SPONTANEOUS RECOVERY (SR) AND DETERIORATION

Estimates of spontaneous recovery have changed over time:

Bergin’s 1st. edition of handbook, 1971--SR=30% (range = 15-45%)

Bergin & Lambert, 2nd ed. Of handbook, 1978--SR (untreated groups)=43% (range=18-67%);

SR (minimal treatment)=50% (range=8-73%).

Few believe that recovery is truly “spontaneous”, but rather likely comes from non-specific factors such as social support. When seeking help for a problem, people are more likely to seek other sources before a therapist. For example, the results from 1 survey of whom would you seek help for a problem: Clergy--42%, Physician--29%, Therapist--18%.

Subotnick, 1972, argued against the use of waiting lists to measure SR. Subnotnick assumed that untreated people either A) improved, or B) did not improve. Folks characterized by B will (in general) seek treatment elsewhere and be excluded from the study. Thus, wait list groups or therapy drop-out groups are a self-selected group of people who are improving. Thus SR rates are over-estimated by wait list groups. Subotnick also speculates that people who seek therapy may be a subset of the population who are unable to take advantage of non-specific sources of support in personal relationships.---Other data that are somewhat contradictory suggest that people in treatment are more likely to seek and accept advice and council outside of treatment compared with wait-list controls.

DETERIORATION (the development of psychotic or psychophysiological symptoms) is believed to occur. Deterioration is estimated to occur in 5% of folks who need treatment, but are not receiving it; and in 10% of folks receiving treatment they need. (Strupp, Hadley, & Gomez-Schwartz, 1977).

In a study of PREMATURE TERMINATION, Tracey (1987) identified each speaker’s turn as a

A) topic initiation, if

different content

different person or subject

different time reference

different level of specificity

other interruption

B) topic following, if anything else.

Topic Determination (TD) was the proportion of topic initiations followed by the other participant. TD was recorded in 6 dyads that prematurely terminated (<4 sessions), 6 that had successful outcomes, and 6 that had unsuccessful outcomes. Therapists were equated across groups.

When dyad TD < .35, T TD < .40, and P TD < .30; patients failed to return for future appointments. TD above a certain threshold may be necessary for CONTINUATION, TD not related to success vs. Failure. Also no-shows followed sessions with low TD, cancellations were not related to TD of the previous session.

In a review of DETERIORATION in 1995, Mohr reported

for psychoanalytic treatment, 14% deterioration for borderline personality disorder and 17% for borderline personality organization. Deterioration was attributed to low self esteem, impaired personal relations, narcissism, and masochism in clients.

In treatment of OCD with flooding and response prevention, Vaughan & Beech reported a deterioration rate of 28%, which was linked to histrionic, psychopathic, or oppositional personality structures. Foa & Stecketee reported the 3 of 21 OCD clients who developed new symptoms (phobias, paranoia) had anticipated no negative consequence in treatment and had target symptoms that extinguished most rapidly compared with patients that responded successfully to therapy overall.

In relaxation training, there is an incidence of 30-50% of clients experiencing increased anxiety, generally associated with a client fear of loss of control.

OTHER PROGNOSTICATORS OF POOR OUTCOME

Client suspiciousness and difficulty in establishing mature relationships

greater severity of symptoms

errors in therapist technique (incompetence)

low therapist empathy

expressive/experiential group therapy with inpatients

group therapy leaders who are dogmatic, authoritarian, aggressive, or charismatic.

Binder & Strupp 1997 on “NEGATIVE PROCESS”

Evidence indicates that alliance scores averaged over sessions were predictive of outcome in patients with good interpersonal relatedness. INCREASING alliance scores were predictive of good outcome in P with poor interpersonal relatedness. Therapists tend to be annoyed with patients exhibiting behaviors that are dependent, demanding, hostile, negativistic or rejecting. Therapists need to be especially careful about maintaining their composure, and to make as their highest priority adherence to an empathic, respectful stance toward their patients (i.e., to try to avoid NEGATIVE PROCESS).

Strupp 1993 reported that vulnerability to neg. Transference by negative, hostile, and resistant patients can create neg. Outcomes by producing therapist behaviors such as subtle criticism or blaming. Vanderbuilt II was a 5 year study to test whether a manualized training program in TIME LIMITED DYNAMIC psychotherapy (TLDP) would help therapists avoid these problems. A publication of the results by Henry et al., 1993 studied the effects of 1 yr of training on therapist’s behaviors. In addition to having therapists increase in technical skills as a result of the training, the training resulted in the therapists becoming more active and “DELIVERING A HIGHER DOSE OF DISAFFILIATIVE AND COMPLEX COMMUNICATIONS” After training therapists were also “LESS APPROVING AND SUPPORTIVE, LESS OPTIMISTIC, AND MORE AUTHORITATIVE AND DEFENSIVE”.

There were a number of hypotheses proposed to account for the “negative process.”

“Educational counter-transference”

“Uncertainty whether being overly supportive was right or wrong.”

“An authoritarian stance by trainees may have been a coping mechanism in response to the anxiety and defensiveness ;which may accompany training in a new system.”

Also, there was a significant neg. Relationship between hours of previous supervision and adherence to the TLDP model.

Binder and Strupp recommend METACOMMUNICATION for managing negative process. Metacommunication refers to any instance in which the therapist provides verbal feedback that targets the recurring relationship issues between them. Whether conceptualized as alliance ruptures, transference/counter-transference, or hostile complementary transactions; the therapist should seek to understand her/his role in these patterns and overtly acknowledge that role when it could facilitate interaction. This is more of a “HERE AND NOW” STRATEGY with the therapist as a participant, in contrast to more traditional transference interpretations where the patient is primarily responsible for the interchange. Such traditional interpretations may run the risk of leaving the patient feeling criticized, devalued, or dismissed.