Client engagement in psychotherapeutic treatment and associations with client characteristics,therapist characteristics,and treatment factors

Client engagement has been associated with positive psychotherapeutic outcomes, yet it is relatively under-theorized. The aims of this review were to establish how client engagement with psychotherapeutic interventions targeting psychological or behavioral change has been operationally defined and assessed, and the associated client characteristics, therapist characteristic, and treatment factors. Seventy-nine studies were selected for review, revealing inconsistent definitions and assessments of engagement and a broad array of client characteristics and treatment factors investigated. Attendance was frequently used as a proxy for engagement, but may not be reliable. Participation or involvement in conjunction with homework compliance which reflects clients' efforts within and between sessions may more reliably reflect engagement. The findings of associations between client characteristics and engagement variables were equivocal, although clients' capacities to address their problems tended to be positively associated with engagement. Nearly all therapist characteristics, particularly therapists' interpersonal skills, and most treatment factors, particularly strengths-based approaches and the therapeutic relationship, were positively associated with engagement. A theory of engagement that characterizes the function and inter-relations of variables across different psychotherapeutic settings is needed.     

On the relationship of client satisfaction to client characteristics and outcome of treatment

Administered to former psychiatric patients a client satisfaction scale and two general questions about satisfaction with hospitalization. Regression analyses that used the client satisfaction measures as dependent variables indicated that the client satisfaction scale was related more to other treatment outcome measures, especially length of stay and goal attainment. The two general questions on satisfaction had correlated highly with each other, but little relation to other outcome measures. The need for a clearer definition of client satisfaction is discussed.     

Client commitment language during motivational interviewing predicts drug use outcomes

Client language from a motivational interview (MI) and drug use outcome were investigated. Interview videotapes of 84 drug abusers were coded for frequency and strength of utterances expressing commitment, desire, ability, need, readiness, and reasons to change or maintain their habit. Cluster analysis of proportion days abstinent (PDA) revealed 3 groups: high PDA at intake and follow-up (3, 6, 9, 12 months; maintainers); low intake PDA/high follow-up PDA (changers); and low intake PDA/low to moderate follow-up PDA (stragglers). Distinct group patterns emerged for commitment strength (CS) during MI. Clients dishonest in checklist self-report exhibited CS similar to stragglers. CS for client evaluation of a change plan predicted outcome PDA. CS was predicted by strength of desire, ability, need, and reasons, but more strongly predicted outcome PDA, suggesting CS is a pathway for their influence on behavior.     

Therapeutic connection and client progress in drug abuse treatment

This article explores the effects of the therapeutic connection between the drug abuse treatment client and the treatment counselor on the client's progress in psychological functioning during the course of treatment. Two hypotheses of the relationships between therapeutic connection and psychological functioning are formulated. The first predicts that higher levels of connection will be associated with greater improvement in the client's level of psychological functioning. The second predicts that higher levels of functioning at intake will, in turn, be associated with greater connection to counselor. Results from a longitudinal study of 139 participants in a federally sponsored pilot drug abuse treatment program in Houston, Texas show statistically significant associations between both a client's initial level of psychological functioning and therapeutic connection to counselor and between this connection and subsequent improvement in functioning. © 1997 John Wiley & Sons, Inc.     

Goals, benefits, and outcomes of genetic counseling: client and genetic counselor assessment

Most studies of outcomes of genetic counseling have focused on client knowledge, reproductive plans and behavior, or satisfaction. Other measures of the "value" of genetic counseling are needed to guide research assessing the impact of genetic counseling on individuals and populations, as well as to improve the process of providing care. To obtain input from providers, we conducted telephone interviews with six experienced genetic counselors, and then we held a focus group with 10 additional genetic counselors from a variety of practice settings. To obtain input from consumers, telephone interviews were also conducted with 19 past clients of these participating counselors. We found that counselor goals focus on meeting clients' needs, usually educating and providing psychosocial support. Clients often had few goals going into a session because they were unaware of what would be discussed or how the session would be structured. They usually did not expect to receive "counseling," and when they did, it was a welcome surprise. Both clients and counselors commented that a positive interpersonal interaction and "connecting" are primary measures of success. All clients appreciated the large amount of time spent with the counselor, and the manner (clear, comprehensive, and unhurried) of providing information. Many clients said that genetic counseling resulted in improved communication with their partners and other family members. Clients view the counselor as an "expert" and value the counselor as an on-going resource for both information and support. These "outcomes"f genetic counseling need to be assessed, and new measures must be developed.     

Enhancing psychotherapy outcomes via providing feedback on client progress: a replication

Several systems have been developed to monitor and feedback information about a client's responses to psychotherapy as a method of enhancing client outcome. The current study divided 1020 clients into four groups (two experimental and two control) to determine if feedback regarding client progress, when provided to a therapist, affected client outcome and number of sessions attended. Results showed that feedback increased the duration of treatment and improved outcome for clients identified as potential treatment failures thereby replicating an earlier study using nearly identical methodology. Nearly twice as many clients in the feedback group achieved clinically significant or reliable change and fewer were classified as deteriorated by the time treatment ended. For those clients who were predicted to have a positive response to treatment, feedback to therapists resulted in an equal number of treatment sessions and equivalent outcomes compared to the no feedback controls. The results are discussed in terms of quality management in routine clinical practice and the need to base treatment decisions on clients' response to treatment rather than arbitrary session limits. Suggestions for additional research aimed at enhancing the effects of feedback on client outcome are made. Copyright © 2002 John Wiley & Sons, Ltd.     

Client reasons and experiences in treatment that influence termination of psychotherapy

Thirty-one male and female university counseling center clients completed questionnaires that identified reasons for termination and experiences in psychotherapy. Early terminators responded that they ended therapy because of situational constraints and discomfort with services more often than did late terminators. Late terminators said they stopped treatment because of improvement attributed to therapy more often than did early terminators. Late terminators also reported higher levels of belief that the therapist respected them, therapist warmth, and therapist competency than did early terminators. It was concluded that motivational factors in which volition plays a greater (reasons for termination) and lesser (client experiences) role combine to influence psychotherapy termination.     

The influence of outcome measures in assessing client change and treatment decisions

This study investigated the influence that information in the form of outcome measures and client verbal reports can have on treatment decisions and clinician judgment of client change. A random national sample of psychologists (N=810, 45% response rate) were given clinical vignettes and asked questions regarding their view of client progress and subsequent treatment decisions. Despite clinicians reporting that verbal report is more influential in their actual clinical practice than outcome measure information, both sources of information had an equal impact on judgments of client change. Negative information (from either source) influenced clinicians more than positive information. Outcome measure information indicating client deterioration led more clinicians to choose to alter treatment than client verbal report of deterioration. Information indicating client improvement led some clinicians to continue treatment in the same manner as they had been. Insight-oriented therapists were more likely to continue treatment-as-usual than were cognitive-behavioral therapists.     

Optimism and obesity treatment outcomes

To examine the ability of the personality dimension dispositional optimism to predict short-term obesity treatment outcomes (weeks of program attendance and weight loss), 177 consecutive persons seeking outpatient treatment at a university-based weight management center completed the revised Life Orientation Test (LOT-R; Scheier, Carver, & Bridges, 1994) and underwent a comprehensive medically monitored weight loss program. The overall LOT-R and optimism subscales did not correlate with either attendance or weight loss. However, the pessimism subscale was positively associated with weeks of attendance.     

肝胆管结石外科治疗的术式选择与疗效观察

目的探讨肝胆管结石外科治疗的术式选择与疗效。方法选取我院2010年3月至2013年3月肝胆管结石120例病例资料,其中行肝内胆管探查取石术43例;肝部分切除术37例;肝胆管成形术加胆肠吻合术31例;纤维胆道镜取石术9例。回顾性分析不同手术方式的临床疗效。结果术后1~10年的随访,统计分析后发现不同手术之间的术后残石率、术后优良率、术后并发症发生率分别为:肝内胆管探查取石术(42.23%、78.69%、9.23%),肝部分切除术(8.05%、95.93%、18.09%),肝门部胆管成形加胆肠吻合术(13.33%、87.33%、21.32%),纤维胆道镜取石术(31.98%、78.04%、15.69%)。术后总残石率24.17%、总优良率85.83%、术后并发症发生率15.83%。结论根据患者的病史选择合理的手术方式,能降低患者残石率和术后并发症发生率,并提高术后优良率。     

Effects of physician communication style on client medication beliefs and adherence with antidepressant treatment

The goals of this study were to examine how physician communication style impacts client beliefs and medication taking behavior during treatment for depression. The study uses a communication framework and prospective design to examine physician communication and client beliefs as treatment is initiated and again 2 months later. Two telephone interviews were conducted with 100 clients enrolled from 23 community pharmacies. Clients report that physician communication styles vary. In follow-up, 25% of the clients were not satisfied with their medication and 82% reported missing doses or stopping treatment earlier than recommended. Path analysis showed that physician initial communication style positively influences client knowledge and initial beliefs about the medication. Clients with more positive beliefs about the treatment are more likely to see the physician in follow-up and are more satisfied with treatment after attempting medication use. Physician follow-up communication style and client satisfaction are both predictive of better medication adherence.     

Client variables and the behavioral treatment of recurrent tension headache: A metaanalytic review

Meta-analysis revealed that in studies evaluating behavioral treatments for tension headaches, the treatment outcome has varied with the client samples (e.g., age, gender, referral source) that have been used but not with the treatment procedures (e.g., type of behavioral intervention, length of treatment, whether or not efforts were made to facilitate transfer of training) or the research designs (e.g., internal validity, explicitness of diagnostic criteria) that have been used. Mean client age proved the best predictor of treatment outcome, accounting for 30% of the outcome variance following behavior therapy. Significantly poorer outcomes have also been reported in recent studies than were reported in early studies. These findings suggest that (1) outcomes obtained with behavioral interventions have been less dependent upon the treatment variables that have been the primary focus of research attention than upon characteristics of client samples and (2) behavioral interventions may be less effective in reducing headache activity than has previously been assumed.Preparation of this article was supported in part by National Institute of Mental Health Grant MH37464 to Kenneth A. Holroyd.