapy and the respective individual production of GCIs. Outcome, in turn, is understood as the final result of therapy and was measured by Lambert's Outcome Questionnaire (OQ 45.2). Results: Using the Reliable Change Index of this measure, which qualifies the difference between initial and final scores, therapies were grouped into “good outcome” and “poor outcome” cases. Findings indicate that therapies with good final outcome show a greater presence of Stage III GCIs during the process. Furthermore, in these therapies there is a significant association between Stage I GCI productivity and the productivity of Stages II and III GCIs. This is not the case for poor outcome cases, where results show a greater productivity of initial stage GCIs, mostly in the second half of therapy and no relation of this productivity with Stage II and Stage III GCIs. Conclusions: Results support the relation of ongoing change and final outcome. Possibilities for the clinical use of GCIs, specifically for monitoring ongoing therapies, are discussed.

Abstract

Objectives: This paper analyzes the relationship between ongoing change and final outcome in therapies carried out in natural settings with 39 clients. Method: Ongoing change was assessed through generic change indicators (GCIs), an observational method designed to label the content of change moments by selecting one specific GCI from the sequence of 19 that covers from more rudimentary and low complexity to more elaborated and complex changes. These GCIs can also be grouped into three broad stages of change, according to their level of complexity. Productivity indicators were generated to account for the number of GCIs (total and grouped by stage) adjusted by the length of therapy and the respective individual production of GCIs. Outcome, in turn, is understood as the final result of therapy and was measured by Lambert’s Outcome Questionnaire (OQ 45.2). Results: Using the Reliable Change Index of this measure, which qualifies the difference between initial and final scores, therapies were grouped into “good outcome” and “poor outcome” cases. Findings indicate that therapies with good final outcome show a greater presence of Stage III GCIs during the process. Furthermore, in these therapies there is a significant association between Stage I GCI productivity and the productivity of Stages II and III GCIs. This is not the case for poor outcome cases, where results show a greater productivity of initial stage GCIs, mostly in the second half of therapy and no relation of this productivity with Stage II and Stage III GCIs. Conclusions: Results support the relation of ongoing change and final outcome. Possibilities for the clinical use of GCIs, specifically for monitoring ongoing therapies, are discussed.

Zusammenfassung:

Ziele: Diese Studie analysiert den Zusammenhang zwischen kontinuierlicher Veränderung und dem Therapieergebnis in Therapien, durchgeführt mit 39 Klienten im naturalistischen Setting. Methode: Kontinuierliche Veränderung wurde über generische Veränderungsindikatoren erfasst (GCIs), eine Beobachtungsmethode, um den Inhalt von Veränderungsmomenten zu benennen, in dem man einen spezifischen GCI au seiner Sequenz von 19 heraussucht, welcher rudimentäre und wenig komplexe bis mehr elaborierte und komplexe Veränderungen abdeckt. Diese GCIs können je nach Komplexitätslevel in drei breite Stufen von Veränderung gruppiert werden. Produktivitätsindikatoren wurden aus der Anzahl der GCIs (total und gruppiert nach Stufen) generiert, adjustiert nach Länge der Therapie und der respektiven individuellen Anzahl von GCIs. Outcome wird im Gegensatz hierzu als das finale Ergebnis der Therapie verstanden und wurde gemessen über Lambert’s Outcome Questionaire (OQ 45.2). Ergebnisse: Therapien wurden unter Verwendung des Reliable Change Index (RCI), welcher die Differenz zwischen initialen und finalen Scores qualifiziert, in Fälle von „gutem Outcome“ und „schlechtem Outcome“ gruppiert. Die Befunde indizieren, dass Therapien mit gutem Outcome eine höhere Präsenz von Stufe III GCIs im Prozess zeigen. Weiterhin besteht in diesen Therapien eine signifikante Assoziation zwischen der Stufe I-Produktivität und der Produktivität auf Stufe II und III GCIs. Das ist nicht der Fall für Therapien mit einem schlechten Outcome, bei denen die Ergebnisse eine größere Produktivität von initialen GCI Stufen zeigen, die meiste in der zweiten Hälfte der Therapie. Außerdem gibt es keinen Zusammenhang zu der Produktivität der GCI Stufen II und III. Zusammenfassung: Die Ergebnisse unterstützen das Verhältnis zwischen kontinuierlichen Veränderungen und dem finalen Therapieergebnis. Es werden die Möglichkeiten der klinischen Nutzung der GCI diskutiert, besonders für noch laufende Therapien.

Objetivos: Este artigo analisa a relação entre as mudanças em curso e o resultado final de terapias realizadas em ambientes naturais, com 39 clientes. Método: A mudança em curso foi avaliada por meio de indicadores genéricos de mudança (IsGM), um método de observação desenvolvido para rotular o conteúdo de momentos de mudança através da seleção de um IGM específico, a partir da sequência de 19 indicadores que cobrem/incluem desde mudanças mais rudimentares e de baixa complexidade até mudanças mais elaboradas e complexas. Estes IsGM podem também ser agrupados em três grandes fases de mudança, de acordo com o seu nível de complexidade. Foram gerados indicadores de produtividade para contabilizar o número de IsGM (total e agrupados por fase) ajustados à duração da terapia e à respetiva produção individual de IsGM. O resultado, por sua vez, foi concetualizado como o produto final da terapia, e medido pelo Lambert’s Outcome Questionnaire (OQ 45.2). Resultados: Usando o Reliable Change Index desta medida, que qualifica a diferença entre a pontuação inicial e final, as terapias foram agrupadas em casos de “sucesso” e casos de “insucesso”. O estudo indicou que as terapias com sucesso mostram uma maior presença de IsGM de Fase III durante o processo. Além disso, nestas terapias, houve uma correlação significativa entre a produtividade de IsGM de Fase I e a produtividade de IsGM das Fases II e III. Tal não se verificou nos casos de insucesso, dado que os resultados mostraram uma maior produtividade de IsGM de fase inicial, principalmente na segunda metade da terapia, e nenhuma relação entre esta produtividade e IsGM das Fase II e III. Conclusões: Os resultados sustentaram a relação entre as mudanças em curso e o resultado final. Foram também discutidas possibilidades para o uso clínico de IsGM, especificamente na monitorização de terapias em curso.

目的：本研究分析三十九名案主在治療關係中的改變及最終治療成效。方法：研究以通用改變指標(GCI)來測量治療歷程中的改變，並使用觀察法從19種指標中擇一來標訂改變時刻的內容，指標範圍涵蓋從初步且低複雜度的改變到詳細且較為複雜的改變。這些指標根據其複雜程度，亦可被歸納為三個改變階段。生產力指標是用來呈現GCIs的數量(不同階段的總和)，其計算是根據治療長度以及個別的GCIs修正而來。治療成效，也就是最終治療結果，則是用Lambert的效果調查表(OQ45.2)來測量。研究結果：使用這個測量的可靠改變指標(RCI)來計算在初始及最後分數間的差異，所有治療案例被分成「好成果」與「壞成果」兩類。研究發現顯示有好的最終治療成效的案例在治療第三階段有較多的通用改變指標。更甚者，這些案例中，在第一階段的通用改變指標與生產力，和第二階段的生產力與第三階段的通用改變指標有顯著關聯。但在壞成果的案例中則無此狀況，雖然結果顯示在初期、大部分在治療後半部有較高產能的通用改變指標，但這類產能與第二階段、第三階段的通用改變指標毫無關係。結論：結果支持過程中持續出現的改變與最終治療成效有關係。本文並針對臨床上使用通用改變指標的可能性，特別是針對檢視正在進行之療程進行討論。

Keywords:

• process research
• brief psychotherapy
• generic change indicators
• outcome

Acknowledgments

We gratefully acknowledge the funding of: (1) The Chilean National Fund for Science and Technology, projects No 1030482, 1060768, 1080136. (2) The Millennium Scientific Initiative of the Ministry of Economy, Development and Tourism, project NS100018.

Notes

¹ Most therapies in this study were carried out in supervision or training settings that included observation through one-way mirrors by the raters as well as by staff and/or students of the mental health services. Clients and therapist were aware of this observational and research situation, given the specific conditions of treatment delivery of these establishments.

² In the case of those therapies whose total number of sessions was an odd number, the odd session was assigned to the first half of the therapy.

³ This analysis considers those therapies that had at least six sessions.

⁴ The two Gestalt individual therapies took place on a setting that had no one-way mirror; therefore, raters could only observe them through videotape records.