3.2. How can I Study the
Process and Outcome of my Use of PE Therapy?
In
our view, it is important for therapists of all persuasions – including PE
therapy -- to integrate appropriate research procedures into their practice of
therapy. In order to help you do
that, we present simple methods that simultaneously
•Help you learn more about the process and outcome of the therapy
you do;
•Help you improve your work as a therapist; and
•Help your clients get more out of their therapy.
Contrary
to what you might believe, accomplishing this seemingly ambitious set of goals
does not require a research center and large federal grant! In fact, it can be accomplished by
using a modest collection of measures of important outcomes and change processes,
in the context of a systematic single case study (Elliott, 1983; Elliott,
2002b; Barker, Pistrang & Elliott, 2002), a type of quasi-experimental
design in which one or more clients are tracked session by session and
periodically reassessed.
This form of practice-based research uses systematic quantitative and qualitative methods in order to reduce many of the problems with traditional case studies, and to make it possible to make valid judgments about whether the client has changed over the course of therapy, and whether therapy is responsible for apparent changes. In doing this, it is a good idea to begin small and then to enlarge the data collection to the limits of your interests and setting.
3.2.1. Demonstrating
that Change Has Occurred
The first research task is to improve upon anecdotal impressions of client improvement or deterioration. Our suggestions are ordered from least to most time-consuming or intrusive.
(1) Use one or more standardized general outcome measures, before therapy and every 8 or 10 sessions. These may include overall measures of clinical distress, in particular, global symptom inventories such as the SCL-90-R (Derogatis, Rickels & Roch, 1976) or the CORE Outcome Measure (Barkham et al., 2001). (The latter can be obtained from: www.core-systems.co.uk/home.html .) It’s a good idea to complement the general clinical distress measure with a measure of interpersonal distress such as the Inventory of Interpersonal Problems (Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988).
(2) Develop an individualized problem measure with the client, to be filled out before each session. Such measures ask clients to identify the major problem areas that they want to change, and to rate the severity of these problems. Examples include the target complaints procedure (Battle, Imber, Hoehn-Saric, Stohe, Nash, & Frank, 1966) or the Simplified Personal Questionnaire (Elliott, Mack, & Shapiro, 1999; Wagner & Elliott, 2001). These measures are more work to create than pre-existing general measures, but they are more in keeping with an experiential approach to therapy in that they do not force the client into pre-determined items. Also, they are short enough that they can be filled out before each session, so that they can be used to track client progress over the course of therapy. These measures can also be used for communicating with insurance companies, and serve many of the same orienting and communication functions as diagnosis. For example, a Personal Questionnaire takes about a half hour to develop, and can be set up either during a pretherapy intake or assessment process, or at the second session of therapy. (See Elliott, Mack & Shapiro, 1999, for details; available at: http://experiential-researchers.org/instruments/elliott/pqprocedure.html .)
(3) Add a qualitative interview.
McLeod (2001) has argued that outcome has qualitative as well as
quantitative elements, and that qualitative interviews can be more sensitive to
negative or unexpected effects while also allowing you to understand your
client’s experience of therapy.
The Change Interview (Elliott, 1999; Elliott, Slatick & Urman, 2001)
is an example of such a semi-structured qualitative outcome interview that can
be given every 8 to 10 sessions, and at the end of therapy. Table 14.3 outlines a simplified Change
Interview that can be administered by the therapist as part of a review
session. (From a research point of
view, it is somewhat better to have a colleague interview the client.) The Change Interview includes questions
about changes over therapy, and also questions about the processes that may
have brought about change.
(4)
Add one or more self-report measures of experiential processes, such as
the following:
•Self-esteem (e.g., Tennessee Self-Concept
Scale, Fitts & Warren, 1996; Rosenberg Self-Esteem Scale, Rosenberg,
1965).
•Access to emotions (e.g., Toronto Alexithymia
Scale- 20; Bagby, Parker & Taylor, 1994)
•Experientially-based and reflective coping (Problem
Focused Style of Coping, PF-SOC; Heppner, Cook, Wright & Johnson, 1995)
•Relationship between coach-critic and
experiencing aspects of self (Structural Analysis of Social Behavior Introject
Questionnaire; Benjamin, 1995, 1996)
According
to its theory, PE therapy helps clients via change in these specific aspects of
functioning (e.g., Elliott et al., 1990, Watson et al., in press).
(5) Repeat this process for a series of similar clients, creating a clinical replication series, a type of multiple-baseline single case design (Hayes, Barlow & Nelson-Gray, 1999).
In
order to evaluate whether or not change has occurred, it is important to
consider the possibility that the apparent change is illusory, that is, that it
may in fact be negative or trivial, or due to statistical errors, relational
issues (not wanting to disappoint the therapist), or cognitive biases (trying
to convince self). Elliott (2002b)
presents methods to carrying out evaluating these possibilities.
3.2.2. Evaluating Change Processes
and Linking Changes to Therapy
The second research task is to learn what has brought about the apparent client changes, specifically whether therapy can be judged to have helped bring about the observed changes. This means that it is important to consider alternate possibilities, such as that the client has improved on his or her own, entirely without the help of therapy; that extra-therapy factors (life events, help from other sources) are responsible; or that psychobiological factors (especially medication) can account for the changes (Elliott, 2002b). In order to do this, the following methods may be useful (again ordered from least to most time-consuming):
(1) Client post-session questionnaires may be useful for identifying and assessing important therapeutic processes. The most useful of these is the Helpful Aspects of Therapy (HAT) form (Llewelyn, 1988), a qualitative measure of client perceptions of significant therapy events. To this can be added a measure of the therapeutic alliance, which can be administered after every session, or every three to five sessions (e.g., the 12-item short form of the Working Alliance Inventory (Tracey & Kokotovic, 1989). A global measure of session evaluation, such the Generic Helpfulness Scale (Elliott, 1985), or ratings of session quality or the extent to which client perceived something as having shifted in the session, can also be used. An example of a client postsession questionnaire containing these measures is provided in Appendix B.
(2) The Change Interview (Elliott, 1999) described above as an outcome measure (see Table 14.3), also contains questions about change processes, including medication the client is taking, what the client thinks might have brought about the changes noted, whether any of the changes were surprising to the client, helpful aspects of therapy, and difficult, hindering or missing aspects of the therapy. These last questions are of particular importance for encouraging clients to provide feedback to identify and correct problems in the therapy that may be blocking the change process.
(3) Next, the Experiential Session Form (Elliott, 2002a) allows the therapist to record process notes and to rate his or her therapeutic work from the point of view of the concepts introduced earlier in this book, including treatment principles (Chapter 1), client modes of engagement (Chapter 4), therapist experiential and nonexperiential response modes (Chapter 5), and therapeutic tasks (Chapters 6 through 12). This provides a qualitative summary of the session (process notes) and quantitative ratings of the major components of the therapy. As such, it provides an opportunity for self-supervision, an aide to formal supervision (it can also be completed by the supervisor after he or she listens to the session), and a quantitative record of what happened in the session, which can be used to index sessions for later study (e.g., with meaning creation tasks in them). In addition, therapist qualitative process notes are often an efficient source of information about important client extra-therapy life events.
(4) Finally, audio- or video-recordings, while
time-consuming to deal with, can be invaluable for allowing closer study of
important changes processes, and to complement therapist process notes and
client post-session and Change Interview data.
3.2.3. Analyzing Information about
Therapy
Many different strategies, both quantitative and qualitative,
exist for analyzing the kinds of data we have described. Quantitative outcome data can be
graphed and statistically compared.
Quantitative session ratings by clients and therapists can be related to
outcome. The rich qualitative data
from the Change Interview, clients’ postsession descriptions of significant
events, therapist process notes, and transcripts of sessions can be analyzed
quantitatively using process analysis measures like the Client Experiencing
Scale (Klein et al., 1986), the Narrative Process Coding System (Angus, Levitt
& Hardtke, 1999), and so on (see Greenberg & Pinsof, 1986, for a useful
survey of therapy process measures).
Alternatively, they can be analyzed qualitatively using any of a variety
of methods, including task analysis (Greenberg, 1984b, 1992), grounded theory
analysis (Rennie, Phillips & Quartaro, 1988), conversation analysis (Labov
& Fanshel, 1977; Morris & Chenail, 1995), and comprehensive process
analysis (Elliott, 1989). (For an
overview, see Elliott et al., 2001.)
Finally, mixed interpretive qualitative/ quantitative methods have
recently been developed for using these data to infer the causal influence of
therapy (Bohart, 2000; Elliott, 2001, 2002b)
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Materials designed to
accompany the book Learning Emotion-Focused Therapy: The
Process-Experiential Approach to Change from APA Books.
©2003 Robert Elliott, Jeanne Watson, Rhonda Goldman, and Leslie Greenberg
http://www.process-experiential.org/learning