Department of Psychology, Boston University, MA 02216, USA.
J Consult Clin Psychol. 2013 Jun;81(3):443-54. doi: 10.1037/a0031437. Epub 2013 Jan 21.
Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change.
(a) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change.
Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment.
Significant between- and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity.
Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.
尽管与结果的关联并不一致，但治疗师的依从性和能力仍然受到关注，尤其是在越来越关注基于证据的治疗方法的传播、实施和可持续性的背景下。迄今为止，关于治疗师依从性和能力的研究主要集中在治疗师的平均水平上。除了少数例外，研究未能解决依从性和能力的多种来源的可变性，确定可能导致可变性的重要因素，或者在检查与症状变化的关联时考虑这些可变性来源。
（a）从统计学上证明依从性和能力评分的治疗师间和治疗师内变异性，并检查患者特征作为这种变异性的预测因素；（b）检查依从性/能力与症状变化之间的关系。
从认知行为治疗惊恐障碍的随机对照试验中随机选择录音会话进行治疗师依从性和能力评分。患者在每次治疗前完成惊恐症状严重程度的自我报告量表，在治疗开始前完成人际问题清单-人格障碍量表。
观察到依从性和能力的显著治疗师间和治疗师内变异性。依从性和能力在治疗过程中显著恶化。较高的患者人际攻击性与依从性和能力的下降有关。无论是依从性还是能力都不能预测随后的惊恐严重程度。
在对照试验中可以观察到依从性和能力的变异性和“漂移”。培训和实施工作应涉及对多个病例的持续咨询，以考虑到相关的患者因素，并促进在多个疗程和患者之间的可持续性。
