Effect of Therapist Process Variables on TreatmentOutcome for Parent-Child Interaction Therapy

Michelle D. Harwood, B.S. and Sheila M. Eyberg, Ph.D.Department of Clinical and Health Psychology, University of Florida, Gainesville,

FloridaThis study examines the role of specific classes of therapist verbal behavior that reflect the therapeutic alliance and their role in treatment outcome for Parent-Child Interaction Therapy (PCIT). Participants were 22 mother-child dyads drawn from a larger PCIT outcome study, including 11 treatment completers and 11 dropouts. The therapist content categories from Chamberlain’s Therapy Process Code were used to measure therapeutic alliance during the clinical intake interview and the discussion at the beginning of the first CDI coaching session. We reasoned that a strong, early therapist-parent alliance would be reflected in therapists’ use of Facilitate, Information Seek/Questions, and Interpret/ Reframe. Results supported our hypotheses that therapists would use more questioning and less facilitation with parents who later drop out of treatment than with those who complete. The data also revealed a higher frequency of supportive statements with treatment dropouts. These findings suggest that the dropout families may initially present obstacles to treatment compliance that elicit therapist support as well as redirection.

Therapy process refers to all observable behaviors in the interaction between patient and therapist. Process variables have been found to account for treatment outcome better than preexisting patient characteristics in adult psychotherapy. Further, the strength of the therapeutic alliance early in psychotherapy has distinguished treatment dropouts from completers.

Chamberlain’s Therapy Process Code (TPC) was used to examine the interaction between parent(s) and therapist in the context of Parent-Child Interaction Therapy (PCIT). PCIT is an empirically based treatment for young children with behavior problems and their parents, founded on principles of attachment and social learning theories. The TPC is an observational coding system of moment-by-moment interactions between the therapist and patient. Categories of therapist verbalization were used for the current study.

In previous research with the TPC, patient resistance has been positively related to therapist teaching, confronting, and reframing. Patient cooperation has been associated with therapist support and facilitation. The purpose of this study was to examine the predictive ability of therapist process variables on treatment outcome for PCIT. Based on previous research and pilot testing, we hypothesized that dropout would be predicted by high rates of Questions and Reframing and low rates of Facilitation. Because of inconsistency between pilot testing and previous research findings, the category Support was examined as an exploratory variable.  

INTRODUCTION

ABSTRACT

Families participated in a pretreatment assessment that included a semi-structured clinical interview, diagnostic interview, screening measures (DISC-IV-P, CBCL, PPVT-III, and WPT), behavioral observation, and several other measures that were part of the larger outcome study. After completing the assessment, all families attended the Child Directed Interaction (CDI) teaching session and First CDI Coaching Session. The therapist began the coaching session with a discussion with the parent(s) about the assigned daily CDI homework and parental stressors. After this session, families in this study either completed treatment or dropped out prior to meeting the treatment termination criteria.

Therapist behavior was coded for the first 20 minutes of the initial clinical interview and 10 minutes of the discussion with the parent(s) during the First CDI Coaching Session. The seven categories of therapist verbal behavior from the Therapy Process Code were used. These therapist codes allowed for analysis of the therapist process skills, and more specifically, the skills that engage parents early in the treatment process.

PROCEDURE

PARTICIPANTS•22 mother-child dyads drawn from a larger PCIT outcome

study, including 11 treatment completers and 11 dropouts•All children were between 3 and 6 years of age and met DSM-IV criteria for Oppositional Defiant Disorder

Child gender 73% boys (n = 16)Child age M = 4.55 years (SD = 1.14)Child ethnicity86% Caucasian (n = 19)

9% Bi-racial (n = 2)5% African-American (n

= 1)•SES (family Hollingshead) M = 37.77 (SD = 11.22)

CONCLUSIONS

Code Definition ExampleSupport Positive responses toward the client that show

warmth, humor, understanding, and/or encouragement.

It is good that you are coming in for help with those behaviors.

Teach Instruction, telling clients what to do or how to do it. Also for reviewing assignments; especially questions about how the assignment worked.

It is important to be consistent.

Information Seek/ Questions

Inquiries requiring a response. Interrogative words are a primary cue for this category. Clarification comments that lead the client to provide information.

When did you first notice these kinds of problems?

Structure Directing the conversation or setting ground rules for how the session or interaction will proceed.

I am now going to ask questions about his development.

Disagree/Confront/Challenge

Behaviors that tend to push the client, such as the following: disagreement, disapproval, or negative, sarcastic, or hostile remarks, and challenges.

I don’t think that is a good idea.

Interpret/Reframe Behaviors in which the therapist speculates about or states the meaning of something, makes a prediction, or alters the meaning of what someone has said.

He is doing that to get attention.

Facilitate The therapist is basically listening to the client , but making short utterances to indicate s/he is paying attention and the other person should keep on talking.

Okay.

p < .05.

RESULTS

χ2 = 9.41 (3, 19), Λ = .60, p = .024

Mean Therapist Codes

Code Category

FacilitateQuestionSupport

Code

Fre

quen

cy

140

120

100

80

60

40

20

Treatment Status

dropout

completer

Discriminant Functions AnalysisClassification Results

Predicted Group

Membership

Actual Group Membership

Dropout 8 3Completer

3 8

p = .057.

73% of actual group membership was correctly classified by Facilitate, Support, and Question

THERAPY PROCESS CODE: THERAPIST CODES

Therapist process variables predicted PCIT outcome

•A high rate of support and questioning and a low rate of facilitation predicts treatment dropout

Engagement of patients may be best achieved by actively listening while minimizing the frequency of direct inquiries

It may be that high-rate questioning occurs because of insufficient use of open-ended questions or because of vagueness in parent reporting

Greater distress among dropouts may elicit the higher rates of therapist supportive statements

Examination of patient behavior may help explain this finding

•An early patient-therapist alliance may be critical to treatment completion 

Note. No significant differences existed between groups for other code categories. Reframe was not included in the analyses because of the infrequency of this behavior (M = 10.55, SD = 5.63).