Volker Tschuschke, Aureliano Crameri, Margit Koemeda, Peter Schulthess, Agnes von Wyl, Rainer Weber, Miriam Köhler, Katharina Muth, Jessica Mallmann, Pia Pulte, Antonia Roth-Ehrang Treatment Adherence and Outcome in Psychotherapy - First Results From the PAP-S-Study

FMPP-IFP Congress Luzern 2010 Treatment integrity in psychotherapy... is essential for psychotherapy research... it is obvious that no control of treatment delivery by therapists in research studies leads to questionnable results... therefore process research is indispensable... there is a need to examine and determine that treatments said to have been provided were indeed the treatments provided (Kendall et al., 2004)... and its implications for treatment outcomes is still unknown. A review of relevant psychological journals revealed that systematically addressed treatment integrity procedures are virtually absent in the literature (Perepletchikova et al., 2007), only 3.5% of the studies or less than 6% (Waltz et al., 1993)

FMPP-IFP Congress Luzern 2010 Process Study of Outpatient Psychotherapy Treatment Switzerland (PAP-S) process-outcome study (start in 2006, end in 2012) large outcome battery (pre, post, follow-up) diagnostic assessments by trained raters (ICD, OPD, SKID-II) in major Swiss cities (Basel, Berne, Lausanne, Luzern, St. Gallen, Zurich) several process measures administered each 5th session 11 different therapy schools objective ratings of treatment adherence each session being audiotaped three sessions (beginning, middle, and end of treatment) will be depicted for integrity ratings raters are blind toward school affiliation of therapists and patient data 4 out of 5 raters are trained psychotherapists so far the average interrater reliability (Kappa) lies between.50 and.60 for three raters (codings of event-by-event, each therapist intervention, approx ratings per session) a detailed rating manual including 101 intervention categories was being developed rating manual‘s categories comprise intervention categories from each school including 22 nonspecific intervention categories each therapist intervention is being rated taking into account context (contents of patient‘s utterances) therapists code their school specific behavior after each session using a check- list of their used particular school categories including nonspecific interventions (subjective ratings)

FMPP-IFP Congress Luzern 2010 RatingsRatings concept true intervention ratings in relationship to nonspecific intervention ratings example Gestalt Therapy session: raw score interventions true to Gestalt therapy = intervention categories raw score nonspecific interventions = intervention categories scores > 1 mean more specific codings compared to nonspecific, and scores < 1 mean less specific codings compared to nonspecific ones 35 / / 22 = 2.12

FMPP-IFP Congress Luzern 2010 Score

FMPP-IFP Congress Luzern 2010 Score Sessions

FMPP-IFP Congress Luzern 2010 Score

FMPP-IFP Congress Luzern 2010 Score Sessions

FMPP-IFP Congress Luzern 2010 subjective ratings by therapists tend to estimate treatment integrity significantly higher compared to observer ratings as is found in other studies (Martino et al., 2009) even therapists consider a fairly high amount of nonspecific ingedients in their intervention style observers‘ ratings suggest that most of the intervention activity of psychotherapists is nonspecific, thus leaving therapists‘ ratings as probably not valid (Waltz et al., 1993) although both therapists seem to have little treatment integrity, their treatments seam to be efficient (at least the given two cases) both therapists used mainly unique and essential, essential but not unique and acceptable but not necessary interventions and very little proscribed interventions so far the question is unanswered whether higher treatment integrities are correlated with better outcomes (the PAP-S Study will address this question) it may also be the case that more severely disturbed patients - complex interventions, demanding, tedious, extended in time etc - generate serious problems in maintaining treatment integrity (Yeaton and Sechrest, 1992) the PAP-S-study will be able to look at different disturbance levels and therapists‘ techniques in these treatments ConclusionsConclusions

FMPP-IFP Congress Luzern 2010 References Kendall et al. (2004): Methodology, design, and evaluation in psychotherapy research. In Lambert (ed.): Handbook of Psychotherapy and Behavior Change. 5th ed., John Wiley & Sons, New York, pp Martino et al. (2009): Correspondence of motivational enhancement treatment integrity ratings among therapists, supervisors, and observers. Psychotherapy Research 19: Perepletchikova et al. (2009): Barriers to implementing treatment integrity procedures: survey of treatment outcome researchers. Journal of Consulting and Clinical Psychology 77: Waltz et al. (1993): Testing the integrity of a psychotherapy protocol: assessment of adherence abd competence. Journal of Consulting and Clinical Psychology 61: Yeaton / Sechrest (1992): Critical dimensions in the choice and maintainance of successful treatments: strength, integrity, and effectiveness. In Kazdin (ed.): Methodolgical Issues & Strategies in Clinical Research. American Psychological Association, Washington D.C., pp