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Posts Tagged ‘Chadwick

The implicit Contract by Therapist and Patient in Psychotherapy

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Idea for an experiment:

I proposed to prime therapists with the case of a patient that could easily be identified as one disorder (for example depression or dementia) and then present another case in which the information is ambiguous and thus allowing the possibility for both disorders to be present. Having read the articles by Chadwick, Williams and Mackenzie (2003) I wonder if disorder specific information is the “big thing” about case formulation. Rather it could be seen as a contract between the therapist and the client in which the therapist can prove his knowledge and skill to the client by structuring the clients’ life history, behaviour and cognitions in a meaningful way. A case formulation is like the therapist saying: “I know what is wrong with you, I have decided to help you and that is how were are going to do it!”. For the patient this might raise hope and contribute to remoralization. For the therapist the case formulation might be an important step-by-step guideline on what to concentrate on in therapy and how to do it. I stick with my experiment, but I would like to include another sub experiment. The case formulations by the novice and the expert are shown to the patient and he or she rates them in on their affective impact. As a control condition the patient could receive either personal case formulations that structure behaviour, life story and cognition in parsimonious ways, but do not reference to specific disorders. As an alternative, standard case formulations could be used.

Written by Martin Metzmacher

October 20, 2008 at 5:19 pm

More on the Topic of Experience in Psychotherapy

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In one of the last posts I summarized three articles that all came to the conclusion that there was no big difference between novice and expert therapists. I came to the conclusion that the tasks used were presenting ready-to-judge material, which was in no way ecological valid. I hypothesised that the true merit of expertise would rather lay in the skill of information gathering and a vast network of knowledge including contra-indications and possible developmental pathways that need to be taken into account. The article by Kuyken, Fothergill, Musa and Chadwick (2005) The reliability and quality of cognitive case information further elaborates on the process that take place in therapy and focuses mainly on the stage of information gathering. The authors had participants of different experience levels make case formulations using the J. Beck Case Conceptualization Diagram (CCD). 115 mental health practitioners were given extensive information about a hypothetical case (Anna), which included an account of the presenting problem, a psychosocial history, observation of the client during the assessment, standardized psychological assessments and a multi-axial diagnosis. Quality of the case formulation was rated with the Cognitive Case Formulation Scale and was defined as a ‘parsimonious, coherent and meaningful account of a client’s presenting problems in cognitive therapy terms. Interrater reliability for the judges who rated the CCD was good, although the rating of dysfunctional assumptions (in subcategories) only reached a kappa of 0,63. The case formulations of the participants were rated against a benchmark formulation provided by J. Beck and ranged from very poor to good. Only 44,2% of the formulations were found to be at least “good enough”. Such benchmarking by an allegedly expert must be interpreted with caution, because the agreement with the systematic approach of the CCD is measured and not validity of the case formulation. Chi-square analysis revealed that the quality of the formulations did differ between the three groups (novice, experienced and expert). Participants who had a professional qualification or a BABCP accreditation provided case formulations of a better quality than the other participants. So for the time being I keep on believing that the true expertise is found in the systematic and comprehensive information gathering and not in the interpretation of (hypothetical) data. I would like to see an experiment in which novices and experts talk to a (real) client and gather information. The information that is produced by that session could then be presented to other novices and experts. Those would have to make several predictions about the patient that could be verified in a longitudinal study. I hypothesis that variance on the second task will mainly be explained by the expertise level of the first therapist with almost no interaction with the expertise level of the second therapist.

Written by Martin Metzmacher

October 12, 2008 at 11:15 am