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                                               What is Better?

                        A Preliminary Investigation of Between Session Change


                                               Hakan Reuterlov1
                                               Torbjorn Lofgren
                                               Karin Nordstrom
                                                Ann Ternstrom

                                            Family Therapy Team
                                             Danderyd Hospital
                                             Stockholm, Sweden

                                               Scott D. Miller 2
                                               Chicago, Illinois




1
  This paper is dedicated to the memory and work of Hakan Reuterlov, who died tragically and unexpectedly as this
study neared completion.
2
  All correspondence regarding this article and requests for reprints may be sent to: ISTC, POB 578264, Chicago, IL
60657-8264.
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                                          What is Better?

                       A Preliminary Investigation of Between Session Change

        Several studies of pre-treatment change (PTC) have appeared in the solution-focused

literature. Weiner-Davis, de Shazer, and Gingerich (1987) published what most consider the

original solution-focused study on the topic. Briefly, these researchers found that 66% of their

clients reported experiencing positive, treatment-related gains prior to the formal initiation of

therapy when asked about such change at the beginning of their first session. This study was

later replicated with a larger sample by Lawson (1994) who found that 60% of clients reported

positive, complaint-related, PTC. Other research has established a link between PTC and

outcome. For example, solution-focused researchers Beyebach, Morejon, Palenzuela, and

Rodriguez-Aris (1996) found that clients who reported PTC were four times more likely to finish

treatment with a successful outcome.

        Less information and virtually no studies have appeared on the topic of between session

change (BSC) in the solution-focused literature. In their book on problem drinkers, Berg and

Miller (1992) reported that “the majority of our clients report that „it is a bit better‟ when they

return for a second session‟ (p. 130). Other studies have reported client ratings of outcome at

        the end of treatment and at various follow-up periods (c.f., Hopwood and de Jong, 1996;

McKeel, 1996). Still no studies have been published regarding clients‟ session-to-session report

of improvement in solution-focused brief therapy (SFT). This is problematic given the emphasis

placed by proponents of the approach on asking clients “what‟s better?” at the beginning of each

session after the first.

        The general research literature strongly suggests that the majority of people in treatment

experience gains between visits. For example, in a meta-analytic study of nearly 2,500 clients
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seen in a traditional, week-to-week format, 30-40% reported measurable improvement by the

third session, 50-60% by the eighth, and 75% within six months (Howard, Kopte, Krause, &

Orlinsky, 1986). This same literature provides evidence of a link between the client‟s experience

of meaningful change from visit to visit and both continuation in and outcome of treatment

(Miller, Duncan, and Hubble, 1997; Hubble, Duncan, and Miller, 1999).


                                            The Study

       This study sought to determine the percentage of clients reporting positive, treatment-

related gains between sessions of solution-focused brief therapy. Treatment was conducted by

the Family Therapy Team on the Alcohol and Drug Rehabilitation Unit at Danderyd Hospital in

Stockholm, Sweden. The therapists in the study had all trained extensively in SFT at the Brief

Family Therapy Center in Milwaukee, Wisconsin and practiced with regular consultation from a

member of that team (Scott D. Miller). Participants included in the study were 129 Swedish

citizens that had either sought out treatment on their own or been mandated to care by State or

other authorities because of their drug or alcohol use. All cases were seen between October 1993

and April 1994. On average, the participants seen by the Family Therapy team come for 4.5

sessions (range 1 to 10). Over 90% attend 2 or more visits. Previous in-house research has

found that 80% of clients had either met or made significant progress toward their goals while in

treatment with the Family Therapy Team.

       As per standard solution-focused protocol (Berg and Miller, 1992; de Shazer, 1996), all

clients in the study were asked, “What is better since the last visit?” at the beginning of each

session following the first. Team members watching the case behind a one-way mirror recorded

the client‟s response on a protocol form. If the client reported any change, the team members

recorded a “yes,” no change or worsening was recorded as “no.” At the conclusion of each
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interview, all clients were asked the scaling question; “If 10 is when this problem is solved, and

1 is when this problem was at it‟s worst, where would you say things are on the scale today?”

The team also recorded these responses.

       Specifically, clients who had answered “yes” to the “what‟s better” question and whose

score on the scale was higher than in their previous visit were recorded “yes-better.” Those who

answered “yes” to the initial question but reported a scaling score that was the same as on their

last visit were recorded “yes-same.” Clients who said they were better but reported a lower

scaling score than in their previous session were recorded “yes-worse.” Similarly, clients who

answered “no” to the “what‟s better?” question but gave a higher score on the scaling question

than in their previous visit were recorded “no-better.” Those who answered “no” to the initial

question and whose score was the same as on their last visit were recorded “no-same.” And

finally, clients who said there were not better and reported a lower scaling score than in their

previous visit were recorded “no-worse.”

       Using this format, usable information was obtained on all of the original 129 clients over

a total of 93 sessions. The results are summarized in Table 1.

                                               Table 1

                                   What‟s Better by Scaling Scores

                          Better        Same             Worse          Total
                  Yes     79            19               0              98

                  No      4             13               14             31



                                             The Results

       As can be gleaned from the table, 98 out of 129 or 76% of clients answered that

something was better from session to session of solution-focused therapy when asked at the
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beginning of the visit. Of this group, 79 or 81% confirmed their initial report of improvement

with a higher scaling score taken at the end of the visit. When the four cases who initially

answered “no” to the “what‟s better?” question but later reported a higher scaling score are

added (98 + 4), nearly 80% of the total sample indicated that some improvement had taken place

between visits.

        At the same time, 31 out of 129 or 24% of the clients answered that nothing was better

from session to session of solution-focused therapy when asked at the beginning of the visit. Of

this group, an equal number confirmed their initial reported by reporting via their answer to the

scaling question that they were either the same or worse than on their previous visit. Only 4 or

13% (4 / 31) of those initially reporting no change went on to report change via the scaling

question at the end of the visit.

                                            Discussion

        In this study, the preponderance of clients (76%) reported experiencing treatment-related

gains between sessions when asked at the outset of each visit. Moreover, clients‟ reports of

change at the beginning of sessions were largely consistent with their answer to the scaling

question at the end of the visits. For example, over 80% of those reporting change in response to

the “what‟s better?” question reported a higher end-of-session scaling score than in their

previous session. Similarly, nearly 90% of those who reported no change at the outset of the

session confirmed their initial report with a scaling score that was the same or worse than in their

previous session.

        These findings are both similar and different from research on PTC. To begin, similar to

the research on PTC, the present study finds that a large percentage of people will report

treatment-related gains when asked about it at the outset of the session. In contrast to the
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original study of PTC by Weiner-Davis et al. (1987), however, the present study did not find that

clients reporting no change at the outset of any given session were likely to, “recall . . . changes

later in the session” (p. 361). Indeed, only 13% who initially said things were not better went on

to report change via the scaling question at the end of the visit.

       Several possible explanations for this difference were considered. For example, one idea

was that the therapists may have failed to use appropriate solution-focused techniques for

“constructing the interval between sessions as having included some improvement” (de Shazer,

1996, p. 135). Miller, Duncan, and Hubble (1997) advanced this idea based on a preliminary

report of the data from this study (see p. 50). However, more clients and a review of the

videotapes proved otherwise. In each case, the therapist had attempted to listen and punctuate

client stories for change. In the end, the most likely explanation for the difference is the small

sample size of the Weiner-Davis et al. (1987) study (N = 30). The number of clients not

reporting PTC in that study was only 10 and no exact figure was reported for those said to,

“recall pretreatment changes later in the session.” Such small numbers can magnify very small

differences in the data that are unrelated to the variables under study.

       The present research suggests that clients reports of a lack of progress at the outset of the

visit be taken seriously and not subjected to any therapeutic maneuver aimed at “re-framing,”

“re-storying,” or “re-constructing” the time between sessions as a success. Specifically, reports

of a lack of change likely signal the need to alter treatment in order to maintain the relationship

and increase the chances of success. This conclusion is bolstered by other studies which have

found that the client‟s experience of meaningful change in the first few visits is one of the best

predictors of eventual treatment outcome (Miller, Duncan, and Johnson, 1999). Indeed, in one

study of several thousand therapists and clients conducted not in a laboratory but real world
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setting, researchers found that clients reporting no improvement by the third visit on average

showed no improvement over the entire course of treatment! In addition, clients who worsened

by the third visit were twice as likely to drop out of treatment than those experiencing

improvement (Brown, Nace, and Dreis, 1999).
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                                          References

Berg, I.K., and Miller, S.D. (1992). Working with the Problem Drinker. New York: Norton.

Beyebach, M., Rodriguez-Morejon, A.R., Palenzuela, D.L., and Rodriguez-Arias, J.L. (1996).

       Research on the process of solution-focused brief therapy. In S. Miller, H. Hubble, and

       B. Duncan (eds.). Handbook of Solution-Focused Brief Therapy. San Francisco, CA:

       Jossey-Bass, 299-334.

Brown, J., Nace, and Dreis (1999). What works in therapy and why does managed care want

       to know. In Hubble, M.A., Duncan, B.L., and Miller, S.D. (eds.) (1999). The Heart and

       Soul of Change. Washington, D.C.: APA Press.

De Shazer, S. (1996). Words were originally magic. New York: Norton.

Hopwood, L. and de Jong, P. (1996). Outcome research on treatment conducted at the Brief

       Family Therapy Center, 1992-3. In S. Miller, M.A. Hubble, and B.L. Duncan (eds.).

       Handbook of Solution-Focused Brief Therapy. San Francisco, CA: Jossey-Bass, 272-

       298.

Howard, K.I., Kopte, S.M., Krause, M.S., and Orlinsky, D.E. (1986). The dose-effect

       relationship in psychotherapy. American Psychologist, 41(2), 159-164.

Hubble, M.A., Duncan, B.L., and Miller, S.D. (eds.) (1999). The Heart and Soul of Change.

       Washington, D.C.: APA Press.

Lawson, D. (1994). Identifying pretreatment change. Journal of Counseling and Development,

       72, 244-248.

Miller, S.D., Duncan, B.L., and Hubble, M.A. (1997). Escape from Babel. New York: Norton.

Miller, S.D., Duncan, B.L., and Johnson, L.D. (1999). The Verdict is the Key. Family Therapy

       Networker (March/April).
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Weiner-Davis, M., de Shazer, S., and Gingerich, W.J. (1987). Building on pretreatment change

       to construct the therapeutic solution. Journal of Marital and Family Therapy, 13(4), 359-

       363.

								
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