"Importance of Objective Measures of Therapy" by Peter Kemp

[Dolphin]

Originally posted by Peter on Co-Cure:

Importance of Objective Measures of Therapy



In the PACE Trial Protocol White et al remark that (http://www.biomedcentral.com/1471-2377/7/6):



Some CFS/ME charity members have reported that they feel worse after exercise therapy, and to a lesser extent CBT [13,14], whereas the trial evidence suggests minimal or no risk with these treatments.



I am not sure that all the research trials of GET and CBT show minimal risk with these treatments. Drop-outs are sometimes quite high and reasons are not always provided. Furthermore there is a difference between monitoring participants and patients receiving a treatment.



Firstly, researchers know the difficulty of recruiting and retaining participants, especially in lengthy trials. It is only natural that participants receive favorable and considerate treatment in such circumstances. Losing one participant can represent the loss of a great deal of work. This might be avoided by showing consideration to participants that patients in regular medical care might not receive.



Secondly, the consideration shown to participants is going to be an aspect of the therapeutic relationship. In psychological therapy this relationship is considered so important that it is frequently the subject of research and text books. Yet it is this very relationship that can make any measurement of change difficult with subjective measures.



When a therapy client is asked, did you find therapy helpful, their reply can relate to several things other than how therapy actually helped them or not. These other factors can be highly significant and include things like; how much the client believes they can trust the therapist, how much they like the therapist (and believe the therapist likes them); how much loyalty they believe they owe to the therapist etc.



A client that works with a therapist they think is wonderful, is much less likely to simply say, therapy did not help me at all; as opposed to a client that worked with a therapist they are indifferent to. This distortion could easily be reflected in questionnaires (i.e. SF-32).



It is therefore essential to use objective measures wherever possible in all types of therapy.



Peter Kemp

 

[Dolphin]

Another article by Peter Kemp:

The PACE Trial and Objective Measures in Therapy

In his article, "Clients' Deference in Psychotherapy", Rennie (1994) explored aspects of the therapeutic relationship and stated:

"Deference is commonly defined as the submission to the acknowledged superior claims, skill, judgment, and so forth of another person. In the therapy dyad, the therapist is generally considered to be more expert than the client-a situation that could be expected to potentiate the client's deference to the therapist."

It is easy to see that this understanding of deference can be applied to many other therapeutic relationships. This is particularly relevant where the expertise of the therapist and learning of the client are givens of the work. In these situations, client trust in the therapist and faith in the therapy is sought to encourage compliance and have been positively correlated with outcome (Hubble, Duncan, Miller. 2002).

In analysing 16 therapy sessions Rennie identified no less than 348 examples of client deference. These most commonly related to the client's, "Concern about the therapist's approach", closely followed by "Fear of criticising the therapist".

Rennie refined other aspects of client deference and remarks:

"Threatening the therapist's self-esteem.
This property represents a relatively rare occurrence in which the client verbally attacks the therapist in a moment when the client feels relentlessly pressured by the therapist. The attack is motivated by a need to reduce the therapist's power and authority. The client feels precarious in such a moment; the attack is made indirectly and subtly, with considerable dread of retaliation, and the client quickly defers to the therapist to offset this possibility."

It is interesting to note that in this "relatively rare occurrence" the client appears driven by desperation and feels dread when criticizing their therapist, suggesting that clients rarely feel they have the right to be critical, tend only to do so when under duress and quickly revert to a deferential position.

Rennie goes on to observe:

"Indebtedness to the therapist.
Represented by this final property of client's deference is the client's experience of feeling grateful to the therapist for being interested in the client and for the therapy received… the feeling of indebtedness may be strengthened when the therapy has been subsidized so that the client has not had to pay for it…"

This suggests that client deference might be even more significant in a research setting where the therapy is provided free and the participant receives special attention. I suggest that this might be particularly so when a participant has M.E. PWME may feel lacking in validation, their self esteem is likely to be undermined by the drastic restrictions the illness can impose and they may be desperate for help and recovery.

In the PACE Trial, measured outcomes might also be distorted because some of the therapies are likely to alter the participant's perception of symptoms. If participants are trained to 'think positively' about their symptoms, to feel empowered and in control, their response to subjective measures will change because they have been taught to assess their subjective experience differently. These participants might be viewed as 'programmed' to perceive improvement that might or might not exist; and to some extent their subjective assessment of their symptoms could be influenced by deference to the therapist.

As the PACE Trial depends on 'fatigue' as the symptom required for inclusion, the potential complications described above might be avoided by using objective outcome measures that record activity and response to activity.



REFERENCES

Dineen, T. (1999) Manufacturing Victims. What the Psychology Industry is Doing to People. Revised U.K. edn. London: Constable.

Hubble, M. A., Duncan, B. L. & Miller, S. D. (2002) The Heart and Soul of Change, Washington: American Psychological Association.

Rennie, David, L. (1994). Client's Deference in Psychotherapy. Journal of Counseling Psychology. 41.4.427-437.

 

[Dolphin]

More on Objective Measures in Therapy

Another article by Peter Kemp:

The PACE Trial and Objective Measures in Therapy

In his article, "Clients' Deference in Psychotherapy", Rennie (1994) explored aspects of the therapeutic relationship and stated:

"Deference is commonly defined as the submission to the acknowledged superior claims, skill, judgment, and so forth of another person. In the therapy dyad, the therapist is generally considered to be more expert than the client-a situation that could be expected to potentiate the client's deference to the therapist."

It is easy to see that this understanding of deference can be applied to many other therapeutic relationships. This is particularly relevant where the expertise of the therapist and learning of the client are givens of the work. In these situations, client trust in the therapist and faith in the therapy is sought to encourage compliance and have been positively correlated with outcome (Hubble, Duncan, Miller. 2002).

In analysing 16 therapy sessions Rennie identified no less than 348 examples of client deference. These most commonly related to the client's, "Concern about the therapist's approach", closely followed by "Fear of criticising the therapist".

Rennie refined other aspects of client deference and remarks:

"Threatening the therapist's self-esteem.
This property represents a relatively rare occurrence in which the client verbally attacks the therapist in a moment when the client feels relentlessly pressured by the therapist. The attack is motivated by a need to reduce the therapist's power and authority. The client feels precarious in such a moment; the attack is made indirectly and subtly, with considerable dread of retaliation, and the client quickly defers to the therapist to offset this possibility."

It is interesting to note that in this "relatively rare occurrence" the client appears driven by desperation and feels dread when criticizing their therapist, suggesting that clients rarely feel they have the right to be critical, tend only to do so when under duress and quickly revert to a deferential position.

Rennie goes on to observe:

"Indebtedness to the therapist.
Represented by this final property of client's deference is the client's experience of feeling grateful to the therapist for being interested in the client and for the therapy received the feeling of indebtedness may be strengthened when the therapy has been subsidized so that the client has not had to pay for it"

This suggests that client deference might be even more significant in a research setting where the therapy is provided free and the participant receives special attention. I suggest that this might be particularly so when a participant has M.E. PWME may feel lacking in validation, their self esteem is likely to be undermined by the drastic restrictions the illness can impose and they may be desperate for help and recovery.

In the PACE Trial, measured outcomes might also be distorted because some of the therapies are likely to alter the participant's perception of symptoms. If participants are trained to 'think positively' about their symptoms, to feel empowered and in control, their response to subjective measures will change because they have been taught to assess their subjective experience differently. These participants might be viewed as 'programmed' to perceive improvement that might or might not exist; and to some extent their subjective assessment of their symptoms could be influenced by deference to the therapist.

As the PACE Trial depends on 'fatigue' as the symptom required for inclusion, the potential complications described above might be avoided by using objective outcome measures that record activity and response to activity.



REFERENCES

Dineen, T. (1999) Manufacturing Victims. What the Psychology Industry is Doing to People. Revised U.K. edn. London: Constable.

Hubble, M. A., Duncan, B. L. & Miller, S. D. (2002) The Heart and Soul of Change, Washington: American Psychological Association.

Rennie, David, L. (1994). Client's Deference in Psychotherapy. Journal of Counseling Psychology. 41.4.427-437.