بررسی اثر رفتاری درمانی شناختی ارائه شده توسط دانش آموز در برنامه روانشناسی آموزشی: یک مطالعه اثربخش
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|30014||2012||14 صفحه PDF||سفارش دهید||9344 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Behavior Therapy, Volume 43, Issue 1, March 2012, Pages 160–173
Relatively little is known about the efficacy of clinically inexperienced student therapists carrying out cognitive behavior therapy (CBT) under supervision during a professional, psychologist training program. The current study evaluated this by collecting pre- and posttreatment data on 591 consecutive patients receiving treatment at the Psychotherapy Clinic of the Department of Psychology, Stockholm University, Sweden, over an 8-year period. The patients had mainly anxiety disorders or depression with a mean duration of 15 years, and received individual CBT for a mean of 18 sessions. They improved significantly on both general measures (Beck Anxiety Inventory [BAI], Beck Depression Inventory [BDI], and Quality of Life Inventory [QOLI]) and disorder-specific self-report scales. The proportions of recovered patients on the BAI (63%) and the BDI (60%) were higher than those of a comparison effectiveness study. On the specific self-report scales the current sample improved as much as the samples in extant efficacy trials. We conclude that clinically inexperienced student therapists who receive supervision from experienced supervisors can achieve treatment effects that are on a par with those of experienced licensed psychotherapists.
Cognitive behavior therapy (CBT) is the form of psychotherapy having the largest evidence base and is an empirically supported treatment for more disorders than any other therapy (Nathan and Gorman, 2007, Roth and Fonagy, 2005 and Silverman and Hinshaw, 2008). Thus, there is little doubt that various forms of CBT are effective for a wide range of psychiatric disorders. One question that often is raised is whether CBT works equally well in routine clinical care. Effectiveness studies are done to investigate this issue and so far at least two reviews have been published. Hunsley and Lee (2007) reviewed a total of 35 studies, 21 with adults and 14 with children and adolescents. The adult studies concerned various anxiety disorders and depressive disorders, whereas the child studies were more diverse (anxiety, depression, disruptive behavior, and conduct disorder). The conclusion drawn was that improvement rates in the effectiveness studies were comparable with those obtained in efficacy studies. Subsequently, Stewart and Chambless (2009) reported a meta-analysis of 56 effectiveness studies on various anxiety disorders in adults. They found that uncontrolled effect sizes (ESs) for disorder-specific measures were large (0.92–2.59) and concluded that benchmarking indicated that the results from effectiveness studies were in the range of those obtained in selected efficacy studies. The largest effectiveness study in CBT to date is that of Westbrook and Kirk (2005) describing the outcome of CBT at the Oxford Adult Mental Health Psychology Department, a part of the National Health Service for Oxfordshire, England. This study included 1,276 patients referred for treatment between 1987 and 1998. The patients were not formally diagnosed but mainly presented with various anxiety, depressive, and eating problems (as determined by the therapists). Their mean age was 35.1 years and problem duration was on average 11.8 years. They were treated by psychologists having a specialist training in CBT for a mean of 13.2 sessions. The results showed that on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) 34.3% were recovered and 13.6% reliably improved, for a good outcome of 47.9%. The corresponding figures on the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) were 31.5%, 18%, and 49.5%, respectively. Benchmarking showed that the effects were somewhat lower than for efficacy studies for anxiety disorders but on a par with those for depression. The current study evaluates the treatment outcome obtained by undergraduate students during their fourth and fifth years of the 5-year psychologist training program at Stockholm University, Sweden (equivalent to a master's degree). Thus, it is relevant to review what kind of results clinically inexperienced students doing CBT under supervision obtain. Ryum, Stiles and Vogel (2007) reported on the outcome for 117 patients treated by students in the psychologist training program at Trondheim University, Norway. The treatments were described as eclectic, as the form of treatment was decided upon by the supervisors of the student clinicians, whose theoretical orientations were cognitive, humanistic, or psychodynamic. The patients were treated by 117 students who received supervision 1 hour per week. On the SCL-90-R the sample had an uncontrolled ES of 0.48 and on the Inventory of Interpersonal Problems (IIP-64) it was 0.38. Thus, the ESs were in the small range, which might be accounted for by the fact that only an unknown proportion of the patients got CBT. An interesting study (Solem, Hansen, Vogel, & Kennair, 2009) from the same department tested whether it was possible to train 10 young (M age = 22.4 years) psychology students, who only had completed 1 year and 6 months of their 5-year training program, to treat obsessive-compulsive disorder (OCD) patients with exposure and response prevention. Before starting to treat patients the students had a didactic introduction to the treatment of OCD based on the manual of Kozak and Foa (1997). Over a period of three semesters the students obtained 60 hours of group and 30 hours of individual supervision from four supervisors with extensive experience in the treatment of OCD. Twenty patients were treated by the students and they improved significantly on the Clinical Severity Rating (CSR; ES = 2.90), Obsessive-Compulsive Inventory-Revised (ES = 1.97), and BDI (ES = 0.76). Furthermore, 17 of the 20 patients no longer fulfilled diagnostic criteria for OCD after therapy. Rakovshik and McManus (2010) reviewed studies on training in CBT, but only 8 out of 37 studies were considered “true” training studies, and were not part of a random controlled trial describing the training of the therapists working in the study. Most of the training studies assessed therapist competence and found that it increased after the training. Two studies that measured patient symptoms found significant reductions after the posttraining treatment, and one found no significant increase in therapist competence or significant reductions in patient symptoms. Stein and Lambert (1995) presented a meta-analysis of 36 studies investigating the relationship between therapist training and patient outcome. They found a positive but small ES (.27) favoring trained therapists on client satisfaction, outcome measures, and attrition. Similar ESs were obtained on psychological tests and objective measures of symptoms (.30), as well as independent assessor ratings (.33). Howard (1999) reported a study comparing therapists with or without specialist training for anxiety disorder. He found that therapists with specialist training (CBT) completed treatment significantly faster and their patients had significantly lower relapse rates during a 2-year follow-up period than the patients of the therapists without specialist training. The issue of whether paraprofessionals perform as well as professional therapists and yield equivalent patient outcomes was thoroughly reviewed some years ago by Atkins and Christensen (2001), showing that most of the published studies had methodological problems, including the confounding of degree of training, level of clinical experience, and amount of supervision. Therapists without a doctoral degree in clinical psychology can also be regarded as paraprofessionals. Although they have less of a formal training they may have much more clinical experience than a doctoral-level psychologist, which may explain their good results. Another factor that may differ between groups of therapists is the amount and frequency of supervision, and if paraprofessionals receive regular and more supervision, this too may help to explain the results. The current study is a natural effectiveness study, without the possibility to randomize the therapists to different conditions. However, the student therapists in this study all went through the same psychotherapy training course and they all had the same frequency and amount of supervision by well-trained supervisors. What varied between therapists was the degree of clinical experience they had acquired before starting the psychotherapy course. Nonetheless, the clinical experience they received during the course was very similar as they all treat two or three patients. Another often discussed issue is whether comorbidity affects treatment outcome negatively. This question is investigated in the current study. Based on studies on anxiety disorders in children (e.g., Ollendick, Öst, Reuterskiöld, & Costa, 2010) it was predicted that comorbid disorders would improve significantly without being treated and that the presence of comorbidity would not have a negative impact on the treatment of the primary disorders. The present study attempted to answer the following questions: (a) Are patients statistically and clinically improved after treatment carried out by student therapists under close supervision? (b) How do the treatment effects fare compared to benchmark studies? (c) What happens with comorbid disorders after treatment of the primary disorders? and (d) What influence does comorbidity have on outcome of the primary disorder?
نتیجه گیری انگلیسی
Number of Sessions The total mean number of therapy sessions was 17.2 (SD = 8.1). This was divided into the behavioral analysis phase, which took an average of 5.2 (SD = 2.0) sessions, and the actual treatment that took a mean of 12.0 (SD = 7.0) sessions.