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Methodological Issues In Psychotherapy System

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Question:

Discuss about the Methodological Issues in Psychotherapy System.
 
 

Answer:

Introduction:

Both psychotherapy and counseling are professional therapeutic activities, which utilizes the interpersonal relationship between a therapist and the client to help the client to develop self-understanding, which leads them to make changes in their lives. The most seen issues, which a psychotherapist or a counselor faces in his or her practice, are the dilemma over many issues. One of the important dilemma the psychotherapists faces is the dilemma over showing responsiveness and recursiveness to the clients. Another major issue the psychotherapists face while treating the youth is the application of many methodologies as most of the youth tries to resent the therapy. To study the effectiveness of the methodologies the psychotherapists follow, the researchers always depends on the process studies and outcome studies (Anker,  Duncan, & Sparks, 2009). Process research can be stated as the interactive study between patients and the therapists. Outcome research depends on the outcome of any health structure, which is needed for the well-being of the population. The purpose of the article is to explore these mentioned dilemmas the psychotherapists faces in practice (Markowitz, Lipsitz, & Milrod, 2014). The article would also explore some evidence based outcome studies on these mentioned methodological issues. The article will explore the outcome result of the relevant studies which states about the methodological dilemmas the psychotherapists faces in their life.

The psychotherapic treatment is considered as hazardous as the psychiatrists always face the burden of keeping substantial relationship  with the clients. The relationship between the psychiatrist and the clients has a thin border. There are many complex ethical questions the that the therapists encounter during their practice. Many of these dilemmas are contextual, complex and dynamic. Some of the ethical dilemmas, which are most frequently cited, are related to the professionalism and therapeutic boundaries (Stiles, 2009). To resolve these ethical dilemmas, the psychiatrists and the counselors uses the medical ethics as the medical ethics addresses many ethical dilemmas, which is better, expressed in a method. There are another important dilemma which can be seen in the psychiatrists is their obligation towards the clients

 

Overview of outcome research:

The article would help the readers to identify the importance of solving the methodological dilemma faced by the therapists. The article would also address the current problem of the youth psychotherapy.

The experiment logic and the usage of Randomized control trial over the psychotherapy research are beyond confounding due to the presence of many non-independent contributing factors. However, some of the factors such as treatment, therapist, and clients depend on each other.

There are many issues and dilemmas over the methodologies; a psychotherapist faces over his or her career. The counselors face many issues over the methodologies. Such as, the counselors and psychotherapists have to maintain a strict treatment frame (Borkovec, & Ruscio, 2001). If the treatment frame is weak, the line between professionalism and personalization is breached. A counselor might feel strong emotion regarding the condition of a client, but the counselor has to maintain the treatment frame. Sometimes the therapist tries to apply another approach instead of the usual approach while treating the client. The methodological difference of these two approaches might bring some dilemma over the mind of the therapist (Luty et al., 2007). Another important issue, a psychiatrist faces when the abused client falls in love with the therapist even if the therapist is maintaining a completely different relationship with them. As the abused clients’ faces difficulty with intimacy, they easily fall in love with the therapist due to their new experience of having someone who actually listens to their problems (Cuiipers et al., 2011).

One of the key issues this article is going to discuss is responsiveness. The competency of a therapist depends on his responsiveness regarding the information the client gives. The responsiveness from the side of the client makes the outcome of the therapy more positive. The feedback of the client for the study is also a part of being responsive (Etherington, 2009).  One study was done on responsiveness of the couples who has attended couple therapy session. The study over the responsiveness of the couples has done a randomized control research.

The psychotherapists face some issues while providing therapy to the patients with anxiety disorder. The psychotherapists mostly treat the clients with generalized anxiety disorders with CBT (Cognitive behavioral therapy). As the patients with anxiety deals with the negative thoughts, they try to reject the therapist’s idea about preventing the anxiety producing thoughts. The therapists are now trying to treat the patients with Interpersonal psychotherapy (IPT). The therapy is successful while treating patients with mood disorder and eating disorder.  Few therapists have been using this method as a test methodology while treating patients with anxiety disorder.  This mentioned issue is going to be discussed in this article (Barker, Vossler, & Langdridge, 2010).

 

Methodological issues in outcome research:

Issue 1: One of the issues, which are going to be explored in this article, is the issue over responsiveness the psychotherapists faces. Being responsive is human nature as the people are always responsive to each other. Both the therapist and the client are responsive over each other for a period. To give an example, a therapist is being responsive when he or she is prescribing the client or treating the client based on the issues the client has. A client also behaves responsively to the therapist over some issues, such as, when the client is giving feedback to the therapist (Cooper, & McLeod, 2010). As the psychotherapists are trained to be responsive towards the indication of improvement or corrosion from the behavior of the client. This implies that, the feedback of the client in necessary for the psychotherapists to be responsive. This helps them to get relevant information about the outcome measures . This depends on the client patient alliance. The therapist may feel ethical dilemma as a client may not be responsive to the treatment prescribed by the therapist and the therapist might face ethical dilemma over changing the therapy procedure as the patient might resent it as well (Palmer, 2007). To study the outcome result, a essay named “Using Client Feedback to Improve Couple Therapy Outcomes: A randomized Clinical Trial in a Naturalistic Setting” were chosen (Anker,  Duncan, & Sparks, 2009).

Study design: The study about responsiveness was done on 453 couples who went to couples therapy in a community based outpatient settings. The groups were randomized into two groups (Feedback group and Treatment as usual group) before the therapists were assigned to these couples. After the session, the clients of the feedback group were invited to give feedback about improving the process of the therapy. 

Limitation of the study: The therapists used just one outcome measure in the analysis. Other than that, the instruments used by the patients were brief. It limited the understanding of the given feedback by the patients. If the clients and the therapists had alliance that is more extensive then the assessments would have given better result. Intentionally, the study is more pragmatic and replicates the happenings of the clinical practice.

The therapists were told to be their own control. There were no special allegiance between the therapists serving in TAU group and feedback group.

Result of the study: The study was done to determine the effect of giving feedback over couple’s therapy in comparison with a TAU group ( Treatment as Usual) in a natural condition of a community clinic. The result is the study was in consistency with the hypothesis as the result of the feedback group were emerged as superior from the results of the TAU group.

In the end, it was seen that the post treatment average score of the couples in the feedback group (26.35) were five points greater than the score of the TAU group (21.69). 

In the above study, the research used patient focus research paradigm to overcome outcome challenges related to irresponsiveness of client during psychotherapy. The advantage of this strategy was that it enhanced outcome by taking continuous progress feedback from clients and results was evident by improvement in outcome of patient in feedback group compared to treatment as usual group. It helped in systematic evaluation of client’s response to treatment and helped to address issues of dropout in research too.  The effect of regular feedback of client was also consistent with other research. However, there are many areas in the responsiveness issues of psychotherapy, which remained unexplored. As there might be diverse type of clients coming with different types of risk during psychotherapy, the consideration for future will be to tailor feedback process so that people with communication difficulties can also participate actively in such session.

The methodology of Interpersonal psychotherapy (IPT) is efficient in treating both mood disorder and eating disorder. CBT or cognitive behavioral therapy is known as the best therapy method for the patients with anxiety disorder. IPT is an attachment-focused psychotherapy, which resolves the interpersonal problems. The approach is known for the symptomatic recovery of the patients. IPT is highly structured approach and ends within a definite period (Feltham,  Hanley, & Winter, 2017). As IPT is a structured framework, some therapists use it treat the patients suffering from anxiety. Using IPT for treating anxiety disorder is a methodological issue as it is still untested as a method for treating anxiety. For this issue, a paper named “Critical Review of Outcome research on Interpersonal Psychotherapy for Anxiety Disorders” is chosen. As there is lack of the evidence-based study, the chosen article reviews the effect of IPT on social phobia, panic disorder, PTSD and from these evidences, the possible effect of IPT on anxiety disorder is discussed (Markowitz, Lipsitz, & Milrod, 2014).

Rationale: There are two reason of choosing IPT as a method to treat the patients with anxiety. The first reason is, anxiety disorders have some interpersonal features and shares this characteristic with panic disorder, PTSD and social phobia as all of these disorders have interpersonal features. The second reason is the time limitation of IPT, which requires the therapist to complete the therapy within 12-16 weeks.

Study designs: The paper searched many literature using Pubmed and Scholarly, and selected 11 studies, 4 of which on social phobia, six for open trials, two studies on panic disorder and 5 for PTSD.

 

Social phobia and Social Anxiety disorder:

In the first set of studies, 14 week of IPT was conducted for 9 patients who have social phobia and anxiety. Another study was conducted with providing 14 weeks IPT and psychodynamic therapy to 70 patients with social anxiety disorder in two different randomized groups. The results were compared.

Another study in Norway compared 10 weeks of group IPT with Group CBT in a specialized way as 80 patients were treated in a residential setting.

There were two studies where 106 medication free patients were randomized for 16 session of CBT or IPT for DSM-IV and Social Anxiety Disorder. In this study, all of the therapists had background with CBT but one of the therapists was specialized in IPT.

Results- In the first set of studies, 7 out of 9 patients were reported as improved. They were rated by the Clinical Global Improvement scale (CGI). The patients who were reported improvement were tasted on Liebowitaz Social Anxiety Scale (LSAS) and were reported 78% improved.

In the second set of study, the patients of both of the group have significantly improved. The LSAS score was just a little bit better in IPT than psychodynamic therapy.

In the third set of study which was conducted in Norway, where all of the patients were also given medication along with the therapy in  two groups, one receiving CBT and another was receiving IPT. Both of these groups showed significant improvement on the Anxiety Disorder Interview schedule. There was no significant difference between both groups (Ponterotto, Kuriakose,  & Granovskaya, 2008).

In the last study, the German trial, which randomized 106 patients without medication, has showed a distinct result. The group treated with IPT showed less improvements. 66% of the patients of CBT showed improvement, whereas 32% of the patients receiving IPT were moderately improved (Riessman, & Speedy, 2007).

There was a study in Australia, who treated 13 patients who battled PTSD for 1 year. They were given group IPT and nine of them were given medications. Some of the symptoms associated with CBT were improved (Kazdin, 2008).  However, there were no overall improvements. Similar results were found on different studies as well.

Result- There were many studies on the effect of IPT on PTSD. The results showed improvement on the symptoms of PTSD such as social personality disorders and many more. However, the overall improvement of PTSD remained unclear (Fava et al., 2008).

These results show that IPT lowered anxiety symptoms and was well tolerated by all the patients. IPT definitely showed promise as an intervention for treating anxiety disorder.

The above article recognized the methodological issue of conducting psychotherapy in patients with anxiety and employed the technique of interpersonal psychotherapy to overcome the issue. The use of this approach is effective because it specifically targets people with mood disorders and focuses on useful meaning of emotions to develop therapeutic relationship with client during the therapy. Review of different research using IPT for patients with PTSD and panic disorder showed that IPT reduced anxiety symptoms and promotes getting better outcomes for patient. Another advantage of IPT is that it overcomes the limitation of CBT and focus on feelings in interpersonal situation instead of cognition to understand signals of client during interpersonal encounter sessions in therapy (Dagöö et al., 2015). However, some disadvantage found in the research study was that mediating factors influencing IPT’s effect and adaptation rate was not properly explained by the researcher. Hence, as IPT may not work for different patient subsamples, there is a need to consider specific process for adaptation of IPT to yield greater efficacy in research outcome.

 

Conclusion:

As the treatment of psychotherapy is a holistic approach, the therapists are bound to have many issues while treating the patients with different problems. Many issues they face are ethical and many of the issues are methodological. The article is concerned with the outcome result of two such methodological issues. The first issue, which has been discussed, is responsiveness, which is necessary for the therapist to make a positive outcome for the patients. Responsiveness from the patients comes through their feedbacks of the therapy. One study named “Using Client Feedback to Improve Couple Therapy Outcomes: A randomized Clinical Trial in a Naturalistic Setting” was chosen for the outcome study. From this study, it can be concluded that responsiveness is necessary for the revised treatment of the patients. The second issue was the usage of IPT methodology instead of CBT for the patients who have anxiety disorder. The study, which was chosen for the outcome result, is “Critical Review of Outcome research on Interpersonal Psychotherapy for Anxiety Disorders”. The result showed that the patients could be treated to an extent with IPT methodology instead of CBT. From this above discussion, it can be concluded that there is scope for the IPT methodology to improve as it can be successfully used as an intervention method to treat the patients with anxiety. Further researches are needed in this area. From the first case study, it can be concluded that to battle the dilemma, the psychotherapists should take feedback from the clients, as responsiveness is the only way to give the patients with proper treatment.

 

References:

Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of consulting and clinical psychology, 77(4), 693.

Barker, M., Vossler, A., & Langdridge, D. (2010). Understanding counselling and psychotherapy. Sage.

Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. The Journal of Clinical Psychiatry.

Cooper, M., & McLeod, J. (2010). Pluralistic counselling and psychotherapy. Sage.

Cuijpers, P., Geraedts, A. S., van Oppen, P., Andersson, G., Markowitz, J. C., & van Straten, A. (2011). Interpersonal psychotherapy for depression: a meta-analysis. American Journal of Psychiatry, 168(6), 581-592.

Dagöö, J., Asplund, R. P., Bsenko, H. A., Hjerling, S., Holmberg, A., Westh, S., ... & Andersson, G. (2014). Cognitive behavior therapy versus interpersonal psychotherapy for social anxiety disorder delivered via smartphone and computer: A randomized controlled trial. Journal of anxiety disorders, 28(4), 410-417.

Etherington, K. (2009). Life story research: A relevant methodology for counsellors and psychotherapists. Counselling and Psychotherapy Research, 9(4), 225-233.

Feltham, C., Hanley, T., & Winter, L. A. (Eds.). (2017). The SAGE handbook of counselling and psychotherapy. Sage.

Luty, S. E., Carter, J. D., McKENZIE, J. M., Rae, A. M., Frampton, C. M., Mulder, R. T., & Joyce, P. R. (2007). Randomised controlled trial of interpersonal psychotherapy and cognitive–behavioural therapy for depression. The British Journal of Psychiatry, 190(6), 496-502.

Markowitz, J. C., Lipsitz, J., & Milrod, B. L. (2014). Critical review of outcome research on interpersonal psychotherapy for anxiety disorders. Depression and anxiety, 31(4), 316-325.

Palmer, S. (2007). PRACTICE: A model suitable for coaching, counselling, psychotherapy and stress management. The Coaching Psychologist, 3(2), 71-77.

Stiles, W. B. (2009). Responsiveness as an obstacle for psychotherapy outcome research: It's worse than you think. Clinical Psychology: Science and Practice, 16(1), 86-91.

Ponterotto, J. G., Kuriakose, G., & Granovskaya, Y. (2008). Counselling and psychotherapy. The Sage handbook of qualitative research in psychology, 455-471.

Riessman, C. K., & Speedy, J. (2007). Narrative inquiry in the psychotherapy professions. Handbook of narrative inquiry: Mapping a methodology, 426456.

Fava, M., Rush, A. J., Alpert, J. E., Balasubramani, G. K., Wisniewski, S. R., Carmin, C. N., ... & Warden, D. (2008). Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR* D report. American Journal of Psychiatry, 165(3), 342-351.

Kazdin, A. E. (2008). Evidence-based treatment and practice: new opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American psychologist, 63(3), 146.

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