A Qualitative study on Curative Factors Influencing Psychotherapeutic Intervention

The awareness of different factors contributing to positive therapeutic outcome would make the process faster and predictable. As Miller (1999) put forward that the positive outcome of intervention depends on “Extra-therapeutic” Factors (40%), Therapeutic Alliance (30%), Therapy Model or Technique (15%), Placebo Effect (15%). The awareness of the curative factors would help to raise the effectiveness of therapeutic interventions. This study intends to examine the role of different curative factors on psychotherapeutic intervention in Indian context. In this study purposive sampling was chosen and the participants included were psychotherapy practitioners and counselors. The study carried out the semi structured interview process to evaluate the different curative factors. Thematic analysis is used to focus on themes within the data. A comprehensive analysis of themes is analyzed and interpreted to understand the factors contributing to effectiveness of the outcome of therapy.


I Introduction
Decades of scientific research studies have documented the effectiveness of psychotherapy. The research reviews of thousands of scientific studies have revealed that nearly 75-80% of patients who enter any kind of psychotherapy show some kind of advantage (Lambert & Ogles, 2004;Wampold, 2001). These decades of careful scientific research stipulate that success of psychotherapy is influenced by the relationship between the therapist and the patient, client, the therapist, the treatment method used by the therapist, and the framework, context and similar other factors.
Research on what factors contribute to psychotherapy success has been explored. The viewpoints that emerged through such research are like many factors account for success (and failure): the patient, the model of therapy treatment method used, the client, the therapist, the framework, the context, and the therapeutic alliance between the therapist and the patient. It was been observed that ideal combination of the aforementioned factors, a suitable fit tend to promote effective treatment.
According to Arkowitz (1989), an understanding of common factors contributing for positive outcome is one of the main routes to psychotherapy integration. By identifying the core therapeutic ingredients that are effective across different forms of psychotherapy (Frank, 1973), it would help the therapists to more actively focus on facilitating those methods as agents of change. The advantage of understanding the common factor is to capitalize on therapeutic elements with demonstrated efficacy while still letting the therapist to work within his basic experienced framework.
Lipsey (1992) meta-analyses result reveals that nearly 22% of the variance in treatment outcomes may be due to length of treatment, and treatment modality. While Karver, Handelsman fields and Bickman (2006) postulated that among the best predictors of youth outcomes were interpersonal skills of counselor, therapist influencing skills, client willingness to participate in treatment, parent willingness to participate in treatment, youth/client participation in treatment, and parent participation in treatment.
To identify and disseminate what works in the therapy relationship, American Psychological Association's (APA) Division of Psychotherapy and Clinical Psychology division jointly sponsored a task force (Norcross, 2011). A series of original meta-analyses is done to investigate the association between elements of the therapy relationship and treatment effectiveness. The results of these 20+ meta-analyses come together to form into a series of conclusions and implications (Norcross, 2011).
• The relationship between therapist and client makes substantial and consistent contributions to patient success in all types of psychotherapy applied for instance the different therapies like CBT, behavioral, psychodynamic, humanistic, and systemic. The therapy relationship and particular treatment method also accounts for why clients improve or fail to improve. • Practitioners' regular monitoring helps to repair alliance ruptures, improve the relationship, modify technical strategies, and avoid premature termination. • The relationship acts in concert with treatment methods used/model, patient/client characteristics, and therapist's qualities in determining effectiveness. • Adapting or tailoring the relationship to several patient characteristics (in addition to diagnosis) enhances effectiveness.
The aforementioned Meta analytic studies showed that the therapeutic alliance is the strong facet of the therapeutic outcome. Therapeutic alliance is largely viewed as involving an agreement between therapist and patient on the goals of treatment. The therapeutic alliance factors like, alliance in adult and psychotherapy, cohesiveness in group therapy, empathy, Goal Consensus and Collaboration, Positive Regard and Affirmation, Congruence/Genuineness are the important factors contributing for positive outcome (Bordin, 1979). He identified three major features of a working alliance including clarity on goals as well as assignment of tasks and the development of bonding between therapist and patient. On the other hand, Ackerman and Hilsenroth (2003) reviewed on therapist characteristics and conclude that the factors found to increase therapeutic alliance are the therapist being flexible, honest, and warm jointly good with interventions such as accurate interpretation and facilitating affective expression.
• Research continues to indicate that therapy is effective to some degree. The next question, however, is what specific methods of therapy help which problems It is been observed from various studies that ample understanding of effective and ineffective factors will help us to consider the various effective determinants and their optimal combinations. However very few qualitative studies was been found on understanding the factors contributing for positive outcome in Indian context. In view of the aforementioned reason, the study intends to examine the contributing effect of different factors like Pharmacological treatment, client factors, therapist factors, Extra-therapeutic Factors, Therapeutic Alliance, Therapy Model or Techniques, Placebo Effect for positive outcome through qualitative approach.
2 Method 2.1 Aim: To understand the factors contributing for positive outcome by conducting a qualitative study.

Problem Statement:
To identify the factors that contributes for positive outcome in a therapeutic intervention process.

Objectives:
• To examine different factors contributing for positive outcome. • To examine the percentage of contribution of different factors. • To examine the sub-curative factors influencing therapeutic outcome.

Participants:
Participants are psychologist, counselors having experience of at least 3 years.

Sampling:
Purposive sampling has been used, the psychologist, counselor are approached and open-ended semi structured questionnaire is conducted.

Research design:
Qualitative research design

Measures:
It is a semi structured field survey. 10 questions based open ended questionnaire is developed.

Procedure:
Using a survey format method the data is collected by giving the open-ended questionnaire to the purposive sample (psychologist, counselor). Based on their answers content analysis is done and the sub themes are derived.

Data Analysis:
• Content and Thematic analysis is carried out to analyse the data.
3 Results and Discussion: The qualitative study is carried out to examine the factors contributing for positive outcome. The following steps are followed for data analysis: • Firstly the study attempts to review Meta analytic studies and have derived different themes from the meta-analytic research studies. • The open ended questionnaire is formed and accordingly the data collected from psychologist and counselor. • The participants are asked for the factors contributing and asked to assign percentage to each theme. • Based on their answers, content analysis is done & importance of each theme is derived through assessing the assigned percentages and second order analysis is applied to identify the recurrent range of responses • By applying a thematic analysis, the sub themes are derived from psychologist and counselors responses on positive outcome of any psychological intervention.
By taking into consideration all the variables, it felt conceivable that the content analysis of the open ended questions may be more indicative of the relevant factors contribute. From the data analysis as shown in table 3.1, for the following themes the percentages is derived and the rank order procedure is followed and range of response is taken which are contributing for positive outcome. The analysis of data concludes that the therapeutic alliance contributes 90% as a curative factor; the frequency repeated is more when compared to other factors. Hence it is ranked as the main factor contributing to positive outcome. "Therapeutic alliance is largely viewed as involving an agreement between therapist and patient on the goals of treatment, the tasks needed to accomplish those goals, and a sense of a personal bond between therapist and patient" -Bordin, 1979. While it is been observed that therapy model is contributing as a second most important factor as per the frequency with percentage of 70%. However the research studies do not support this. As Miller (1999) put forward that the Therapy Model or Technique contributes to only 15%. However the current study concludes that therapy model plays an important role. Thirdly therapist factor is contributing after the above two. Although mostly therapist and client factors are considered equally important in most of the responses and research studies, yet still therapist factor shows the third order in regard to the given percentages in the current study. However, Hubble, Duncan, andMiller (1999, 2005) advocate that successful treatment arises less from a therapist-driven model and more from adopting the client's frame of reference. Extra-therapeutic factors and pharmacological factors seem to contribute as equally as client factor at 50%. However pharmacological factors contribute to 50% often to the case of severe mental disorder. Lastly but still important is the placebo effect that seems to contribute to 30 percent.
In support to objective 1 and objective, the main theme factors are derived and analyses of percentages assigned are shown in Combination with other psychotherapy and Adherence to medication Thematic analysis of the data: As it is shown in the table 3.2, by thematic analysis, the different subthemes contributing to positive outcome are derived from the main themes. The analysis revealed that many factors contribute for positive outcome. The current study concludes that if the therapy process takes care of these variables the results outcome is mostly positive.
The study also tried to analyze the responses based on experience. It was observed that the psychologist and counselors with less experience emphasized more of support, environmental factors, while those who have more experience emphasized on lower symptom severity, use of evidence based therapies, sound case formulation. Similarly, a study by Dimcovic (2001) noted that client's more positive expectations after the start of psychotherapy predicted a greater degree of therapeutic change.
From the above, it can be concluded that awareness of factors would make the process smoother and quicker. By identifying the core therapeutic ingredients that are effective across different forms of psychotherapy (Frank, 1973), it would help the therapists to more actively focus on facilitating those methods as agents of change. The advantage of understanding the common factor is to capitalize on therapeutic elements with demonstrated efficacy while still allowing the therapist to work within their practiced, grounding framework.

Conclusion:
The objectives of the study are to examine the factors leading to positive outcome.
• The present study has shown the order of importance of contributing factor as follows: • Therapeutic alliance derived as a main factor • Therapy model • Therapist factor • Client factor, Extra-therapeutic factor, Pharmacological factor • Placebo • Among each theme the sub themes are derived to understand in detail the factors contributing under each theme. • The factors like empathy, hope, rapport, therapist's/counselor's skills, motivation, perseverance, positive outcome expectancies, readiness to change, supportive environment are some of the important factors derived from the analysis.
5 Limitations of the study: • The subtheme percentages are not taken into consideration • Only psychologist and counselors are considered for this study, the psychiatrist, the patient, the observer would also be a valuable contributor to the study.
6 Implications of the study • Identifying the curative would help to capitalize on therapeutic outcome with demonstrated efficacy. • Identifying the core factors would make the process faster and predictable