Showing papers in "Journal of Consulting and Clinical Psychology in 1991"

Clinical significance: a statistical approach to defining meaningful change in psychotherapy research.

Abstract: In 1984, Jacobson, Follette, and Revenstorf defined clinically significant change as the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population. In the present article, ways of operationalizing this definition are described, and examples are used to show how clients can be categorized on the basis of this definition. A reliable change index (RC) is also proposed to determine whether the magnitude of change for a given client is statistically reliable. The inclusion of the RC leads to a twofold criterion for clinically significant change.

The Process of Smoking Cessation: An Analysis of Precontemplation, Contemplation, and Preparation Stages of Change.

Abstract: Traditionally smoking cessation studies use smoker and nonsmoker categories almost exclusively to represent individuals quitting smoking. This study tested the transtheoretical model of change that posits a series of stages through which smokers move as they successfully change the smoking habit. Subjects in precontemplation (n = 166), contemplation (n = 794), and preparation (n = 506) stages of change were compared on smoking history, 10 processes of change, pretest self-efficacy, and decisional balance, as well as 1-month and 6-month cessation activity. Results strongly support the stages of change model. All groups were similar on smoking history but differed dramatically on current cessation activity. Stage differences predicted attempts to quit smoking and cessation success at 1- and 6-month follow-up. Implications for recruitment, intervention, and research are discussed.

Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling.

Abstract: Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.

Community Mental Health Services for Ethnic Minority Groups: A Test of the Cultural Responsiveness Hypothesis.

Abstract: This study investigated services received, length of treatment, and outcomes of thousands of Asian-American, African-American, Mexican-American, and White clients using outpatient services in the Los Angeles County mental health system. It tested the hypothesis that therapist-client matches in ethnicity and language are beneficial to clients. Results indicate that Asian Americans and Mexican Americans underutilized, whereas African Americans overutilized, services. African Americans also exhibited less positive treatment outcomes. Furthermore, ethnic match was related to length of treatment for all groups. It was associated with treatment outcomes for Mexican Americans. Among clients who did not speak English as a primary language, ethnic and language match was a predictor of length and outcome of treatment. Thus, the cultural responsiveness hypothesis was partially supported.

Characteristics of aggressors against women: testing a model using a national sample of college students.

Abstract: Structural equation modeling was used to study the characteristics of college men (N = 2,652) who aggressed against women either sexually, nonsexually, or both. According to the model, hostile childhood experiences affect involvement in delinquency, leading to aggression through two paths: (a) hostile attitudes and personality, which result in coerciveness both in sexual and nonsexual interactions, and (b) sexual promiscuity, which, especially in interaction with hostility, produces sexual aggression. In addition, sexual and nonsexual coercion were hypothesized to share a common underlying factor. Although its development was guided by integrating previous theory and research, the initial model was refined in half of the sample and later replicated in the second half. Overall, it fitted the data very well in both halves and in a separate replication with a sample for whom data were available about sexual but not about nonsexual aggression.

Self-efficacy in weight management.

Abstract: Self-efficacy is an important mediating mechanism in advancing understanding of the treatment of obesity. This study developed and validated the Weight Efficacy Life-Style Questionnaire (WEL), improving on previous studies by the use of clinical populations, cross-validation of the initial factor analysis, exploration of the best fitting theoretical model of self-efficacy, and examination of change in treatment. The resulting 20-item WEL consists of five situational factors: Negative Emotions, Availability, Social Pressure, Physical Discomfort, and Positive Activities. A hierarchical model was found to provide the best fit to the data. Results from two separate clinical treatment studies (total N = 382) show that the WEL is sensitive to changes in global scores as well as to a subset of the five situational factor scores. Treatment programs may be incomplete if they change only a subset of the situational dimensions of self-efficacy. Theoretical and clinical implications are discussed.

Effects of Interparental Violence on the Psychological Adjustment and Competencies of Young Children.

Abstract: Preschool children (N = 107) were divided into 4 groups on the basis of maternal report; home and shelter groups exposed to verbal and physical conflict, a home group exposed to verbal conflict only, and a home control group. Parental ratings of behavior problems and competencies and children's self-report data were collected. Results show that verbal conflict only was associated with a moderate level of conduct problems: verbal plus physical conflict was associated with clinical levels of conduct problems and moderate levels of emotional problems; and verbal plus physical conflict plus shelter residence was associated with clinical levels of conduct problems, higher level of emotional problems, and lower levels of social functioning and perceived maternal acceptance. Findings suggests a direct relationship between the nature of the conflict and residence and type and extent of adjustment problems.

Communication, conflict, and psychological distance in nondistressed, clinic, and divorcing couples.

Abstract: This study compared communication patterns and conflicts over psychological distance in 25 nondistressed couples, 15 clinic couples, and 22 divorcing couples. Data consisted of questionnaire reports completed independently by husbands and wives. The two distressed groups, compared with nondistressed couples, had less mutual constructive communication, more avoidance of communication, more demand/withdraw communication, and more conflict over psychological distance in their relationships. In addition, the divorcing group had less mutual constructive communication than the clinic group and evidenced a trend for more conflict over psychological distance than the clinic group. Consistent with past research, wife demand/husband withdraw communication was more likely across all groups than husband demand/wife withdraw communication. Results are discussed in terms of skills deficits and incompatability models of marital discord.

Academic underachievement and the disruptive behavior disorders.

Abstract: Academic underachievement (AU) was studied among 177 clinic-referred boys reliably diagnosed as having attention-deficit hyperactivity disorder (ADHD) or conduct disorder (CD). Unlike previous studies, the present study assessed AU using a formula that determined the discrepancy between a child's predicted level of achievement and actual level of achievement while controlling for regression and age effects. AU was associated with both ADHD and CD when the disorders were examined individually. However, when examined in multivariate logit model analyses, the apparent relation between CD and AU was found to be due to its comorbidity with ADHD. When boys with ADHD were divided into those with attention deficits only and those with co-occurring hyperactivity, findings did not support the hypothesis that the association with AU is stronger for attention deficits without co-occurring hyperactivity.

Implications of therapist effects for the design and analysis of comparative studies of psychotherapies.

Abstract: Technical reasons are presented as to why therapist should be included as a random design factor in the nested analysis of (co)variance (AN[C]OVA) design commonly used in psychotherapy research. Incorrect specification of the ANOVA design can, under some circumstances, result in incorrect estimation of the error term, overly liberal F ratios, and an unacceptably high risk of Type I errors. Review of studies indicates that the great majority of investigators continue to ignore this issue. Computer simulation studies revealed that considerable bias can be introduced by not specifying therapist as a random term. Finally, a reanalysis is presented of data from 10 psychotherapy outcome studies that indicated that therapist effects vary considerably and at times can be large. More recent studies that implement better quality controls appear to demonstrate less variance due to therapist. The implications of these results for the design of future studies are discussed. In most psychotherapy research studies, each participating psychotherapist sees more than one patient. Over 10 years ago, Martindale (1978) presented evidence that this apparently minor methodological detail was an important statistical consideration. On the basisof reanalysesofseveral examplesdrawn from the published literature, he concluded that the failure to include the therapist as a blocking or stratification factor in the statistical design could seriously distort testsof statistical significance. The implications of Martindale's paper were sobering. His methodological opinion was that, strictly speaking, almost all of the published findings in the psychotherapy research literature applied only to the specific samples of therapists used in each study. If researchers want to generalize their results to a larger population of therapists, he argued, then they must treat therapists as a random factor in the statistical analyses. His own review of the literature, however, indicated that this practice was very much the exception rather than the rule. Unhappily, adoption of his methodological counsel would result in serious reductions in statistical power in most studies. Furthermore, Martindale's statistical reanalyses suggested strongly

Children's memories of a physical examination involving genital touch: Implications for reports of child sexual abuse.

Abstract: Evaluation of child sexual abuse often necessitates interviewing children about genital touch, yet little scientific research exists on how best to obtain children's reports of genital contact. To examine this issue, 72 five- and seven-year-old girls experienced a standardized medical checkup. For half of the children, the checkup included a vaginal and anal examination (genital condition); for the other half, the checkup included a scoliosis examination instead (nongenital condition). The children's memories were later solicited through free recall, anatomically detailed doll demonstration, and direct and misleading questions. The majority of children in the genital condition revealed vaginal and anal contact only when asked directly about it. Children in the nongenital condition never falsely reported genital touch in free recall or doll demonstration; when asked directly, the false report rate was low. Significant age differences in free recall and doll demonstration, found only in the nongenital condition, implicated socioemotional factors as suppressing the reports of older children who experienced genital contact.

Toward a theory of sexual aggression: a quadripartite model.

Abstract: Sexually aggressive behavior against adult females is an increasingly serious societal problem. The need for a unified theoretical model is addressed by integrating the elements of existing models into a quadripartite model in which the heterogeneity of sexual aggressors is accounted for by the prominence of potential etiological factors. The components of the model--physiological sexual arousal, cognitions that justify sexual aggression, affective dyscontrol, and personality problems--function as motivational precursors that increase the probability of sexually aggressive behavior. The relative prominence of these precursors within different sexually aggressive populations is used to define major subtypes. Language: en

Control beliefs, coping efforts, and adjustment to chronic pain.

Abstract: This study examined factors hypothesized to influence adaptation to chronic pain in 118 patients who were interviewed to gauge adjustment (psychological functioning, medical services utilization, and activity level) and several widely discussed predictors of adjustment. Control appraisals and the practice of ignoring pain, using coping self-statements, and increasing activities were positively related to psychological functioning. Control appraisals and the practice of diverting attention, ignoring pain, and using coping self-statements also yielded a positive relation to activity level, but only for those patients reporting relatively low levels of pain severity. None of the predictors were related to medical services utilization. Future research is needed to replicate these findings and help clarify when appraisals and coping strategies are most productive among patients with chronic pain.

Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder.

Abstract: In a controlled clinical trial, 57 Ss meeting DSM-III-R criteria for generalized anxiety disorder, and fulfilling an additional severity criterion, were randomly allocated to cognitive behavior therapy (CBT), behavior therapy (BT), or a waiting-list control group. Individual treatment lasted 4-12 sessions; independent assessments were made before treatment, after treatment, and 6 months later, and additional follow-up data were collected after an interval of approximately 18 months. Results show a clear advantage for CBT over BT. A consistent pattern of change favoring CBT was evident in measures of anxiety, depression, and cognition. Ss were lost from the BT group, but there was no attrition from the CBT group. Treatment integrity was double-checked in England and in Holland, and special efforts were made to reduce error variance. Possible explanations for the superiority of CBT are discussed.

Cognitive therapy and pharmacotherapy for depression.

Abstract: Cognitive therapy (CT) for depression has generated considerable interest in recent years. Comparisons with tricyclic pharmacotherapy in nonbipolar outpatients have suggested that (a) CT may be roughly comparable in the treatment of the acute episode: (b) combined CT-pharmacotherapy does not appear to be clearly superior to either modality (although indications of potential enhancement do exist to justify additional studies with larger samples), and (c) treatment with CT during the acute episode (either alone or with medications) may reduce the risk of subsequent relapse following termination. Nonetheless, for a variety of reasons (e.g., limitations in study design and execution, inadequate design power, and possible differential retention), these conclusions can be considered only suggestive at this time. More than a decade after the publication of the first controlled study involving CT, the approach remains a promising, but not adequately tested, alternative to pharmacotherapy in the treatment of depression.

Analysis of change: modeling individual growth.

Abstract: Research on change is complicated by problems of measurement and analysis stemming from a conceptualization of change as a series of accumulating increments and decrements. In contrast, individual growth curves depict change as a continuous process underlying individual performance. These two perspectives are reviewed, and some problems with the use of difference scores in the study of change are clarified. Traditional methods are contrasted with growth curve analysis for the purposes of measuring change and studying its correlates. An illustrative example of the use of growth curves is provided from research on recovery of cognitive function following pediatric closed head injury.

Cognitive-behavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity

Abstract: Forty-seven asymptomatic, healthy gay men were randomly assigned to a cognitive-behavioral stress management (CBSM) condition or an assessment-only control group 5 weeks before being notified of their HIV-1 antibody status. Seventy-two hours before and 1 week after serostatus notification, blood samples and psychometric data were collected. Control subjects showed significant increases in depression, but only slight decrements in mitogen responsivity and lymphocyte cell counts pre- to postnotification of seropositivity. Seropositive CBSM Ss did not show significant pre-post changes in depression, but did reveal significant increases in helper-inducer (CD4) and natural killer (CD56) cell counts as well as a slight increment in proliferative responses to phytohemagglutinin (PHA). Individual difference analyses suggest that the psychological buffering and immunomodulating effects of the CBSM manipulation may be attributable, in part, to relaxation skills learned and practiced or to a general willingness to comply with the intervention guidelines.

Marijuana and cocaine effect expectancies and drug use patterns.

Abstract: Self-reports from 704 college students were content analyzed and used to develop the Marijuana Effect Expectancy Questionnaire and Cocaine Effect Expectancy Questionnaire. Responses were examined using exploratory and confirmatory principle components analysis. Six marijuana expectancies (34.6% of variance) were identified: (a) cognitive and behavioral impairment, (b) relaxation and tension reduction, (c) social and sexual facilitation, (d) perceptual and cognitive enhancement, (e) global negative effects, and (f) craving and physical effects. Five cocaine expectancies (32.5% of variance) consisted of (a) global positive effects, (b) global negative effects, (c) generalized arousal, (d) anxiety, and (e) relaxation and tension reduction. Drug effect expectancies distinguished between patterns of nonuse and varying degrees of use of these two drugs.

Self-help quit smoking interventions: effects of self-help materials, social support instructions, and telephone counseling.

Abstract: Smokers requesting self-help materials for smoking cessation (N = 2,021) were randomized to receive (a) an experimental self-quitting guide emphasizing nicotine fading and other nonaversive behavioral strategies, (b) the same self-quitting guide with a support guide for the quitter's family and friends, (c) self-quitting and support guides along with four brief counselor calls, or (d) a control guide providing motivational and quit tips and referral to locally available guides and programs. Subjects were predominantly moderate to heavy smokers with a history of multiple previous quit attempts and treatments. Control subjects achieved quit rates similar to those of smokers using the experimental quitting guide, with fewer behavioral prequitting strategies and more outside treatments. Social support guides had no effect on perceived support for quitting or on 8- and 16-month quit rates. Telephone counseling increased adherence to the quitting protocol and quit rates.

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

Abstract: 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 lessons 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, therapistclient matching, ecological validity, outcome variables, statistical power, aggregation, and person independence. Example studies and hypotheses about the nature of ATI processes are also included. In many fields of psychological, social, educational, and medical science, treatments are designed as interventions to achieve some individual or common good for human beings. When alternative treatments aimed at the same goal are available, the question is, Which treatment is best? Even when one treatment is adopted, a continuing question is, How can this treatment be made better? Because the persons treated usually are observed to differ in their response to treatment, and also to differ from one another in many other correlated ways, an important addition to these questions is,... best or better for whom, when, and why? The aptitude-treatment interaction (or ATI) paradigm was invented to address these questions in consort. ATI methodology is designed to take individual differences among treated persons into account systematically in treatment evaluation— to assess the degree to which alternative treatments have different effects as a function of person characteristics and thus determine whether particular treatments can be chosen or adapted to fit particular persons optimally. Beyond methods for assessing interactions among person and situation variables, however, the approach offers a framework for new theories of aptitude interpreted as personal readiness to profit from particular treatment situations. This article summarizes lessons learned in ATI research on educational treatments that should help advance ATI research on psychotherape utic treatments. Dance and Neufeld (1988) have discussed the basic principles of ATI method with examples from psychotherapy research, so these need not be reiterated here. But the extensive experience with ATI in educational research suggests some clarifications and extensions of their discussion as well as some further recommendations.

Identifying critical dimensions for discriminating among rapists.

Abstract: Considerable evidence has amassed in studies of both nonoffender and offender samples that demonstrates both that sexual aggression is determined by a multiplicity of variables and that convicted sexual offenders are markedly heterogeneous (Knight, Rosenberg, & Schneider, 1985; Malamuth, 1986). Attempts both to identify sexually coercive men in normal samples and to assess etiology, concurrent adaptation, treatment efficacy, and recidivism for convicted sexually aggressive offenders have also suggested that the critical determining components of sexual aggression interact in complex ways. The purpose of this article is to survey both the offender and nonoffender sexual aggression research for evidence about which dimensions should be included in multivariate models that attempt to discriminate rapists from nonrapists, to identify subgroups among rapists, or to enhance the efficiency of dispositional decisions about these offenders.

Marital therapy as a treatment for depression.

Abstract: The purpose of this study was to compare cognitive-behavioral therapy (CT; n = 20), behavioral marital therapy (BMT; n = 19), and a treatment combining BMT and CT (CO; n = 21) in the alleviation of wives' depression and the enhancement of marital satisfaction. BMT was less effective than CT for depression in maritally nondistressed couples, whereas for maritally distressed couples the two treatments were equally effective. BMT was the only treatment to have a significant positive impact on relationship satisfaction in distressed couples, whereas CO was the only treatment to enhance the marital satisfaction of nondistressed couples. On marital interaction measures CO was the only treatment to significantly reduce both husband and wife aversive behavior and to significantly increase wife facilitative behavior.

Mediators and moderators in meta-analysis: there's a reason we don't let dodo birds tell us which psychotherapies should have prizes.

Abstract: In primary studies, psychotherapy researchers frequently search for mediator and moderator variables that can help them understand the relationship between treatment and outcome. Yet a review of past psychotherapy meta-analyses revealed that none examined the possible role of mediator variables; and although all of them searched for moderators of study outcome, that search was generally not as complete as it could have been. This article illustrates methods for studying such mediator and moderator variables in meta-analysis, discusses their advantages and disadvantages, and shows how the inclusion of these variables can change interpretation of meta-analytic results. In particular, the perennial interpretation of past psychotherapy meta-analyses that therapeutic orientation makes no difference to outcome--or as the dodo bird put it: "Everyone has won and all must have prizes"--may be wrong. Orientation may make significant difference, but only by virtue of its moderating and mediating effects.

Sexual recidivism among child molesters released from a maximum security psychiatric institution.

Abstract: The recidivism of 136 extrafamilial child molesters who had received phallometric assessment in a maximum security psychiatric institution from 1972 to 1983 was determined over an average 6.3-year follow-up. Fifty had participated in behavioral treatment to alter inappropriate sexual age preferences. Thirty-one percent of the subjects were convicted of a new sex offense, 43% committed a violent or sexual offense, and 58% were arrested for some offense or returned to the institution. Subjects convicted of a new sex offense had previously committed more sex offenses, had been admitted to correctional institutions more frequently, were more likely to have been diagnosed as personality disordered, were more likely to have never married, and had shown more inappropriate sexual preferences in initial phallometric assessment than those who had not. Behavioral treatment did not affect recidivism.

Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures.

Abstract: Group cognitive therapy (CT), focused expressive psychotherapy (FEP; a form of group experiential psychotherapy), and supportive, self-directed therapy (S/SD) were compared among 63 patients with major depressive disorder (MDD). Variation among patients' coping styles (externalization) and defensiveness (resistance potential) was used in a prospective test of hypothesized differential treatment-patient interactions. Results suggest that patient characteristics can be used differentially to assign psychotherapy types. Externalizing depressed patients improved more than nonexternalizing depressed patients in CT, whereas nonexternalizing (internalizing) patients improved most in S/SD. Conversely, high defensive (resistant) patients improved more in S/SD than in either FEP or CT, whereas low defensive patients improved more in CT than in S/SD.

Have all won and must all have prizes? Revisiting Luborsky et al.'s verdict.

Abstract: Although most reviews of comparative psychotherapy literature have failed to find significant differences among treatments, it is premature to give up the search for differential effects. There are a large number of patient, therapist, and treatment variables that may mediate the effects of treatments. Given the enormity of the task of exploring potential interactions among the many patient, therapist, and psychotherapy types, a guiding model is needed by which to narrow our search for variables that mediate between treatment type and outcome. However, theoretical constructs that represent both patient and therapy variations frequently are poorly defined. Tests of treatment selection models that cut across narrow theoretical differences among psychotherapies and that operationalize definitions of patient types hold promise for revealing meaningful Patient x Therapist interaction effects in psychotherapy.

Long-Term Effectiveness of Behavioral Versus Insight-Oriented Marital Therapy A 4-Year Follow-Up Study

Abstract: Four-year follow-up data regarding marital status and marital accord were obtained for 59 couples receiving either behavioral (BMT) or insight-oriented (IOMT) marital therapy in a controlled outcome study. Although no significant group differences had been observed between the 2 treatment conditions at either termination or 6-month follow-up, by 4-year follow-up a significantly higher percentage of BMT couples had experienced divorce (38% for BMT couples compared with 3% for IOMT couples). Results are compared with previous outcome research in this area, and recommendations are made for further research.

Replications of a Dual Failure Model for Boys' Depressed Mood.

Abstract: A structural equation model for depressed mood was examined for three samples of boys (N = 317) from at-risk families. It was assumed that rejection by normal peers and academic failure were significant covariates for preadolescent boys' depressed mood. The model accounted for from 51% to 68% of the variance in the criterion construct. The confirmatory factor analyses showed an adequate fit of the measurement model to the data sets for each of the three samples. The hypothesized negative path coefficients from the good peer relations construct to the child depressed mood construct were significant for all three samples. The path from the academic skills construct to the child depressed mood construct, however, was highly variable and significant for only two of the samples. Multigroup comparisons were carried out to determine the degree to which the factor loadings and the structural relations between constructs were invariant across the three samples.

Promoting competent young people in competence-enhancing environments : a systems-based perspective on primary prevention

Abstract: Recent studies indicate that 15-22% of American children and adolescents suffer from diagnosable mental disorders. Researchers estimate that 25-50% engage in risk behaviors for negative health and behavior outcomes, such as drug abuse, unwanted pregnancy, AIDS, delinquency, and school dropout. The prevalence of problem behaviors, as well as current social trends, demands that effective primary prevention programs be developed and disseminated. This article reviews successful family-, school-, and community-based prevention efforts aimed at reducing the incidence and severity of children's psychosocial problems. High-quality, comprehensive, competence-promotion programs that focus on both children and their socializing environments represent the state of the art in prevention. Establishing enduring, effective preventive interventions requires increased attention to program design, implementation, and institutionalization.

Coping styles, homework compliance, and the effectiveness of cognitive-behavioral therapy.

Abstract: Factor analysis of the Self-Help Inventory (Burns, Shaw, & Crocker, 1987) in a group of 307 consecutive outpatients seeking cognitive-behavioral therapy (CBT) for affective disorders revealed 3 factors that assessed the frequency with which subjects used active coping strategies when depressed, the perceived helpfulness of these coping strategies, and their willingness to learn new coping strategies. The Frequency and Helpfulness scales did not predict patients' subsequent compliance with self-help assignments or their rate of improvement during the first 12 weeks of treatment. These findings suggest that very resourceful patients are not better candidates for CBT than other patients and that patients' expectations about the value of active coping strategies do not predict the response to CBT. In contrast, the Willingness scale was correlated with the degree of improvement during the first 12 weeks of treatment. The Willingness scale and compliance with self-help assignments made additive and separate contributions to clinical improvement. Further research on motivational factors may be indicated.