A Review and Critical Appraisal of 2008

Health Technology Assessment 2008; Vol. 12: No.
24
Health Technology Assessment 2008; Vol. 12: No. 24
A review and critical appraisal of

measures of therapistpatient
interactions in mental health settings
J Cahill, M Barkham, G Hardy, S Gilbody,
Therapistpatient interactions in mental health settings

D Richards, P Bower, K Audin and J Connell
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J Cahill,1* M Barkham,2 G Hardy,2 S Gilbody,3

D Richards,4 P Bower,5 K Audin1 and J Connell1
1
Psychology Therapies Research Centre, University of Leeds, UK
2
Clinical Psychology Unit, Department of Psychology, University of Leeds,
UK
3
Academic Unit of Psychiatry and Behavioural Sciences, University of
Leeds, UK
4
Department of Mental Health Nursing, University of Manchester, UK
5
National Primary Care Research and Development Centre, University of
Manchester, UK
* Corresponding author. Present address: Institute of Psychological Sciences,

University of Leeds, UK
Declared competing interests of authors: none
Published June 2008
This report should be referenced as follows:
Cahill J, Barkham M, Hardy G, Gilbody S, Richards D, Bower P, et al. A review and

critical appraisal of measures of therapistpatient interactions in mental health settings.
Health Technol Assess 2008;12(24).
Health Technology Assessment is indexed and abstracted in Index Medicus/MEDLINE,

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Abstract
A review and critical appraisal of measures of therapistpatient
J Cahill,1* M Barkham,2 G Hardy,2 S Gilbody,3 D Richards,4 P Bower,5 K Audin1
and J Connell1
1
Psychology Therapies Research Centre, University of Leeds, UK
2
Clinical Psychology Unit, Department of Psychology, University of Leeds, UK
3
Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, UK
4
Department of Mental Health Nursing, University of Manchester, UK
5
National Primary Care Research and Development Centre, University of Manchester, UK
* Corresponding author. Present address: Institute of Psychological Sciences, University of Leeds, UK
Objectives: To assemble and to appraise critically the associated with them) were framework, therapist and
current literature on tests and measures of patient engagement, roles, therapeutic techniques and
therapistpatient interactions in order to make threats to the relationship. These areas relate to the
recommendations for practice, training and research, three key developmental processes outlined above. Of
and to establish benchmarks for standardisation, the 83 measures matching the content domain, 43 met
acceptability and routine use of such measures. the minimum standard. A total of 30 measures
Data sources: Major electronic databases (including displayed adequate responsiveness or precision. None
PsycINFO) were searched from inception to 2002. of the 43 measures that met the minimum standard
Review methods: A comprehensive conceptual map was fully addressed in terms of acceptability and
of the subject area of therapistpatient interactions was feasibility evidence. The majority of these measures
developed through data extraction from, and analysis had three or fewer components described. Therefore,
of, studies selected from the literature searches. The out of a total of 83 measures matching the content
results of these searches were assessed and appraised domain, no measure could be said to have met an
to produce a set of possible therapistpatient industry standard.
measures. These measures were then evaluated. Conclusions: The findings indicate that the
Results: The contextual map included the various therapistpatient interaction can be measured using a
concepts and domains that had been used in the wide range of instruments of varying value. However,
context of the literature on therapistpatient due care should be taken in ensuring that the measure
interactions, and was used to guide the successive is suitable for the context in which it is to be used.
stages of the review. Three developmental processes Following on from this work, it is suggested that
were identified as necessary for the provision of an specific research networks for the development of
effective therapeutic relationship: establishing a therapistpatient measures should be established, that
relationship, developing a relationship and research activity should prioritise investment in
maintaining a relationship. Eighty-three increasing the evidence base of existing measures
therapistpatient measures having basic information on rather than attempting to develop new ones, and that
reliability and validity were identified for critical research activity should focus on improving these
appraisal. The areas of the conceptual map that existing measures in terms of acceptability and
received most coverage (i.e. over 50% measures feasibility issues.
iii
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Contents
List of abbreviations .................................. vii Candidate measures by theoretical
orientation/discipline and perspective ....... 26
Executive summary .................................... ix Candidate measures by theoretical
orientation and population group ............. 26
1 Background to the project ........................ 1 Measures meeting the minimum
Main effects model ..................................... 1 standard ...................................................... 26
Contextual model in search of common Developing an industry standard for
factors ......................................................... 1 research ...................................................... 27
The measurement agenda ......................... 2
Overall aims of project ............................... 3 6 Conclusions and recommendations for
further research ......................................... 29
2 The conceptual map .................................. 5 Conclusions ................................................ 29
Scoping review ........................................... 5 Recommendations for further
Introduction to the conceptual map .......... 6 research ...................................................... 29
Establishing the relationship ..................... 7
Developing the relationship ....................... 9 7 Clientpractitioner interaction: future
Maintaining the relationship ..................... 10 directions ................................................... 33
Patient factors ............................................. 12 Addendum to 2003 report ......................... 33
Therapist factors ........................................ 13 Terminology ............................................... 33
Contextual factors ...................................... 13 Quality appraisal criteria ........................... 33
Roles ........................................................... 15 Use of Fitzpatrick criteria .......................... 35
Framework of the relationship ................... 15 Inter-rater reliability estimates .................. 35
Summary .................................................... 16 Conclusions and recommendations ............ 39
3 Review to identify candidate measures of Acknowledgements .................................... 41

patienttherapist interaction .................... 17
Review question .......................................... 17 References .................................................. 43
Literature searching techniques ................. 17
Selection of measures and associated Appendix 1 Search strategy used for
studies ......................................................... 18 scoping review (18862002) ....................... 49
Working list of measures ............................ 18
Appendix 2 Data summary sheet used for
4 Appraising the psychometric attributes scoping review ............................................ 51
of measures of therapistpatient
interaction .................................................. 19 Appendix 3 Measures search strategy ....... 53
Overview ..................................................... 19
Psychometric sieve ...................................... 19 Appendix 4 Measures excluded by the
Excluded measures ..................................... 20 electronic sieve ........................................... 59
Data extraction ........................................... 21
Access database .......................................... 22 Appendix 5 Measures excluded on the basis
Measure summaries .................................... 22 of content ................................................... 61
5 Results ........................................................ 25 Appendix 6 Database access extraction

Primary evidence associated with candidate forms .......................................................... 63
measures ..................................................... 25
Content of candidate measures ................. 25 Appendix 7 Data summary sheet .............. 67
Psychometric properties of candidate
measures ..................................................... 26 Appendix 8 Measure summaries ............... 71
v
Contents
Appendix 9 Content description of Health Technology Assessment reports

candidate measures .................................... 391 published to date ....................................... 409
Appendix 10 Psychometric properties of Health Technology Assessment

candidate measures .................................... 399 Programme ................................................ 425
vi
List of abbreviations
ACL Adjective Check List MSA multidimensional scale analysis
ADHD attention deficit hyperactivity NA not applicable

disorder
NA nursing assistant
ANOVA analysis of variance
ns not significant
BDI Beck Depression Inventory
PCA principal components analysis
BPD borderline personality disorder
PCM Paragraph Completion Method
CBT cognitive behavioural therapy
PCS Psychotherapy Check Sheet
CFA confirmatory factor analysis
PTSD post-traumatic stress disorder
CST client speaking turns
RE relationship episode
df degrees of freedom
RIA racial identity attitude
FAQ frequently asked question
RN registered nurse
GAS Goal Attainment Scaling
SCA simultaneous components
ICC intraclass correlation coefficient analysis
IIP Inventory of Interpersonal SD standard deviation

Problems
SE standard error
IPR interpersonal process recall
STDP short-term dynamic
ISQ Interpersonal Schema psychotherapy
Questionnaire
TSF Twelve-Step Facilitation
LOF Level of Facilitation
TSR Therapy Session Report
MANOVA multivariate analysis of variance
All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or
it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices in which case
the abbreviation is defined in the figure legend or at the end of the table.
vii

viii
Executive summary
Background Literature searches
As a first step to defining the kinds of
There is currently considerable practice and questions/areas to be addressed by the review, a
research activity arising from the drive to establish pinpoint exercise was conducted at the first
a secure evidence base for interventions and steering group meeting. The participants came
treatments in mental healthcare. However, this from a variety of professional and academic
line of research has followed a main effects model; backgrounds (clinical psychology, counselling,
that is, one that attempts to determine main liaison psychiatry, psychiatric nursing, primary
effects in mental healthcare delivery that can be care). The final search strategy was run on the
labelled as specific factors influencing outcome. PsycINFO database (18862002). The
While such a line of research has covered development of the search strategy was a highly
important components in the delivery of effective iterative process, involving frequent and intensive
mental healthcare, these components do not collaboration with the library team.
explain the activity between therapist and patient,
as reflected by common factors. There has been Selection and rating of studies
increasing evidence of the important role played All references were incorporated into a database
by common factors, which operate across different and independently assessed by two project
kinds of therapies (psychological and drug). It is members acting as raters. Abstracts were included
therefore important to focus on the question of on the basis of the following criteria: therapist
how to secure reliable and valid measurement of (however defined); patient (however defined); all
core processes. In the context of clinical therapistpatient interactions in mental health
governance and the increasingly central role irrespective of setting, clinical background, training
placed on user perspectives, the quality of the and orientation; all populations; all psychological
interactions between therapist and patient therapies; review or conceptual/theoretical papers;
becomes paramount. With regard to the field of no time span limit. All abstracts which met the
therapistpatient interactions, it is essential that above inclusion criteria were then rated on a five-
measures are subject to quality-control procedures. point scale in order of content relevance to the
project (5 = most relevant to 1 = least relevant).
Objectives Data extraction

All articles rated 4 and 5 were data extracted by
The purpose of this report has been (1) to project staff hired specifically for this level of
assemble the current literature on tests and work, using a data summary sheet. The purpose of
measures of therapistpatient interactions; (2) to the summary sheet was to summarise
subject this literature to critical appraisal with the comprehensively information on areas pertinent to
aim of making recommendations for practice, the scoping review (e.g. therapistpatient
training and research; and (3) to establish interaction measured, theoretical orientation,
benchmarks for standardisation, acceptability and measures used). The data summary sheets from
routine use of such measures. the 5-rated articles were then analysed to
produce a conceptual map of the subject area.
Methods I Data analysis

Three people independently read and listed key
Conceptual map themes and concepts from the summary sheets.
Literature scoping The three lists were then combined and reviewed.
The initial aim of the project was to scope out the Similar themes were combined and grouped.
subject area of therapistpatient interactions. The During this process the summary sheets were
purpose of the scoping review was to develop a revisited to check that the list of themes was
comprehensive conceptual map of the review area. grounded in the articles. Using qualitative
ix

Executive summary
methodology, items were then grouped and literature on therapistpatient interactions, and
reduced as overlapping terms and concepts were was used to guide the successive stages of the
identified. review.
Review of therapistpatient measures Three developmental processes were identified

Literature searches as necessary for the provision of an effective
The explicit aim was to include all possible therapeutic relationship: establishing a
relevant literature relating to both studies of relationship, developing a relationship and
therapistpatient interactions and tests/measures maintaining a relationship.
of interactions. This review involved the search of
a diverse range of electronic and non-electronic Review of therapistpatient
sources to maximise the likelihood of capturing measures
all relevant material. As there is no single Candidate measures
electronic database that is comprehensive enough Eighty-three measures were identified having basic
in either subject or publication format coverage information on reliability and validity for critical
to retrieve all articles relevant to the review appraisal.
question, a range of electronic databases was
searched. All electronic searches covered the years Content coverage
18862002. The general strategy was to combine The areas of the conceptual map that received
the search used for the scoping exercise with a most coverage (i.e. over 50% measures associated
search strategy containing specific descriptors such with them) were framework, therapist and patient
as assessment instruments and tests and engagement, roles, therapeutic techniques and
measures. threats to the relationship. These areas relate to
the three key developmental processes outlined
Selection and rating of studies above.
Two project staff sifted through these references
and extracted a list of candidate measures using Eighty-six per cent of the measures were
specified inclusion and exclusion criteria. A series developed in the USA. The remaining measures
of desirable attributes for psychometric were developed in the UK, Canada, Australia and
instruments was selected from a recent systematic Germany. The majority of the measures were
review commissioned by the UK HTA Programme. developed within pan-theoretical or
These were classified under the six broad headings psychodynamic/psychoanalytic perspectives, were
of reliability, validity, responsiveness, precision, observer rated and related to adult population
acceptability and feasibility. groups.
Data extraction Psychometric status

Summaries of each of the criteria were entered into Of the 83 measures matching the content
an electronic database and key references addressing domain, 43 met the minimum standard. A total of
each attribute were cross-referenced using the 30 measures displayed adequate responsiveness
relational functions of the database. A measure or precision. None of the 43 measures that met
summary sheet was designed to address each of the the minimum standard was fully addressed in
six psychometric properties. All information terms of acceptability and feasibility evidence.
pertaining to these criteria was retrieved from the The majority of these measures had three or
database and entered on to the summary sheet. fewer components described. Therefore, out of a
total of 83 measures matching the content
Quality appraisal domain, no measure could be said to have met an
Two research staff then applied coding industry standard.
instructions for quality assessment to each of the
six criteria. This procedure required consensus
between the two staff. Conclusions
The findings from the report indicated that the
Results therapistpatient interaction can be measured
using a wide range of instruments of varying
Conceptual map value. Due care should be taken in ensuring that
The map included the various concepts and the measure is suitable for the context in which it
x domains that had been used in the context of the is to be used.
Recommendations for further base of existing measures rather than

attempting to develop new ones. Where
research research effort and time is invested in new
The following recommendations for further measures this should be done strategically in a
research are listed below in priority order. fashion that will service national policy needs.
It is recommended that research activity should
Specific research networks for the development focus on improving existing measures in terms
of therapistpatient measures should be of acceptability and feasibility issues.
established.
It is recommended that research activity should
prioritise investment in increasing the evidence
xi

Chapter 1
Background to the project
his chapter sets out the background and aims Statistical Manual of Mental Disorders (DSM-IV)
T for a review and critical analysis of studies
assessing the nature and quality of
or the Tenth Revision of the International
Classification of Diseases and Related Health
therapistpatient interactions in the treatment of Problems (ICD-10) classifications, and
patients with mental health problems. (2) treatments via attempts to define a set of
empirically supported treatments;5 that is,
treatments supported by a robust research
Main effects model evidence base. This paradigm has been wholly
consistent with the evidence-based practice
There is currently considerable practice and movement. It is also consistent with the search for
research activity arising from the drive to establish specific effects.
a secure evidence base for interventions and
treatments in mental healthcare. This activity
incorporates primary, secondary and tertiary Contextual model in search of
services and is driven by, among other things, the common factors
desire to plan and deliver high-quality but cost-
effective services to patients as set out in the Informative though this strategy is, it does not
National Service Framework for Mental Health.1 take into account major aspects of activity
occurring between patient and the mental health
Research initiatives professional as reflected by common factors. The
A range of initiatives has fed into this activity. interest in common factors has reflected the view
These include the following: ongoing Cochrane that differences in outcomes (in psychological
Reviews of mental health interventions,2 treatments as well as drug treatments) can be
a comprehensive and critical review of the accounted for by factors that cut across differing
psychotherapies3 and clinical practice guidelines therapies and other interventions, rather than
for, among others, treatment choice in necessarily factors that are specific or unique to
psychological therapies and counselling.4 individual interventions or treatments. Estimates
However, almost without exception, the conceptual as to the extent of the common factors effect
models upon which reviews are based have differ, but they vary from 30% for common factors
followed a main effects model. A main effects versus 15% for specific factors6 to 70% for general
model is one that attempts to determine main factors versus 8% for specific factors.7 (These
effects in mental healthcare delivery that can be percentages refer to the explained variance in
labelled as specific factors influencing outcome. outcomes.)
Hence, the focus has been on, for example, issues
of psychiatric diagnosis with the aim of Evidence for common factors
establishing which mental health intervention There has been increasing evidence of the
works best for which disorder and attributing the important role played by common factors, which
effect or outcome to specific components of the operate across different kinds of therapies
intervention. (psychological and drug). Rosenzweig first
proposed the concept of common factors in 1937.8
Limitations of the main effects model He suggested that common factors existed across
While such a line of research has covered differing forms of psychotherapy and that the
important components in the delivery of effective most salient ones would include the relationship
mental healthcare, these components do not and that they all involved a system of explanation
explain the activity between therapist and patient, (i.e. by the therapist to the patient). Importantly,
although the important role of this relationship Rosenzweig proposed that because common
has been acknowledged.4 The focus on diagnoses factors were so omnipresent, any comparative
and treatments comes in part from the respective treatment study would be expected to show non-
investments in developing specific taxonomies for significant differences in outcomes. The
classifying: (1) diagnoses via the Diagnostic and commonality between and across interventions has 1

Background to the project
been espoused,9 and there has been a consistent The measurement agenda
message from intervention studies suggesting that
there is broad equivalence of outcomes,10 although The Department of Health has recently instigated
there are clear exceptions within specific policy initiatives to steer services towards
disorders.3 For example, cognitive therapies, recognising the need to standardise outcome
strongly driven by technique (specific factors), are measurement procedures. There has been a
recommended for specific phobias. In other forms specific call for services to Incorporate measures
of treatment, the context in which the treatment is of outcome into your psychological therapies
offered or delivered, particularly the relationship service as a matter of routine.17 In addition, the
between patient and therapist, remains an Outcomes measures implementation: best practice
important factor in the successful delivery of guidance18 has built on this call and subsequently
treatment. For example, drug placebo conditions identified four levels of outcome activity,
have been found not to be significantly less incorporating measurement, data monitoring,
effective than active psychological treatments, and service and treatment management, and
patients in such conditions have rated similar benchmarking.
levels of therapeutic alliance to those patients
receiving active psychological treatments.11 This report, focusing as it does on the process
between therapist and patient, has the potential to
Common factors associated with complement and counterbalance the outcome
therapistpatient interaction agenda by focusing on important factors that may
Factors that have been associated with the be salient in the broader context of outcomes.
therapistpatient interaction include the Indeed, they may be predictive of outcomes or, as
therapistpatient relationship and alliance12 stated earlier, moderate them. However,
concepts, with a key component being the comparatively little effort has been expended on
interdependence of one with the other. For organising process measures. The review of
example, research on the concepts of attachment13 recommended measures by Hill and Corbett19 has
and of the repair of patienttherapist ruptures,14 been the most recent and notable attempt to
engagement and responsiveness15 all contribute to provide a consensus for researchers on which
this knowledge base. Other factors include the process measures to use. The review was
shared attitudes and beliefs of patients, holding conducted in an effort to promote cohesiveness
similar views of the world, and so on.7 However, and unity in process research. However, the review
these concepts may not only play an important also noted that 38% and 49% of the process
role in determining patient outcomes, but also measures used in studies in Journal of Counseling
show differential impacts across service settings or Psychology and Journal of Consulting and Clinical
explain the influence of other variables on patient Psychology, respectively, were study-specific
outcomes. That is, they can act as both moderators measures and not used subsequently. This
and mediators in clinical settings. A moderated tendency had been noted 20 years previously by
relationship occurs when a relationship is found to Strupp20 and Kiesler.21
hold for some categories of a sample but not
others. For example, the importance of the Measuring therapistpatient
therapistpatient interaction may be different interactions
within primary care settings (e.g. doctorpatient One striking issue has always remained, that of
interactions where the length of interactions may how to measure common factor components. For
be relatively short) as opposed to psychotherapy example, there was considerable effort in
settings (e.g. therapistpatient alliance) and measuring common factors such as empathy
settings in which mental health professionals, during the 1970s (see Hill and Corbett19 for
including nurses, work with patients experiencing overview), but the resulting yield in terms of
severe and enduring illness (e.g. engagement with enhancing the quality of care has been small.
service). A mediator may be thought of as an More recently, there has been a concerted effort in
intervening variable; that is, the therapistpatient developing measures of, for example, the
relationship provides an explanation of the impact therapeutic alliance.22,23
of another variable on outcome. For example, the
therapistclient alliance has been shown to This issue has been ever present in research on
mediate the effect of interpersonal style on the psychological therapies: how to secure reliable
outcome; that is, the relationship between and valid measurement of core processes. In the
interpersonal style was attenuated by the context of clinical governance and the increasingly
2 intervening variable of alliance.16 central role placed on user perspectives, the
quality of the interactions between therapist and that progressing a common factors approach
patient becomes paramount. With regard to the would therefore span all theoretical models and
field of therapistpatient interactions, it is have wide applicability in healthcare settings.
essential that measures are subject to quality- Hence, in this review, the term therapist is viewed
control procedures. When aggregating results as including any mental health professional (e.g.
across studies it is necessary not only that the same doctors, psychiatrists, nurses, clinical psychologists
measures are used, but also that these measures and counsellors) and patient as any user of a
have been proven to meet established, acceptable mental health service.
criteria. The importance of clientpractitioner
interaction research lies in its ability to determine
and delineate the change mechanisms in therapy Overall aims of project
due to the therapeutic relationship. Using
measures that do not meet criteria has The purpose of this report is to assemble the
implications for hypothesis testing in this field. current literature on tests and measures of
The use of psychometrically sound measures will therapistpatient interactions and subject this
ensure that researchers and practitioners will be literature to critical appraisal with the aim of
able to determine reliably what leads to outcome making recommendations for practice, training
and will enable new models of therapy to be and research. The authors recommend minimum
successfully developed. standards for acceptability for measuring
therapistpatient interactions, and the current
The importance of a common factors approach tests are synthesised into a database with the aim
therefore lies partly in its not being specific to any of making this available via a website to other
single school of intervention and partly in the fact researchers and practitioners.

Chapter 2
The conceptual map
Scoping review employed. The authors met the librarians
responsible for designing the search strategy to
The initial aim of the project was to scope out the discuss the broad aims and content area of the
subject area of therapistpatient interactions. The scoping review. It was decided, in the first
purpose of the scoping review was to develop a instance, to design a search strategy to be used on
comprehensive conceptual map of the review area. the PsycINFO database, as its scope seemed the
The map would include the various concepts and most relevant to the proposed content area of the
domains that had been used in the context of the review. The development of the search strategy
literature on therapistpatient interactions (e.g. was a highly iterative process, involving frequent
attachment and alliance), and would be used to and intensive collaboration with the library team.
guide the successive stages of the review. Each draft of the search strategy was tested on the
PsycINFO database to gauge its sensitivity (recall)
Development of a search strategy and specificity (precision). Sensitivity is a measure
Scoping searches typically include searching for of the comprehensiveness of a search strategy, that
existing reviews relevant to the reviews objectives. is, its ability to identify all relevant articles on the
Therefore, any electronic search strategies needed topic under review. Specificity is a measure of the
to be carefully tailored to the research questions. ability of the search to exclude irrelevant articles.
As a first step towards defining the kinds of Searches with high sensitivity tend to have low
questions/areas to be addressed by the review, a specificity. As the purpose of the scoping review
pinpoint exercise was conducted at the first was to be as inclusive as possible, it was decided
steering group meeting. The participants came that the strategy should be oversensitive. The
from a variety of professional and academic result was a large number of false drops
backgrounds (clinical psychology, counselling, (irrelevant articles). However all references went
liaison psychiatry, psychiatric nursing, primary through a selection process, as described below.
care). Participants (n = 8; MB, GH, SG, CA, DR, The final search strategy, which was run on
PB, JCa, KA) were instructed to write down words PsycINFO database from 1886 to 2002, is
pertaining to therapistclient interaction on Post-it presented in Appendix 1.
notes. A list of 36 key terms was generated and
these are presented alphabetically in Box 1. Selection and rating of studies
A total of 5644 hits was returned from the
To assist in the design of an effective electronic PsycINFO database. All references were
search strategy, information experts from the transported into an Endnote database and
University of Leeds Library (MG and SM) were independently sifted by two project members
BOX 1 Keywords
Accept*; Adherence (medical model); Agreement; Alliance; Attachment

Boundaries
Communication; Compliance; Concordance; Contract; Core skills; Counter-transference
Dialogue; Disagreement
Engagement/non-engagement; Expectation of outcome
Friendship
Getting on (e.g. with healthcare practitioner)
Interaction; Involvement
Keeping in touch with services
Length; Like*
Partnership; Patient-centred interviewing; Patient centredness; Power
Relationship; Rupture (and repair)
Sharing power
Therapeutic bond; Therapeutic*; Transference; Trust; Turning up for treatment
Working relationship
5

The conceptual map
acting as raters (JCa and KA). Sifting refers to the analysed by GH (see below) to produce a
process by which inclusion criteria were applied to conceptual map of the subject area.
each abstract. Abstracts were included on the basis
of the following criteria: Data analysis
Key terms and concepts were identified from the
therapist (however defined) summary sheets. Three people (GH, KP, KB)
patient (however defined) independently read and listed key themes and
all therapistpatient interactions in mental concepts from the summary sheets. The three lists
health, irrespective of setting, clinical were then combined and reviewed. Similar themes
background, training and orientation were combined and grouped. During this process
all populations the summary sheets were revisited to check that
all psychological therapies the list of themes was grounded in the articles.
review or conceptual/theoretical papers Using qualitative methodology, items were then
no timespan limit. grouped and reduced as overlapping terms and
concepts were identified.
The above inclusion criteria were specified to
ensure that the scoping review would contain as Two methods of validation were used. First, the 4-
wide a range of articles as possible provided they rated articles were subject to the same procedure
had a bearing on the subject matter. as above with the aim of identifying any new
themes and modifying existing ones. This
Abstracts were allocated to three categories of in, continued until no new themes were being
out or possible. All abstracts were categorised by identified. Secondly, the map containing the
JCa and KA. Any discrepancies between the two grouped themes was scrutinised by the whole
project members concerning the status of an research team for comprehensiveness, face validity
abstract were resolved by consensus and usefulness. Each theme was then considered
agreement/discussion. This left 150 articles that in relation to the remaining themes. Such
were rated as in. All abstracts that met the above grouping led to the generation of a number of
inclusion criteria according to the individual/joint models, which again were discussed with the whole
judgement of the two project team members were research team, and the model shown in Figure 1
then rated on a five-point scale in order of content was agreed. Themes within the stages of the map
relevance to the project (5 = most relevant to or model are detailed in the following sections. In
1 = least relevant). Hard copies of articles were addition, two members of the team (PB, DR)
ordered beginning with those rated as 5. Articles examined the map with the associated references
rated 4 and 3 were also ordered. to ensure the adequacy of the audit trail.
Theoretical saturation
Scoping searches were conducted on the Introduction to the conceptual
MEDLINE and EMBASE databases. However, it map
was decided that a point of theoretical saturation
had been reached when no new domains of The therapist, the patient and the relationship
patient interaction were being identified. they establish all contribute to the experience and
Theoretical saturation was a function of the scope effects of treatment within mental health services.
of the review and the inclusion criteria described For example, even in trials where enormous effort
above, in that studies had not been restricted by is made to control the effects of individual
therapy type or clinical background. therapists, an average of over 6% of the outcome
variance is due to therapists.24 Similarly, the
Data extraction effects of personal characteristics of patients on
All articles rated 4 (n = 67) and 5 (n = 45) were treatment outcome remain over and above
data extracted by a further two project staff hired diagnostic symptoms.25 Finally, the quality of the
specifically for this level of work (KP and KB). The therapistpatient relationship is not just a by-
data summary sheet is presented in Appendix 2. product of therapeutic success, but it is the most
The purpose of the summary sheet was to consistently reported predictor of successful
summarise comprehensively information on areas outcome, with overall effect sizes of between 0.21
pertinent to the scoping review (e.g. and 0.25.26 Indeed, these authors present a
therapistpatient interaction measured, theoretical summary of the literature on predictors of
orientation, measures used). The data summary outcome in psychotherapy, showing that 15% of
6 sheets from the 5-rated articles were then outcome is due to expectancy effects, 15% due to
techniques, 30% due to common factors which For example, a therapeutic relationship may be
primarily involve the therapeutic relationship, and well developed when there is a break in treatment,
40% to extratherapeutic change.26 resulting in patient-reported dissatisfaction. The
therapist will work to repair this rupture in the
So, what do we understand about the therapeutic relationship and may also return to the use of
relationship and what are the active ingredients engagement skills.
that promote patient change? In trying to answer
these questions the authors have drawn together Therapist, patient and contextual factors determine
the literature to identify the elements of the the nature of the roles and frameworks within
relationship that impact on the quality of the which the therapeutic interactions take place.
therapistpatient relationship. In some cases there These in turn impact on the processes and
is evidence from empirical studies that these outcomes of each phase of the relationship.
aspects of the relationship also impact on
treatment outcome. Although the primary goal in The description of the map begins from the right
this review has not been to consider treatment of Figure 1 going through the processes and
outcome, inevitably many of the articles that were objectives of each phase of the relationship. Next,
reviewed have considered this. Therefore, the the patient, therapist and contextual factors that
authors have indicated where there is evidence moderate the frameworks of, and roles taken, in
that treatment or therapy outcomes improve as a the relationship are described. Figure 1 gives
consequence of establishing certain aspects of the examples of the components of the levels of the
therapeutic relationships. conceptual map, along with a reference to the
tables containing complete listings.
Overview of the map
In the conceptual map (Figure 1) three
developmental processes were identified as Establishing the relationship
necessary for the provision of an effective
therapeutic relationship. These are summarised in There is clear evidence that the early development
establishing a relationship, developing a of a good relationship between therapist and
relationship and maintaining a relationship. Key patient predicts better outcome and remaining in
processes involved in establishing what might be therapy.27 The processes and objectives of this
called mini-outcomes or objectives for each phase of therapy are taken in turn (Table 1).
phase are listed. It is assumed that although these
stages develop across therapy, there will also be a Engagement processes
cycling through these stages within a therapeutic Therapist behaviours and attitudes that encourage
meeting, or over a number of weeks or months. patient engagement are discussed below. In
Patient factors Establishing a

(coping style) relationship
(Table 4) (empathy)
Processes (Table 1)
outcomes
Contextual Framework Developing a

factors roles Therapeutic Processes relationship
(type of therapy) (collaborative) meeting(s) outcomes (exploration)
(Table 5) (Table 7) (Table 2)
Processes
outcomes Maintaining a
Therapist factors relationship
(values) (responsiveness)
(Table 4) (Table 3)
FIGURE 1 Conceptual map 7

The conceptual map
TABLE 1 Establishing the relationship experiencing so that sessions are reported as being
deep and avoiding conflict within the sessions.34
Engagement processes Engagement objectives
Empathy, warmth and Expectancies

Support and guidance
genuineness Some aspects of support are described as being
Intentions important within cognitive and behavioural
Negotiation of goals
Motivation therapies, such as tolerance35 and guidance.36
Collaborative framework
Hope Friedlander and Tuason31 found that directiveness
Support predicted increases in couples positive behaviour,
although only with couples from lower socio-
Guidance
economic backgrounds. Russell and Shirk37 found
Affirmation that children were less hostile with a directive
therapist. Other techniques that improve patient
engagement include providing early clarifications
in the here and now38 and using patient
general, it is assumed that the more therapists preparatory techniques.39
engage appropriately in these activities, the better
will be their relationships with patients. Affirmation
There is mixed evidence for the use of praise in
Empathy, warmth and genuineness developing the therapistpatient relationship,
These three elements of Rogers therapeutic although mutual affirmation is seen as
conditions are linked to outcome, particularly important.40 Ogrodniczuk and Piper41 discuss that
empathy.28 Empathy is the ability of the therapist when working with patients with personality
to enter and understand, both affectively and disorders therapists must balance transference
cognitively, the patients world. Three types of work with supportive work, such as reassurance
empathy have been identified: rapport, and praise. Although most therapies discuss the
communicative attunement and person empathy.29 importance of praise, Sweet42 and Wilson43
Clients experience of empathy (received empathy) describe the mixed evidence for the role of praise
is important in the development of the in behaviour therapy.
relationship.30 Therapist warmth31 and
genuineness or respect32 are also associated with Engagement objectives
the development of a good therapeutic Patient engagement in therapy is the primary
relationship. target at this stage and can be divided into the
following objectives.
Negotiation of goals
Engagement also involves the therapist discussing Expectancies
and agreeing with the patient what are the aims of In the early stages in therapy Frank and Frank
therapy. Agreement between patient and therapist identified the importance of building patients
on what are the problems the patient is bringing positive expectations of therapy.9
to therapy is not related to engagement, but
agreement on goals and tasks is. Goal consensus is Intentions and motivation
one of the relationship objectives (as a part of Intentions and motivation for change also need to
alliance). There is also evidence that it is be sufficiently present for engagement in therapy
important to reach consensus early in therapy. For to occur.30 Therapists behaviours described earlier
example, early session information gathering and are in part designed to develop patients
later session sharing and negotiation of problem expectations. Therapists rate patients as more
formulation and treatment plans improve attractive if they are seen to be motivated to
engagement and return for further sessions of change and committed to work with the therapist
therapy.33 in working out their problems. Such patients are
more likely to become engaged.
Collaborative framework
More generally than just negotiation of goals, Hope
mutual involvement in the helping relationship is Therapists expressed hope for the usefulness of
associated with engagement. Therapist behaviours therapy is important in engaging patients in
that are associated with involvement or a therapy.37 This links to patient expectancies,44,45
collaborative framework include talking rather or to the therapists power base, which in turn
8 than remaining silent, encouraging patient increases therapists ability to influence patients.46
Nathan47 examines hope in relation to difficult attachment models. Direct evidence for this
patients, finding that therapists often lack hope process is limited, but there is evidence that secure
with such patients, which leads to impoverished clients are more cooperative in therapy and that
therapeutic relationships. The importance of security in patients attachment to their therapist
openly addressing hope or the lack of it with is positively associated with a strong alliance.55
patients is discussed by Bordin,48 for example,
improvements in the patienttherapist Feedback
relationship are seen with the early building of a Feedback is usefully conceptualised as an influence
sense of hope with patients who suffer from post- process where the therapist changes the patients
traumatic stress.49 behaviour through the delivery of discrepant,
change-promoting messages or positive
reinforcement of aspects of the patients behaviour
Developing the relationship or self-beliefs. The feedback message can be
descriptive or inferential: research evidence
This section looks at therapists techniques that indicates that descriptive feedback is more useful;
are helpful in progressing therapy and developing positive feedback is generally more acceptable
the therapistpatient relationship, and the (although negative feedback can be useful if
objectives for this phase of therapy (Table 2). In preceded by positive feedback); and if feedback is
addition, during this phase therapists use more collaborative it is less likely to arouse resistance in
self-reflective activities to deepen their the patient.37 Positive feedback also helps to
relationship with their patients. These include an establish and strengthen the relationship.63
awareness of transference and the use of self-
disclosure. Relational interpretations
Relational interpretations are a therapy technique
Exploration and reflection where the therapist makes an intervention that
Exploration and reflection of aspects of the addresses interpersonal links, connections or
therapistpatient relationship are emphasised by themes within the patients stories. Several studies
psychodynamic, interpersonal and humanistic have linked the use of relational interpretations to
therapies. Increased use of exploration is outcome, and a few have looked at interpretations
associated with more positive relationship and the quality of the alliance. Crits-Christoph
ratings.30,41,5062 and Connolly,64 summarising this evidence,
conclude that high levels of transference
Secure base interpretations should be avoided and the primary
This concept is taken from attachment theory and focus of interpersonal interpretations should be on
describes the level of safety a patient may the central interpersonal theme of the patient.
experience in relationships. The aim in the
therapeutic relationship is to develop a base from Non-verbal communication
which patients feel secure and able to explore Non-verbal behaviour is important in therapy;
their problems productively. Dozier and Tyrrell55 it provides information about patients emotional
describe this process as beginning with the patient state and can be used as a tool for improving the
entering therapy with expectations of the therapist therapistpatient relationship. For example,
based on their previous attachment figures, which laughter and humour37 are described as indicating
are then worked on in therapy to explore other a positive change in patients self-concept and as
an expression of a positive relationship. The
experience, interpretation and use of silence are
TABLE 2 Developing the relationship also the focus of discussion in a number of
papers.52
Processes Objectives
Transference
Exploration Openness Many of the papers mention the importance of
Reflection Trust therapists recognition of transferences within the
Secure base Commitment therapeutic relationship. The concept of
transference is complex and has developed in
Feedback meaning.65,66 However, transference
Relational interpretations understandings are essential to the therapies that
Non-verbal communications propose the therapeutic relationship as the vehicle
for the process of change, as patients conflictual 9

The conceptual map
ways of relating to others are identified, understood negatively linked to the quality of the patients
and worked on through the therapistpatient working relationship.75
relationship.33 However, the evidence for the value
of transference interpretations is mixed.
Maintaining the relationship
Self-disclosure
Self-disclosure (the therapist revealing something As therapy progresses it is likely that difficulties in
personal about him or herself) was traditionally the relationship will arise. Although these are
not recommended by psychoanalytic therapists. common, therapy may be impeded if the problems
Other theoretical orientations have seen self- are not resolved. These threats to the relationship
disclosure as a useful part of the therapeutic have been grouped into therapist behaviours,
relationship. Four types of disclosure have been patient behaviours and relationship challenges;
described: facts, insights, strategies and feelings. and therapist actions needed to avoid or resolve
Patients are often more positive about therapist these threats grouped as self-reflection,
self-disclosure than therapists, but the positive metacommunication, flexibility and repair
effects on either the relationship or therapy (Table 3).
outcome have yet to be demonstrated. Because of
the lack of clear understanding of the impacts on Threats
patients it is generally recommended that Therapist behaviour
therapists should only infrequently disclose, and Both patient and therapist may have negative
that if they do so this should be in a positive way feelings towards the other person. Therapists have
to validate reality or normalise behaviour. Careful commonly reported feelings of fear, anger and
attention should be paid to the impact of attraction towards patients. Therapists negative
disclosure on the relationship.67 feelings towards patients have been shown to
result in a decrease in patient functioning during
Relationship development objectives treatment. Often these feelings are not spoken
Once patients are hopeful that therapy may help about as therapists report being ashamed of their
and are motivated to change, it is important that negative reactions, although occasionally they
they are able to turn to the tasks of therapy. To do report recognition of such feelings as having
this they need to have trust in the therapist, positive consequences.76 Other therapist
openness to the process of therapy68 and a behaviours that patients have described as
commitment to working with their therapist.69,70 intrusive and defensive and as having a negative
Therapist engagement and relationship impact on the relationship include therapists
development behaviours described previously help imposing their own values, making irrelevant
these attitudes to develop. Patients who show good comments, or being critical, rigid, bored, blaming,
engagement in therapy often describe their moralistic or uncertain.77 Poor use of therapeutic
therapist as being attractive.32,58,59,7174 In techniques, such as continued application of a
contrast, defensiveness and hostility have been technique when not accepted by or found to be
TABLE 3 Maintaining the relationship
Threats Processes Objectives
Therapist behaviour Self-reflection

Intrusive Metacommunication
Defensive
Negative feelings
Self-disclosure
Patient behaviour Flexibility Satisfaction
Resistance Responsiveness Alliance
Hostility Cohesion
Negative feelings Emotional expression
Changing view of self
Relationship challenges Repair
Ruptures (confrontations or withdrawal)
Misunderstandings
10
helpful by the patient, and poor use of silence are withdrawal, overprotectiveness, sympathy or
linked with a poor relationship.75,78 identification with the patient.85 Management of
counter-transference issues consists of five
Patient behaviour interrelated factors: self-insight, self-integration,
Patients tend to hide their negative feelings (such empathy, anxiety management and
as fear, hostility and anger) and often the therapist conceptualising ability.86
is unaware of what the patient is feeling. Such
patient deference to the therapist has been linked Flexibility
with poor outcome.28,75,79 Of paramount importance in maintaining the
relationship is the therapists ability to tailor
Resistance was originally developed as a therapy to the individual needs and characteristics
psychoanalytic concept of the patients of patients. This involves therapists responding
unconscious avoidance from the analytic work. It appropriately to relational fluctuations so that
was later developed in social psychology as a negative reactions are contained and managed.
theory of psychological reactance that was seen as For example, therapists inflexible adherence to
a normal reaction to a perceived threat. Social treatment strategies (either cognitive or
influence theory defined the concept of resistance interpretations) is associated with poor
as a product of incongruence between the relationships.87 Flexibility is, therefore, required:
therapists behaviour and the power or legitimacy higher alliance ratings are given to therapists who
ascribed to the therapist. Resistance can be seen in are seen as flexible.87
patients as both a state expressed, such as anger
and resentment, and a trait (described above). Responsiveness
Trait-resistant patients are more likely to drop out Appropriate responsiveness refers to therapists
of therapy. Recognition of resistance states should moment-to-moment adjustments to patients
be acknowledged and the therapeutic contract requirements within the framework of an
renegotiated. Treatment plans with patients with individual treatments goals and standards.87 This
high resistance traits should de-emphasise the description of the way therapist and patient
therapists authority and therapists should avoid respond to each other is cyclical, with each
stimulating the patients level of resistance.28,80 participant affecting the behaviour of the other,
which in turn affects their own response.66 This
Relationship challenges mutual influence process suggests why research
Misunderstanding between patients and therapists that assumes a linear relationship between, for
on the goals and tasks of therapy may result in example, patient characteristics and outcome
confrontations, patient withdrawal and produces conflicting findings.
misunderstandings.28,81,82 Such ruptures in
therapy are common and an expected part of Rupture resolution
treatment.28,75,77,83 Crits-Christoph84 describes As described earlier, ruptures are an expected part
ruptures as transference reactions; others when the of the treatment process. Non-resolution may lead
therapist makes mistakes, is anxious or has a to treatment failures. In contrast, there is some
strong need for approval, or when patients evidence that resolution of a rupture leads to a
experience negative feelings about the therapist as deeper and better relationship and treatment
a result of the therapist doing something they did outcome.35,37,52,88
not want, or not doing something they did want.
Safran and colleagues89,90 have developed a model
Processes of rupture resolution which begins with the
Reflection and metacommunication therapist attending to rupture markers, which are
Therapists ability to reflect on their own position usually indicated by patient withdrawal or
and feelings may enable problems in the confrontation. The patient and therapist then
relationship to be resolved.75 This includes explore the rupture experience, including
observation of counter-transference feelings. avoidance, which then leads to the emergence of a
Definitions of counter-transference have changed patients wish or need.
over the years; however, currently, it is seen as an
interactional process, which can be both helpful Maintaining relationship objectives
and problematic and include resistance in the Different types of therapy assume the importance
therapist owing to inner conflicts and specific of different aspects of the relationship: these
reactions of a therapist to specific transferences of various objectives or outcomes of patienttherapist
the patient. Related concepts include therapists interactions have been grouped into five elements: 11

The conceptual map
satisfaction, alliance, cohesion, expressed emotions because the bond develops slowly, whereas task
and changing view of self with others. and goals need to be established quickly.33
These relationship objectives are not separate, Cohesion

discrete elements; they overlap and have common Cohesion refers to a similar concept to alliance,
features. They are not really outcomes, in the except that it refers to relationships established in
sense of change in patient symptoms or quality of group work. Systemic definitions of therapeutic
life, but they represent a meeting point of relationships involve multiple alliances: member
therapist interpersonal behaviours, client to member, member to leader, leader to leader
characteristics and relationship processes, and and leader to group. This means that the features
form a description of the quality of the of the alliances or of cohesion are intrapersonal,
relationship. interpersonal and intragroup, plus a bonding,
collaborative working alliance of the group.97
Satisfaction
The first element includes general satisfaction with Expressed emotion
the relationship and patients positive appraisal of For some therapies the relationship is the vehicle
the relationship.83,91,92 Patients satisfaction with for emotions to be supported and expressed; the
their therapist is associated with their satisfaction emotional relationship is seen as being a cathartic
with therapy in general.93 It is an experiential experience,44,98 although for others the emotional
phenomenon rather than behavioural; patients experience leads to change in cognitions and self-
tend to be less discriminating than therapists understanding and for others experiential insight
about the quality of their relationship, forming a is the key to change.45,79
global positive or negative impression of the
relationship.28 Patients and therapists often value Changing view of self with others
different things; for example, patients satisfaction Several reviews describe the purpose of the
is generally associated with confirmed relationship as enabling alternative views of the
expectations.93 self to be explored. These are sometimes referred
to as narrative truths: social constructionism
Dissatisfaction is the most frequent reason given for describes the processes in therapy as the patient
leaving therapy and for non-compliance.93 Given and therapist constructing the relationship
that about 2559% of patients are non-compliant together, where old problems are deconstructed
with treatment, this is an important issue.94 High and new narratives arise.84,87,91
levels of satisfaction are linked to good compliance
and higher levels of engagement.28,95
Patient factors
Alliance
Achieving a working relationship is the most Patient factors that impact on the quality of the
important aspect of therapy that thus far has been therapeutic relationship are considered here
linked with treatment outcome.96 This is referred (Table 4). Two of the main patient characteristics
to as the alliance (working, therapeutic, etc.). found by Beutler25 to moderate treatment
Although there are important differences in the outcome and poor therapeutic relationships are
definitions of the alliance,26 for example, a major functional impairment and coping style.
controversy exists whether the alliance arises from Functional impairment includes problems in work,
the interpersonal process or is an intrapsychic social and intimate relationships. Problem
phenomenon82 and different therapies will complexity has also been associated with poor
emphasise different aspects of the alliance, it is the relationship development.99 One significant factor
quality and strength of the collaborative related to negative outcome is therapists
relationship between patient and therapist that underestimation of the seriousness of problems.100
appears important.45
In contrast, factors that may be associated with the
The most frequently used definition of the alliance development of good working relationships
is by Bordin,48 who describes three elements of the include patients who have had therapy previously,
relationship: consensus with regard to task; have less severe personality disturbances and have
affective bond (trust, liking, caring); and begun to address their problems.101
agreement on goals (actively committed,
purposeful). It is thought that task and goal are The impact of past and current relationship
12 more important than bond.79 This is in part experiences on the development of the
TABLE 4 Patient and therapist individual differences negative behaviours. Additional therapist
characteristics that are associated with negative
Patient differences Therapist differences aspects of the patienttherapist relationship
Coping style Attachment style
include being rigid, uncertain, distant, tense and
distracted, and their level of experience.77,87
Severity of impairment Attitudinal variable
Relationship experiences Relationship experiences Attitudinal variables that are associated with the
Social support Values development of a good relationship include
perceptions that the therapist is trustworthy,
Defensive style
interested, affirming, confident, respectful and
open.101 These attributes potentially help patients
to develop confidence in and collaboration with
patienttherapist relationship has already been the therapist.
discussed in the section Transference (p. 9). Other
terms used to describe these past relationship There is some evidence that therapists attachment
experiences include dysfunctional relationship style impacts on the quality of the relationship
schemas,90 attachment styles (see below) and formed with patients. For example, therapists who
negative introjects.102 have an insecure, over-involved attachment style
tend to respond less empathically to patients than
Patients particular attachment style has been secure therapists.28 In addition, therapists who
found to influence the quality of the therapeutic impose their values on patients tend to have
relationship, with patients who have insecure poorer alliances.39,56,72,106109
attachment styles less able to form satisfactory
alliances.103 Patients with an avoidant attachment
style are particularly hard to engage in Contextual factors
therapy.28
Both broad factors such as the social grouping to
Systemic therapies describe a process by which which patients and therapists belong, and aspects
therapists initially undertake compensatory of the therapy context and how these impact on
relationships with patients, compensating for any the relationship, are considered next (Table 5).
reduced levels of social support they may have,
and then as external support is achieved therapists Therapy context
take a more subsidiary role.27 Mallinckrodt35 Confidentiality and boundaries
describes a social competency model: maladaptive The impact of these aspects of the relationship has
social interactions learned in childhood are generally been studied only when special cases
identified in therapy, and the therapeutic bring out ethical dilemmas or issues. For example,
relationship provides patients with new confidentiality and boundary issues may be
experiences to broaden their social competencies challenged when working with victims of violence
and to increase the social support available to and abuse,56,110 consideration of boundary issues
them. Peltzer104 describes part of the role of the is sometimes problematic when working with
therapist in providing education and social patients with learning disabilities,111 and abuse of
support for victims of organised violence. power happens when therapists form sexual
relationships with their patients.71,112
Patients defensive styles, particularly the use of
repression, impact negatively on the quality of the
patienttherapist relationship.52,54,60 TABLE 5 Contextual factors
Therapy context Broader context

Therapist factors Confidentiality Race, ethnicity, culture
Some therapists achieve better relationships and Boundaries Social class
outcomes with their patients than others. This is Influence Religion
found even in studies that have attempted to
minimise the effects of individual therapists on Values Age
patient outcomes.105 Patients characterise some of Power Gender
these differences between therapists in terms of Type of therapy
their engagement behaviour and the presence of 13

The conceptual map
Confidentiality issues and the impact that they Race, ethnicity and culture
may have on the therapistpatient relationship Although there is limited evidence that these
are also considered when therapy is observed variables impact on therapy outcome, patients
by others or sessions are audio- or tape- from minority groups are less likely to remain
recorded.113 in therapy and more likely to drop out
prematurely.39,56,93,95,104,106,115,116 This suggests
Influence that there are engagement and relationship issues
Many of the reviews mention the importance of in working with patients from minority ethnic
influence in the therapeutic relationship. For groups.117,118 Again, there is little research on
behaviour therapists, their relationship is good whether patients should be matched with
when they are effective and influential.67,103 This therapists from the same ethnic background,
process is linked to social influence theory:91 the social class, religion, and so on. There is some
ability of the therapist to influence the patient on evidence that perceived similarity with ones
the basis of social power. Influence is also linked to therapist results in greater satisfaction.95 Some of
the credibility of the therapist.73 the reviews suggested that religion should be
brought up to facilitate the development of the
Power therapeutic relationship.95,109
Power has been described as the vital force in
therapy.46 The therapist is the expert (behaviour The impact of diversity issues on the
therapists particularly) and can use this power to therapistpatient relationship occurs through
help patients to change (social influence theory). two routes: first, via each persons knowledge and
However, there is a question of whether the use of understandings of broader and therapy
power is ethical,50 particularly with vulnerable contextual factors, such as how illness and distress
groups of patients, such as people with chronic are understood, what credential the therapist is
personality disorders:47 Veldhuis92 describes how given, and differing concepts of the self; and
feminist therapists work to create a relationship in secondly, through the ability of the therapist to be
which power is shared. Therapists working within empathic and validate patients feelings and
a social constructionist framework aim to empower experiences.119
patients.114
Social class
Type of therapy Similarity in social class between therapist and
All therapies acknowledge the importance of patients has been linked with the formation of a
establishing a good working relationship with better therapeutic relationship,101 although two
patients, although different therapies emphasise further reviews concluded that social class did not
different aspects of the relationship; for example, impact on the quality of the relationship.57
psychodynamic and interpersonal therapists focus Heitler39 concludes that patients from lower social
on the expression of emotion and problems in the classes are more likely to be rejected for
relationship, whereas cognitive therapies psychological treatment and more likely to drop
emphasise patterns of thoughts.51 However, the out of treatment because of lack of engagement
basic elements of the patienttherapist with the therapist.
relationship remain the same for most therapies.
Even in computerised therapies patients still form Gender
strong attachments to the therapy.69 It is clear that male and female therapists act
differently120 although the impact of this on
Broader context the therapeutic relationship is less
The broader context comprises the psychosocial clear.31,32,54,56,58,59,61,112,116,121123
arena in which the relationship develops. At this
stage the focus is primarily on issues of diversity, Processes
such as cultural and demographic variables that Several reviews suggest that better management of
have been found to have an impact on the the above factors requires therapists to be flexible
therapy relationship. It is important to ground in their approach to the relationship, to be
therapeutic work in an awareness and knowledge reflective about their practice, and to gain greater
of best practice for particular diverse groups: understanding of the socio-political forces that
cultural competency, given that most influence their attitudes and greater knowledge of
practitioners are likely to work with patients from the cultural background of their patients.
different groups and backgrounds from Therapists recognition of their own values is also
14 their own. an important part of this process.
The engagement process is potentially Attachment theory describes the role of the
problematic and may lead to patients dropping therapist as one of providing a secure base from
out of therapy. Clarity of roles and treatment aims which the patient can explore their problems.
and methods are very important, and some Although part of this description includes the
methods of improving engagement have been development of a transference relationship with
discussed in the literature. For example, the therapist, this attachment role is not confined
preparatory techniques such as socialising to acknowledging and interpreting the
patients into role expectations and providing transference, but includes a real relationship that
information before meeting may be helpful.39 acknowledges patients needs for security.55
Encouraging discussion about problems that arise
with ones therapist (stabilising) and teaching In contrast, some therapies attribute the
patients about the process of therapy (structuring) competence of the therapist to the authority and
are useful. respect they command.28,67,76,82,91,92,103,124,126
The expert role is linked theoretically to social
influence theory, and the value of being seen as
Roles the expert is that it helps to build clients
expectancies.73 This aspect of the therapists role
The descriptions of the roles each person plays in is put forward as being the route through which
the interactions between therapist and patient are computer and Internet therapies achieve success.69
usually defined by the assumed theoretical Patients who achieve greater change describe their
background of the therapist, the patients therapists as more expert.73 In group therapy the
expectations, and recognition of the unequal leadership role of the therapist is described as
power bases of the two players. The impact of central to the relationship between therapists and
these assumed roles is likely to be strongest during group members, and this role is defined in terms
the early phases of the development of the of authority and knowledge.127
relationship. The various roles ascribed to therapist
and patient are described in turn (Table 6). The blank-screen role of the therapist is
traditionally used in psychoanalysis. There have
Therapist roles been many critiques of this role and it is no longer
Roles that have been ascribed to the therapist common for therapists to assume a blank screen
include friend or companion. For example, with their patients. However, the use of the term
therapists working with children or with people to describe how therapists should adopt a stance
with learning difficulties are often given this role, in relation to transference materials of the patient
along with the role of an advocate.124 These roles is still valued among many analysts, who would
highlight the large potential differences in power recognise that patients form real relationships
bases between therapists and patients, and the with therapists at the same time as transference
acknowledgement that the therapist will often relationships.53,128,129
relate to a number of people in the patients world
as part of their therapeutic involvement. Patient roles
The use of the terms such as patient, client or user
Other writers have described a task of therapy as reflects the increasing recognition of the unique
one of deconstructing the power of the therapist and changing role of the person seeking help for
and entering a more equal friendship mental health problems. The idea that the patient
relationship.125 One of the important is a consumer of mental health services is not new,
characteristics that patients value in their but the implications this has for the relationship
therapists has been described as friendliness.84 has not been studied a great deal.120 The concept
of user-friendliness has been developed as a
process by which patients are asked specifically
TABLE 6 Therapist and patient roles about the quality of their relationship with their
therapist.91
Therapist roles Patient roles
Friend/companion Client
Advocate Patient Framework of the relationship
Attachment figure User This section looks at the structural components of
Expert/authority/leader Consumer the therapistpatient relationship (Table 7). The
framework of the relationship leads on from the 15

The conceptual map
TABLE 7 Framework of the relationship therapists judge the quality of the relationship on
patients active participation and collaboration.
Managing therapy Matching of therapist Together, these make the primary components of
process and patient the initial objectives for the relationship:
Collaborative Convergent expectancies, intentions and hope. Contextual
factors, patient and therapist variables, impact on
Structuring Complementarity
the roles and frameworks adopted in the
Directive Congruent relationship, which in turn impact on the
development of the relationship. As therapy
continues, the relationship becomes an arena in
which therapeutic activity is carried out. These
roles and from individual characteristics of the relational interventions lead to a deepening of the
therapist and patient. therapistpatient relationship, but may also lead
to misunderstandings and negative reactions.
Managing therapy process Maintaining the quality of the relationship then
Although the evidence is that a collaborative involves therapists ensuring they are appropriately
framework is important for maintaining effective responsive to their patients, and repairing any
therapeutic alliance,52,112,130 some patients require ruptures in the relationship. Maintaining the
a more directive and structured approach to relationship requires therapists to individualise
maintain expectancies and motivation.27,37,73,111 their responses to specific aspects of patients
Structuring the sessions is seen as an important needs and relationship styles. In addition, an
part of the management of the relationship,31,39 as understanding of their reactions, styles and
is the ability to remain focused.31,35,41,58,104,127,130 limitations helps to maintain a good working
relationship. The overall objectives in therapy are
Matching of therapist and patient for patients to be satisfied with their therapeutic
There is very little evidence that matching the relationship and to have formed good working
therapist and patient on demographic variables alliances.
improves the therapeutic relationship.61 There is
some evidence, however, that perspective and Inevitably, this map contains a number of
attitude convergence and positive weaknesses. When summarising such a vast
complementarity are associated with higher literature, inevitably areas will have been
ratings of the relationship and better neglected. However, attempts to prevent this have
outcome.28,30,31,53,93 Positive complementarity been made through the rigorous methods used to
involves both reciprocity in terms of control and identify and summarise the literature. This
correspondence in terms of affiliation.83 method, though, has led to a second potential
weakness. The map was not based on a specific
Congruence is both a personal characteristic of a theory of human interaction or on a specific
therapist (genuineness) and an experiential psychological model. In many ways, however, this
quality. The experiential quality of the relationship is a strength. The model encompasses a number
refers to the therapists ability to reveal of theoretical approaches. As it stands, it presents
productively their experience of being with the a useful tool for teaching and training. It
patient to the patient. This may be helpful for highlights both the complex nature of the
patients through improving engagement and clientpractitioner relationship, and the possibility
through the exploration of the relationship.27,30 of focusing on specific tasks at different points in
therapy.
Summary The map is intended as an organising framework,

rather than a model to be tested, However, it
The establishment of a good relationship appears would be useful to research further the elements
to be necessary early in therapy. Patients tend to within the model and the relationship of these
emphasise the important of therapist warmth and elements to treatment outcome, patient
emotional involvement at this stage, while acceptability and differences between therapies.
16
Chapter 3
Review to identify candidate measures of
patienttherapist interaction
Review question electronic databases. As databases differed with
regard to subject headings and thesaurus-derived
The aim of the review was to identify measures of indexing terms, search strategies needed to be
therapistpatient interactions used in mental created for each database. The general strategy
health settings, where: was to combine the search used for the scoping
exercise described in Chapter 2 (which was used to
measures refer to a methodology for quantifying develop the conceptual map; the terms from the
aspects of therapistpatient interactions as search strategy rather than the map were used to
defined in the conceptual map derived from the ensure comprehensive coverage of the area) with a
scoping exercise search strategy containing specific descriptors such
therapist refers to any person delivering a as assessment instruments and tests and
mental health intervention measures. Where electronic databases offered a
patient is any person using a mental health limit to tests and measures function, this was used
service. in addition to descriptors. This twin-track search
strategy increased the possibility of locating
material on tests and measures, which would map
Literature searching techniques on to the conceptual map (derived from the
scoping review). The search strategies are detailed
The explicit aim was to include all possible in Appendix 3. Some databases did not provide
relevant literature relating to both studies of the software to support lengthy complex search
therapistpatient interactions and tests/measures strategies (SIGLE, HMIC, HAPI, Social Sciences
of interactions. Therefore, this review involved the Citation Index). For these databases, terms from
search of a diverse range of sources, as described the conceptual map were put in as individual free
below, to maximise the likelihood of capturing all text searches.
relevant material.
Searching other sources
Search of electronic databases Other non-electronic sources were searched
As there is no single electronic database that is systematically. These included:
comprehensive enough in either subject or
publication format coverage to retrieve all articles Digests and compendia of published/commercial
relevant to the review question, a range of tests: Tests in print, 5th ed.,131 Mental
databases was searched. Electronic databases that measurements yearbook, 13th ed.,132 Tests, 4th
were searched included CCTR (Cochrane ed.133 and Test critiques.134
Controlled Trials Register), CINAHL, EBM Digests and compendia of unpublished/non-
Reviews, EMBASE, HAPI (Health & Psychosocial commercial tests: Directory of unpublished
Instruments), HMIC (Health Information experimental mental measures, Vol. 7,135 Tests in
Management Consortium, comprising DH-Data, microfiche136 and The cumulative index to tests in
the Kings Fund Database and Helmis), microfiche.137
MEDLINE, NHS DARE (Database of Assessments Conference proceedings, searched via the Zetoc
of Reviews of Effects), NHS HTA (Health database.
Technology Assessment), PsycINFO, Social Handsearching of key journals: Journal of
Sciences Citation Index and SIGLE. Counselling Psychology, Journal of Consulting and
Clinical Psychology, Psychotherapy Research, Journal
Development of search strategies of Clinical Psychology and Psychological Assessment.
Information experts (MG, SM) from the University These journals were targeted because they had
of Leeds were employed for the specific purpose the most therapistpatient interaction references
of developing search strategies for each of the (from electronic searches) associated with them.
17

Review to identify candidate measures of patienttherapist interaction
Reference lists of articles on therapistpatient Working list of measures

interaction measures were scanned to increase
the likelihood of capturing relevant studies It was thought strategic to search first the database
associated with therapistpatient interaction that would be most likely to yield the greater
measures. number of relevant tests and measures. Therefore,
PsycINFO was targeted first, as the scope of the
database seemed the most pertinent to the subject
Selection of measures and matter of the review. Then the other main
electronic databases (MEDLINE, EMBASE,
associated studies CINAHL, etc.) were searched for any further
The searches described above yielded a total of measures that had not already been identified by
13,613 references and/or abstracts relating to tests previous searches. Figure 2 is a flow diagram,
and measures. Two project staff (JCa, KA) sifted which presents the order in which electronic
through these references and extracted a list of databases and other sources were searched. The
candidate measures using specified inclusion and number of measures yielded by each source
exclusion criteria. Any measures that seemed to be independently is given (in bold), as well as the
borderline in terms of the inclusion criteria were running total (regular font). A total of 260
put into a possibly file, and then consensus candidate measures was available for review.
agreement was reached by the two project staff.
Inclusion criteria
A measure was marked for inclusion if it pertained PsycINFO
to: N = 133
any patient populations presenting with any MEDLINE

mental health problem of a psychological N = 23
nature (i.e. all people presenting with problems N = 156
or diagnostic groups, e.g. depression, anxiety,
or general) Digests and compendia
any practice settings (i.e. primary, secondary N = 12
and specialist mental health settings) N = 168
any interventions derived from any theoretical
orientation (i.e. all theoretical approaches EMBASE
included, e.g. cognitive-behavioural, N = 40
psychodynamic, interpersonal) N = 208
any types of study/evidence (according to level
of study hierarchy, from I to IV according to CINAHL
NHS Centre for Reviews and Dissemination N = 24
2001 criteria) N = 232
any measure located within the conceptual map
of therapistpatient interactions derived from Other electronic databases
the scoping exercise. N=9
N = 241
Exclusion criteria
A measure was excluded if: Handsearching of key journals
N = 19
it focused on aspects other than the N = 260
therapistpatient interaction (e.g. family
interactions) Conference proceedings
it was non-English language and was associated N=0
with non-English-language articles (however, N = 260
non-English-language versions of English-
language measures were included if English- Candidate measures
language articles were available) N = 260
it focused exclusively on therapist qualities (e.g.
skills) or patient qualities (e.g. personality types)
18 without addressing the interaction. FIGURE 2 Sources of therapistpatient interaction measures
Chapter 4
Appraising the psychometric attributes of measures
of therapistpatient interaction
Overview Psychometric sieve 1: evidence relating
to reliability
A series of desirable attributes for psychometric Each measure identified in the review was
instruments was selected from a recent searched on all available electronic databases for
systematic review commissioned by the UK HTA articles pertaining to reliability. The name of the
programme.138 These were classified under the measure was entered along with terms relating to
six broad headings listed in Box 2. (A seventh reliability and all components thereof:
criterion, appropriateness, was not used for
this review as this criterion was considered [name of measure] and [psychometric propert$ or
more pertinent to the appraisal of outcome reliab$ or internal consisten$]
measures.)
The number of reliability studies was logged for
These headings were used to develop a six-stage each measure. Measures that had been identified
psychometric sieve, which was to be applied to by non-electronic search methods were also
the candidate measures. The authors searched on the electronic databases. It was
acknowledge that the Fitzpatrick criteria were feasible that measures that had not been picked
developed specifically for the appraisal of up at the content level by electronic search
patient-based outcome measures. In the section methods might still have reliability and validity
Use of Fitspatrick criteria (p. 35) the authors information. As a supplement all measures that
highlight where application of these criteria to failed to get through the electronic sieve were
the measures should be treated with caution. handsearched (see Limitations of the electronic
sieve, below).
All measures that had at least one reliability study

Psychometric sieve associated with them proceeded to the next stage.
An electronic sieve, as described below, was used
to determine whether each of the candidate
Psychometric sieve 2: evidence relating
measures had information relating to reliability
to validity
Electronic searches on all available databases were
and validity. This information would enable the
carried out on measures that had passed the first
measure to be evaluated in terms of a minimum
stage to detect articles pertaining to validity. The
standard for critical appraisal. The standard set
name of the measure was entered along with terms
was basic information on reliability and validity,
relating to validity and all components thereof:
information that would enable the measure to
proceed to subsequent quality appraisal. [name of measure] and [valid$]
BOX 2 Fitzpatrick criteria
A. Reliability A reliable measure is one that produces consistent results from the same respondents at different
times where there exists no evidence of change
B. Validity The extent to which a measure really measures the concept that it purports to measure
C. Responsiveness Addresses the question: does the instrument detect changes over time that matter to the patient?
It can be discriminative (between individuals) or evaluative (within an individual across time)
D. Acceptability Addresses the question: is the measure acceptable to users?
E. Feasibility Is the measure easy to administer and process?
F. Precision How precise is the measure?
19

Appraising the psychometric attributes of measures of therapistpatient interaction
The number of validity studies was logged for basis of electronic information (title/abstract), but
each measure. All measures that had at least one through closer examination of content.) These
validity study associated with them proceeded to measures were not subject to critical appraisal in
successive stages of the psychometric sieve. terms of a minimum and industry standard and
are listed in Appendix 5.
Limitations of the electronic sieve
It was found that some articles had failed to pass Personality inventories
through the electronic sieve owing to the following satisfaction scales (measuring satisfaction with
factors: treatment)
measures relating to patient/therapist
The abstract/title/keywords did not include the characteristics rather than the interaction
terms relating to reliability and validity as non-mental health-related measures
specified in the electronic searches described assessment measures
above; for example, an author may have written measures relating to medication adherence
about Cronbachs alpha when referring to the social psychology measures
reliability of the measure. measures relating to therapist techniques (with
The abstract/title/keywords of an article no reference to the interaction)
included terms relating to validity but not treatment outcome measures
reliability, meaning that the measure would not measures for which key primary articles were
have passed through stage 1 of the unattainable
psychometric sieve. On closer examination, qualitative measures.
these articles did in fact address reliability issues
that were not specified in searchable fields. Applying these exclusion criteria left a total of 83
measures to be considered according to the six
The electronic sieve developed for the review was criteria of reliability, validity, responsiveness,
not precise or inclusive enough. However, acceptability, feasibility and precision. Measures
searching methods that rely on abstracts being that demonstrated adequate reliability and validity
precise or explicit are vulnerable to the detection were said to meet a minimum standard, and
of false negatives. In such cases, it is essential to measures that demonstrated adequacy on the
do a manual check on excluded measures. Each remaining four criteria were said to meet an
measure that failed to pass through the first two industry standard. The term industry standard
stages of the electronic sieve (n = 138) was derives from literature on outcome measurement
searched on all databases to retrieve the full and is used to refer to the benchmark set to
reference relating to that measure. Each of these establish a threshold for acceptable measures in
abstracts was reread and the measures status terms of both psychometric properties and clinical
reassessed. In the cases where the abstract did not utility.138,139 Acceptability and feasibility relate to
give adequate information the article was obtained issues of service implementation and user-
and scanned. Of the 138 measures that originally friendliness, while responsiveness and precision
failed to pass through the electronic sieve, 29 relate to the discriminatory capacity and
measures were found to satisfy the minimum interpretability of the instrument, respectively.
standard. These 29 measures were combined with Operational definitions of all six criteria were
the 122 measures that had passed through the drawn from key psychometric textbooks and
electronic sieve to yield a total of 151 measures papers and selected for their relevance to the
that satisfied stages 1 and 2 of the electronic sieve. appraisal of therapistclient interaction measures.
Table 8 gives examples of component attributes for
All measures that failed to pass through stages 1 each of these six domains.
and 2 of the electronic sieve are listed in
Appendix 4. Candidate measures
Eighty-three separate measures were available for
further examination, each of which gave basic
Excluded measures information on reliability and validity. (Where
there was extensive information on each of the
Many of the 151 measures (n = 68) were excluded parallel forms, e.g. therapist, client, observer,
on the basis of the following criteria by two senior these were treated as separate measures for
research staff. (Some of the exclusion criteria purposes of data extraction and appraisal.) All
replicate those described in Chapter 3. This is due references relating to each separate measure were
20 to certain measures being excluded not on the collated and grouped in a bibliographic database.
TABLE 8 Key psychometric attributes138
Criterion Definition
Reliability
Internal reliability As measured by Cronbachs alpha, split-half reliability estimates
Testretest reliability
Inter-rater reliability
Validity
Face validity The ability of a measure to tap, by item content, an underlying dimension
Content validity The ability of a measure to tap all the relevant aspects of the attribute it is intending to measure
Concurrent validity Where a new measure is administered at the same time as a pre-existing one and the two are
correlated
Predictive validity The predictive power of a given measure against some other measure
Construct Hypotheses are generated and a measure tested to determine whether it actually reflects these
prior hypotheses
Convergent A measure converges with other indications of the same concept
Discriminant A measure demonstrates low levels of correspondence with a measure that represents another
concept
Responsiveness Addresses the question: does the instrument detect changes over time that matter to the
patient?
It can be discriminative (between individuals) or evaluative (within individual across time)
Acceptability Addresses the question: is the instrument acceptable to patients?
(to practitioners and Practicality of administration
patients)
Time taken to complete
Length of instrument
Translations
Access by ethnic minorities
Reading age
Feasibility Is the measure easy to administer and process?
Cost and burden to administrative staff
Electronic/optical scanning options?
Scoring systems
Training package
Training manual
Support from measure developers
FAQ facility
Precision Interpretability
Normative data
FAQ, frequently asked question.
The number of references pertaining to each each attribute (AF) were cross-referenced using
measure ranged from one to 90. the relational functions of the database (see next
section).
Data extraction For reasons of practicality and optimal use of

resources, abstracts were first consulted where an
For individual instruments, data were extracted in instrument had 20 or more associated references.
the following ways: for instruments with fewer Only those references likely to yield data relating
than 20 key references, all papers were obtained. to psychometric properties (AF) were obtained
Data pertaining to the industry standard were for further inspection. Before data extraction
extracted onto a standardised form. Summaries of began, all articles were sorted into primary and
each of the criteria (AF) were entered into a secondary references. Primary references typically
Microsoft database and key references addressing concerned issues of measure development and 21

Appraising the psychometric attributes of measures of therapistpatient interaction
validation. Secondary references pertained to the reference can relate to many measures and vice
use and application of the measure. Primary versa. This section is the primary data entry point
articles were then selected for data extraction as for data extracted from the literature and includes
outlined below. As primary references contained the following subsections:
the most relevant psychometric information on the
measure, it was considered an optimal use of time Reliability values for internal consistency, inter-
and resources to prioritise these for data rater reliability, testretest and split-half
extraction. reliability, together with the tests used. Any
further related information can be added to
individual notes sections.
Access database Details in note form on validity, specifically face,
content, criterion, concurrent, predictive and
To aid efficient retrieval and interpretation, convergent validity, plus factor structure and
extracted data were entered into a Microsoft responsiveness information.
Access relational database, which had been Populations/practitioners/services: this
designed specifically for this project. Use of a subsection includes summary information from
relational database, rather than traditional data the literature on the populations with which the
extraction sheets, meant that data could be easily measure has been used (e.g. whether
updated, sorted by specific criteria and combined information on age, gender, ethnicity is
according to specific requirements using the included), by whom it has been used/rater type
query facility, which allows data to be viewed, (e.g. psychiatrist, social worker, counsellors), the
retrieved and analysed in many different ways. To theoretical orientation (e.g. cognitive-
facilitate data entry, viewing and modification, behavioural, psychodynamic) and the level of
three data entry forms were created. These forms service in which it has been used (e.g. NHS,
related to data extracted on measures, references, primary, commercial).
and the interrelationship between references and
measures (necessary as one reference could relate Data extractions were conducted by research staff.
to many measures). See Appendix 6 for examples No formal measure of reliability of data extraction
of data entry forms. was calculated, but disagreements and queries
were resolved by discussion with senior research
Measures section staff.
Data pertaining to the 83 measures reaching
minimum standard were entered. This was a
summary of data from primary references. The Measure summaries
data entered related to the key areas of
responsiveness of the measure (e.g. detection of Development of a measure summary
change), acceptability (e.g. time taken to complete, sheet
number of items, translations, reading age), A measure summary sheet (see Appendix 7) was
feasibility (scoring options and systems, training designed to address each of the six psychometric
requirements) and precision (e.g. availability of properties (AF). All information pertaining to
normative data). The measures section was directly these criteria was retrieved from the database
linked to the references section, making available a and entered on to the summary sheet. To
list of all references relating to a specific measure. retrieve the information, the data from the
three main sections of the database, referred to
References section above, were cross-referenced using the query
This section contains details of the references for facility of the relational database. A rsum of
the current literature relative to the subject area the measure was included at the end of each
and its relation to a specific measure. The summary sheet to give an indication of the
information held in this section is primarily overall status of the measure in relation to how
objective, specifically the title of the reference, each of the criteria had been addressed. As
journal, year, volume, authors, type or article [e.g. before, no formal measure of the reliability of
review, randomised controlled trial (RCT) data summarising was calculated, but queries
development, psychometric]. and disagreements were resolved by discussion.
All summary sheets were checked by senior
References and measures research staff and sample data summaries were
This section brings together the information from discussed at research meetings to ensure
22 the previous two sections and is necessary as one standardisation.
Methods for appraisal of an industry and detailed in Table 9. The codings provide a
standard global estimate of each of the criteria. For
Each measure was critically evaluated using data example, when more than one reliability estimate
from primary articles, which had been entered on is supplied, an average is taken. For full details of
to the summary sheet. When there was enough the psychometric properties of each measure, see
evidence for appraisal from primary articles, Appendix 8.
secondary articles were not consulted. However,
for measures that had fewer primary articles There was an absence of inter-rater reliability
associated with them, secondary articles were estimates associated with the rating of the
consulted for further psychometric data. This was therapistpatient interaction measures, therefore
to avoid any bias that could favour the older, more limiting assessment of quality. However, as an
established measures, which had been extensively extension of the work on which this report is
researched. In cases where reviews on a measure based, the authors are currently using a revised
were available, these were used for the appraisal. coding structure141 and estimating inter-rater
reliability for each of the attributes of the coding
Two research staff then applied coding scheme (for details see the section Quality
instructions for quality assessment to each of the appraisal criteria, p. 33). The attributes and
six criteria. This procedure enabled a quality criteria for measuring them incorporate more
appraisal of each measure, which was reached by succinct operational definitions and assessment of
consensus between the two staff. The coding the rigour of the studys design methodology in
instructions for the six criteria are derived from which the measures are used.
NHS Centre for Reviews and Dissemination140
TABLE 9 Coding instructions for quality assessment
Fitzpatrick criteria Coding Explanation
Reliability a
Adequate 0.70
Partial 0.50 < 0.70
Inadequate <0.50
Unknown Reliability estimates not supplied
Validity Adequate 0.50
Partial 0.30 < 0.50
Inadequate <0.30
Unknown Validity estimates not supplied
Responsiveness Adequate Significant differences found between groups or within individuals
Partial Non-significant trends found between groups or within individuals
Inadequate Not addressed
Acceptability Addressed All of the components described
Partially addressed At least one of the components described
Not addressed None of the components described
Feasibility Addressed All of the components described
Precision Addressed All of the components described
a
Standards for reliability and validity were taken from Barker et al. (1994).142
23

Chapter 5
Results
Primary evidence associated with had only one primary article associated with
them.
candidate measures
Table 10 presents a list of all measures that had Content of candidate measures
basic information relating to reliability and
validity. The measures are ranked in descending Appendix 9 presents a content description of each
order of the number of primary articles associated measure (n = 83) selected for critical appraisal
with each measure. Table 11 lists all measures that together with associated areas of the conceptual map.
TABLE 10 Number of primary articles associated with candidate measures
Measures No. of primary references
Core Conflictual Relationship Theme 30

Affective Sensitivity Scale: Form A, C, D, D-80 and E-80 16
Barrett-Lennard Relationship Inventory 16
California Psychotherapy Alliance Scales 15
Counselor Rating Form 10
Working Alliance Inventory 10
Hill Interaction Matrix 9
Carkhuff 1969 Scales 8
Penn Helping Alliance Rating Scale 8
Session Evaluation Questionnaire 8
Counselor Verbal Response Category System 7
Penn Helping Alliance Questionnaire 7
Comprehensive Process Analysis 6
Counselor Rating Form Short Version 6
Multicultural Counseling Inventory 6
Psychotherapy Process Q Set 6
Truax and Carkhuff 1967 Scales 6
California Therapeutic Alliance Rating System 5
Cross-Cultural Counseling Inventory Revised 5
Truax and Carkhuff Accurate Empathy 5
Counseling Evaluation Inventory 4
Counselor Evaluation Rating Scale 4
Experiencing Scale 4
Hill Interaction Matrix Form G2 4
Missouri Identifying Transference Scale 4
Vanderbilt Therapeutic Alliance Scale 4
Capacity for Dynamic Process Scale 3
Carkhuff Empathic Understanding 3
Client Attachment to Therapist Scale 3
Client Behavior System 3
Counselor Effectiveness Rating Scale 3
Counsellor Effectiveness Scale 3
Counselor Verbal Response Category System Revised 3
Group Assessment of Interpersonal Traits 3
Helping Alliance Counting Signs Method 3
Octant Scale Impact Message Inventory 3
Jourard Self-Disclosure Questionnaire 3
Penn Helping Alliance Questionnaire Revised 3
continued
25

Results
TABLE 10 Number of primary articles associated with candidate measures (contd)
Measures No. of primary references
Therapist Action Scale 3

Vanderbilt Psychotherapy Process Scale: 80 items 3
Agnew Relationship Measure 2
Child Psychotherapy Process Scales 2
Hill Client Verbal Response Category System 2
Integrative Psychotherapy Alliance Scale 2
Program Environment Scale 2
Session Impacts Scale 2
Therapist Representation Inventory 2
Working Alliance Inventory Short 2
TABLE 11 Candidate measures with only one primary article Psychometric properties of
Measure candidate measures
Carkhuff Facilitative Self-Disclosure Appendix 10 presents a key summary of the core
psychometric properties of each measure
Carkhuff Immediacy
according to accepted psychometric criteria and
Client Resistance Scale coded according to the instructions set out in
Coding the Interaction in Psychotherapy Table 9 (p. 23).
Coherence of the Relationship Theme
Counseling Evaluation Inventory Short Version
Counselor Perception Questionnaire Candidate measures by
Empathy Construct Rating Scale: 23 items theoretical orientation/discipline
Empathy Construct Rating Scale: 84 items and perspective
Empathy Test
Table 12 presents the number of measures,
Family Engagement Questionnaire grouped according to theoretical orientation and
Family Therapeutic Alliance Scale perspective. As some measures have parallel
Feminist Self Disclosure Inventory forms, the total number exceeds 83. The figures
FIRO-B show that the dominant theoretical orientations
are psychodynamic/interpersonal and pan-
Grief Experience Inventory
theoretical, and that there is a slight bias towards
Helper Behaviour Rating System observer-related measures.
Helpful Responses Questionnaire
Intersession Experience Questionnaire
Maslach Burnout Inventory Client Candidate measures by
Maslach Burnout Inventory Therapist theoretical orientation and
Patient Action Scale population group
Psychotherapy Process Inventory
Table 13 presents the number of measures grouped
Reasons for Ending Treatment Questionnaire according to theoretical orientation and
Therapeutic Alliance Scales for Children population group. As some measures relate to
Therapeutic Bond Scales more than one population group, the total
Therapeutic Factors Inventory number exceeds 83. The figures show that the
Therapist Behaviour Scale majority of the measures relate to adults.
Truax and Carkhuff Non-Possessive Warmth
Truax and Carkhuff Genuineness
Measures meeting the minimum
Vanderbilt Negative Indicators Scale
standard
Vanderbilt Negative Indicators Scale Short
Vanderbilt Psychotherapy Process Scale: 44 items Table 14 presents the 43 measures that displayed
26 adequate reliability and validity as specified in
TABLE 12 Candidate measures grouped according to theoretical orientation and perspective
Theoretical orientation/discipline Therapist completed Patient completed Observer rated Total
Pan-theoretical 8 8 15 31
Psychoanalytic/psychodynamic 7 11 12 30
Counselling 2 3 7 12
Interpersonal 7 3 1 11
Person centred 2 1 4 7
Mental health nursing 2 2 2 6
Not specified 3 2 0 5
Behavioural 0 0 1 1
Feminism 1 0 0 1
Process experiential 0 1 0 1
Psychiatry 1 0 0 1
Systemic 1 0 0 1
Total 34 31 42 107
TABLE 13 Candidate measures grouped according to theoretical orientation and population group
Theoretical orientation/discipline Adult Child/adolescent Therapists Groups Families Total
Pan-theoretical 20 1 2 2 1 26
Psychoanalytic/psychodynamic 19 1 4 0 1 25
Counselling 5 2 4 0 0 11
Interpersonal 1 0 6 2 0 9
Person centred 5 1 1 1 0 8
Not specified 2 1 1 0 0 4
Mental health nursing 2 0 0 0 0 2
Behavioural 1 0 0 0 0 1
Feminism 0 0 1 0 0 1
Process experiential 1 0 0 0 0 1
Psychiatry 0 0 0 0 1 1
Systemic 0 0 0 0 1 1
Total 56 6 19 5 4 90
Table 9. A measure was required to demonstrate at while responsiveness and precision relate to the
least one aspect of reliability/validity to meet quality of the instrument.
criteria for adequacy. In cases where there was
variability across studies ranging from partial to For criterion 1 a measure was rated in terms of
adequate reliability/validity, the measure was how many components were addressed on
termed adequate. This was to avoid bias against acceptability and feasibility. Acceptability and
measures with a larger research base. feasibility each had six components. This was a
judgement of the evidence base and amount of
information relating to these components (i.e.
Developing an industry standard whether they were addressed) and not a
for research judgement on how acceptable/feasible the measure
was. Thresholds were not established to make such
Each of these measures was then rated in terms of evaluative judgements. For criterion 2, a measure
an industry standard. The twin criteria addressed was deemed to be adequate if the research
were: evidence indicated that it was either responsive or
precise (as set out in the coding instructions in
1. acceptability and feasibility Table 9).
2. responsiveness and precision.
Thirty of the measures displayed adequate
Acceptability and feasibility relate to issues of responsiveness or precision. None of the 43 was
service implementation and user-friendliness, fully addressed in terms of acceptability and 27

Results
feasibility evidence; the majority of the measures may have the potential to be adapted for use in
had three or fewer components described. service settings or in research practice settings, in
Measures that had more than three components that the authors had addressed the concepts of
described on either acceptability or feasibility are user-friendliness and service implementation.
highlighted in bold in Table 14. These measures
TABLE 14 Measures meeting criteria for adequacy on reliability and validity
Measure Name of measure A F R&P No. of primary

ID references
B1 Barrett-Lennard Relationship Inventory 4 2 A 16

C18 Counselor Rating Form 4 2 A 10
W1 Working Alliance Inventory Client 2 2 A 10
H6 Hill Interaction Matrix Statement by Statement 2 4 A 9
A2 Affective Sensitivity Scale Form C 2 2 A 8
C8 Carkhuff Scales 2 3 A 8
P4 Penn Helping Alliance Rating Scale 2 4 8
H7 Hill Verbal Counselor Response Category System 2 2 A 7
P3 Penn Helping Alliance Questionnaire Revised 2 3 7
W3 Working Alliance Inventory Therapist 2 2 A 7
C2 California Psychotherapy Alliance Scales Patient 4 4 6
M3 Multicultural Counseling Inventory 4 2 A 6
P6 Psychotherapy Process Q-Set 2 4 A 6
T10 Truax and Carkhuff Scales 2 4 6
C1 California Psychotherapy Alliance Scale Original 2 3 A 5
C3 California Psychotherapy Alliance Scales Rater 3 3 A 5
C22 Cross-Cultural Counseling Inventory Revised 4 2 A 5
C15 Counseling Evaluation Inventory 3 3 A 4
E4 Experiencing Scale 3 3 A 4
H5 Hill Interaction Matrix Form G 3 3 4
W2 Working Alliance Inventory Observer 2 3 A 4
C5 California Therapeutic Alliance Rating System 3 3 A 3
C6 California Therapeutic Alliance Rating System Scales 3 3 A 3
C7 Capacity for Dynamic Process Scale 2 2 3
C10 Client Attachment to Therapist Scale 2 2 A 3
C16 Counselor Effectiveness Rating Scale 2 1 3
G1 Group Assessment of Interpersonal Traits 2 4 A 3
H3 Helping Alliance Counting Signs Method 3 3 A 3
H8 Hill Counselor Verbal Response Category System Revised 2 3 A 3
T4 Therapist Action Scale 3 3 3
A7 Agnew Relationship Measure 2 2 A 2
I1 Integrative Psychotherapy Alliance Scale 3 4 2
S4 Session Impacts Scale 2 2 2
A5 Affective Sensitivity Scale Forms E-80 and E-A-2 2 2 1
A6 Affective Sensitivity Scale Form H 2 4 A 1
C12 Coding the Interaction in Psychotherapy 3 3 A 1
C19 Counselor Rating Form Short Version 5 2 A 1
C21 Counselor Perception Questionnaire 3 2 1
E1 Empathy Construct Rating Scale 23 2 2 A 1
E2 Empathy Construct Rating Scale 84 2 2 1
F3 Feminist Self-Disclosure Inventory 2 3 A 1
P5 Psychotherapy Process Inventory 3 2 A 1
T3 Therapeutic Factors Inventory 2 2 A 1
A, acceptability; F, feasibility; R&P, responsiveness and precision.
28
Chapter 6
Conclusions and recommendations for
further research
Conclusions techniques and threats to the relationship. These
areas relate to the three key developmental
The conclusions cover issues arising from the processes outlined above.
scoping review (conceptual), methodological issues
and results. Eighty-six per cent of the measures were
developed in the USA. The remaining measures
Scoping review were developed in the UK, Canada, Australia and
Three developmental processes were identified as Germany.
necessary for the provision of an effective
therapeutic relationship. These are summarised in Over one-third of the 83 measures (35%) had only
establishing a relationship, developing a one primary article associated with them.
relationship and maintaining a relationship.
The majority of the measures were developed within
Key processes involved in establishing what might pan-theoretical or psychodynamic/psychoanalytic
be called mini-outcomes or objectives for each perspectives, were observer rated and related to
phase are listed. It is assumed that although adult population groups.
these stages develop across therapy, there will
also be a cycling through these stages within a Towards an industry standard
therapeutic meeting, or over a number of weeks Of the 83 measures matching the content domain,
or months. 43 met the minimum standard. A total of 30
measures displayed adequate responsiveness or
Therapist, patient and contextual factors precision. None of the 43 measures that met the
determine the nature of the roles and frameworks minimum standard was fully addressed in terms
within which the therapeutic interactions take of acceptability and feasibility evidence. The
place. These, in turn, impact on the processes and majority of these measures had three or fewer
outcomes of each phase of the relationship. components described. Therefore, out of a total
of 83 measures matching the content domain,
Identification of measures no measure could be said to have met an
Electronic searches on bibliographic databases industry standard.
identified a total of 241 measures for review and
handsearching methods identified a further 19
measures. Recommendations for further
research
A total of 151 measures had information pertaining
to reliability and validity as demonstrated by the On the basis of the above findings, the authors
electronic sieve. Twenty-nine of these measures make the following observations and
were incorrectly excluded by the electronic sieve. recommendations in five areas: policy, priorities
and planning of research; accessibility of measures
Of the 151 measures, 68 were excluded on the and information relating to them; methodological
basis of their content domain not meeting issues regarding electronic searching; focus of
requirements, leaving a total of 83 measures for research effort; and developing an industry
critical appraisal. standard.
Critical appraisal of measures Policy, priorities and planning

The areas of the conceptual map that received In contrast to outcomes and outcome
most coverage (i.e. over 50% of measures measurement, there is currently no driver from
associated with them) were framework, therapist policy space that provides a rationale for
and patient engagement, roles, therapeutic developing and researching measures of 29

Conclusions and recommendations for further research
therapistpatient interactions. As such, this area Gaining access to some of the measures proved
of work lacks a direct link into policy and difficult, as many are only available from non-
practice. commercial sources.
The authors recommend that a review of policy As many measures as possible should be made
documents should be carried out, focusing on the available from a single source.
effects of common factors.
Methodological issues regarding
The review has shown that it is possible to electronic searching
measure therapistpatient interaction using a wide The electronic sieve did not correctly classify all
range of instruments of varying value. measures.
Care should be taken in ensuring that The authors recommend that electronic searching
therapistpatient interaction measures are techniques be verified and supplemented by
suitable for the context in which they are to be handsearching techniques.
used, by referring to agreed psychometric
standards. Focus of research effort
Although the core developmental processes
Much of the work reviewed lacks any coordinated outlined in the conceptual map are adequately
planning and approach by researchers. There is a covered in terms of content, one-third of the
need for more systematic research on individual measures have only one primary article associated
measures to ensure that they meet the wider with them.
range of psychometric criteria required to justify
their inclusion in research and practice. In the The authors propose that research activity should
UK, the Department of Health-funded prioritise investment in establishing a more robust
Outcomes Measures Implementations Group has evidence base for existing measures, rather than
been set up as a forum to discuss issues related attempting to develop new ones. However, where
to implementation of outcomes measures. At a research effort and time are invested in new
practice research level, the Clinical Outcomes measures, this should be done strategically and in
in Routine Evaluation (CORE) Network is a planned and coordinated fashion that will serve
currently evolving a new paradigm of quality national policy needs.
evaluation.143 Services comprising the CORE
Network collect data from the CORE measures in The majority of the measures are North American
a supported standardised database (CORE-PC) in origin.
and donate them to the CORE system trust to
develop CORE national research databases. The authors recommend that more research
However, there is currently no parallel research activity (as opposed to more measures) in the UK
network activity for the development of should be allocated to the study and development
therapistpatient measures. of process measures to ensure an evidence base
attesting to their transportability.
Building on the recent advances in outcomes
measurement activity, specific research networks The psychodynamic and pan-theoretical
could be established to provide the necessary orientations are currently overrepresented. There
capacity and continuity for development and is a lack of measures relating to non-adult
research on a therapistpatient measure (or group population groups and a bias towards observer-
of measures) to take place. rated measures.
Accessibility of measures and The authors suggest that any development of

information relating to them future measures should relate to other theoretical
Gaining access to information about measures is orientations and more diverse population groups,
time-consuming and may lead to a less than and should focus on therapist and patient
optimal decision. perspectives.
The authors recommend that a website be made Developing an industry standard

available that could house summaries of current Of the additional psychometric criteria defining
research on measures to ease the decision-making the industry standard, acceptability and feasibility
30 process. were not adequately addressed by any measure.
The authors recommend that research activity translations to enhance access by minority ethnic
should focus on improving existing measures in groups, and web or scanning options. Such moves
terms of acceptability and feasibility issues; in would ensure that measures could be successfully
particular, user support from measure developers, implemented in practice and research settings.
31

Chapter 7
Clientpractitioner interaction: future directions
Addendum to 2003 report Study design and methodology
Some measures with reported high reliability and
Since the production of the original 2003 report validity estimates from methodologically poor
the authors have taken the work forward in the study designs were termed as having met the
light of valuable feedback from an American minimum standard of psychometric data. The
Psychiatric Association (APA) journal. Accordingly, converse of this was the exclusion of many high-
points to consider when reading this report are profile measures which were lacking in positive
outlined below. validity evidence as a result of having been
rigorously tested and examined with more robust
Terminology study designs. The positive research evidence
stipulation was a particular problem in this study
A decision was made to change the terminology from relying, as it did, on somewhat crude thresholds
therapistpatient interactions to clientpractitioner and resulting in the exclusion of 26 measures
interactions. The authors believe that this (Table 15) that have been used extensively and
terminology was applicable to and more inclusive productively in the field of process research, as
of a greater range of therapies and professions. indicated by the number of citations in the Web of
Science.
Quality appraisal criteria
Assessment of primary studies
The main issues arising from the application of The authors suggest the introduction of some
systematic quality appraisal criteria to the present guidelines for assessment of the primary studies
area are as follows. that form the evidence base for appraisal of the
TABLE 15 Excluded measures
Measure Author(s), year Exclusion Web of Science citations

category
All Excluding
self-references
Affective Sensitivity Scale A Campbell, Kagan & Krathwohl, 1 0 0

1971
Affective Sensitivity Scale D Kagan & Schneider,1987 2 0 0
Affective Sensitivity Scale D80 Kagan & Schneider, 1987 2 0 0
CALPAS Therapist Gaston & Marmar, 1991 0 0 0
Child Psychotherapy Process Scales Estrada & Russell, 1999 3 2 0
Client Resistance Scale Mahalik, 1994 2 1 0
Coherence of the Relationship Theme Mitchell, 1995 2 1 0
Core Conflictual Relationship Theme Luborsky, 1977 1 61 48
Counsellor Effectiveness Scale Ivey, 1971 0 0 0
Counselor Evaluation Rating Scale Myrick & Kelly, 1971 3 2 2
Empathy Test Layton & Wykle, 1990 2 4 4
Family Engagement Questionnaire Kroll & Green, 1997 2 0 0
Family Therapeutic Alliance Scale Martin & Allison, 1993 3 0 0
Helper Behaviour Rating System Shapiro, Barkham & Irving, 1984 3 0 0
Modified
Helpful Responses Questionnaire Miller, Hedrick & Orlofsky, 1991 3 2 1
continued
33

TABLE 15 Excluded measures (contd)
Measure Author(s), year Exclusion Web of Science citations

category
All Excluding
self-references
Hill Client Verbal Response Category Hill, 1986 3 0 0

System
Intersession Experience Questionnaire Orlinsky, Geller, Tarragona & 2 0 0
Farber, 1993
Maslach Burnout Inventory Linehan, Cochran, Mar, Levensky & 1 1 0
(Therapist and Client Versions) Comtois, 2000
Missouri Identifying Transference Scale Multon, Patton & Kivlighan, 1996 3 4 2
Octant Scale Impact Message Inventory Keisler, Schmidt & Wagner, 1997 1 1 0
Patient Action Scale Hoyt, Marmar, Horowitz & 1 1 0
Alvarez, 1981
Penn Helping Alliance Questionnaire Alexander & Luborsky, 1986 0 3 3
Reasons for Ending Treatment Garcia & Weisz, 2002 3 1 0
Questionnaire
Session Evaluation Questionnaire Stiles, 1980 3 4 4
Session Evaluation Questionnaire Stiles & Snow, 1984 3 6 5
Form 3
Session Evaluation Questionnaire Stiles, Reynolds, Hardy, Rees, 3 4 2
Form 4 Barkham & Shapiro, 1994
Therapeutic Alliance Scales for Children Shirk & Saiz, 1992 1 2 2
Therapeutic Bond Scales Saunders, Howard & Orlinsky, 1989 1 0 0
Therapist Behavior Scale Duckro, George & Beal, 1980 3 0 0
Therapist Representation Inventory Geller, Cooley & Hartley, 1981 1 2 0
Therapist Embodiment Scale
Therapist Involvement Scale
Record of Dreams
Free Response Task
Vanderbilt Negative Indicators Scale Suh, Strupp & Malley, 1986 1 1 1
Vanderbilt Negative Indicators Scale Nergaard & Silberschatz, 1989 3 0 0
Short
Vanderbilt Psychotherapy Process Scale Suh, Strupp & OMalley, 1986 3 8 6
80 items
Vanderbilt Therapeutic Alliance Scale Hartley & Strupp, 1983 3 4 4
Working Alliance Inventory Client Tracey & Kokotovic, 1989 3 2 1
Short Form
Working Alliance Inventory Observer Tracey & Kokotovic, 1989 3 2 1
Short Form
Working Alliance Inventory Therapist Tracey & Kokotovic, 1989 3 3 2
Short Form
measures. At present, several checklists are assessment of primary studies associated with
available for the quality appraisal of both measures. In response to APA reviews, the authors
randomised and non-randomised studies of have identified and adapted review criteria
interventions.144 However, there is a current gap formulated by the Scientific Advisory Committee
34 in the literature for an equivalent tool for the of the Medical Outcomes Trust. These criteria
pertain to key attributes of health status and Validity issues

quality of life instruments (e.g. reliability, validity, Validity is multifaceted, concerning the ways in
responsiveness, interpretability, respondent and which a measure demonstrates that it assesses what
administrative burden, cultural and language it purports to assess. There needs to be an
adaptations). The criteria against which the understanding of the way that the process
instruments/measures are reviewed on these components in psychotherapy operate. For
attributes are much more closely linked to the example, processoutcome correlation logic
rigour of the study in which the measures are overlooks therapist and client responsiveness to
used. A copy of this rating tool is found in varying client requirements for process
Figure 3. Although these criteria are at the components, which is a factor that can cause
piloting stage, they may be used as a starting null findings, responsiveness being inherently
point for reviewing therapistpatient interaction non-linear.147 On this basis, it may be
measures. suggested that any criteria should be critically
appraised themselves, and informed by
Meta-analytic procedures for relevant debates in the process literature,
measures before being used for purposes of critical
In conventional systematic reviews, each trial appraisal.
might be associated with one or more papers (with
the usual number being one), whereas in the Responsiveness
current context, a number of measures was Null findings relating to the ability of an
associated with multiple papers. There was also a instrument to measure change over sessions could
difference in terms of the impact of multiple be reflecting the non-linear nature of client and
studies: each RCT of effectiveness adds to practitioner responsiveness.
knowledge of the effect of a treatment, by
changing the estimate of the effect size and the Acceptability and feasibility
confidence interval through meta-analysis. This Acceptability and feasibility were not
was not the case with data on issues such as operationalised sufficiently clearly in the review.
reliability, where continued demonstrations did This was in part related to the different purpose of
not add to knowledge of the instruments process measures in psychotherapy research and
reliability, but reflected the size of the literature practice. Historically, process measures have been
associated with the instrument. At present, used more for in-house research trials and
there is no direct analogue of the process of monitoring of therapist skills or therapeutic
meta-analysis with measures rather than relationships, rather than benchmarking and
interventions. However, there is an evolving dissemination, as is the case with outcome
technology of the systematic review of diagnostic measures. For this reason, the length of the
and rating instruments used in psychological instrument and details on completion time and
assessment,145 and the techniques of meta-analysis reading age should not be accorded the same
and systematic review have more recently been importance in an assessment of a process measure
applied to the performance of depression rating as for an outcome measure being selected for
scales,146 although in this case such scales can be inclusion in a trial where high response rates from
compared on a common standard (i.e. case patients are essential.
finding). Appropriate systematic appraisal criteria
for process measures would complement and
counterbalance this evolving literature. The Inter-rater reliability estimates
authors anticipate that use of the new rating tool
(Figure 3) may be an important first step towards There was an absence of inter-rater reliability
achieving this. estimates associated with the rating of the
clientpractitioner interaction measures. The
authors are currently using a revised coding
Use of Fitzpatrick criteria structure141 and estimating inter-rater
reliability for each of the attributes of the
The Fitzpatrick criteria were developed specifically coding scheme (see above and Figure 3). The
for the appraisal of patient-based outcome attributes and criteria for measuring them
measures. Areas where such criteria may be incorporate more succinct operational definitions
problematic for the assessment of and assessment of the rigour of the studys
clientpractitioner interaction measures identified design methodology in which the measures
in the present study are described below. are used. 35

ID
Reliability: internal consistency Yes = 1 No = 0 9 = Unable to determine

N/A = Not applicable to measure
1 Methods to collect reliability data Information on (a) methods of sample accrual and
sample size; (b) characteristics of sample; (c) testing
conditions; (d) descriptive statistics for the
instrument
2 Reliability estimates and standard errors for all
score elements (classical test) or standard error
of the mean over the range of scale and marginal
reliability of each scale (modern item response
theory)
3 Data to calculate reliability coefficients or actual
calculations or reliability coefficients
4 Above data for each major population of interest e.g. Different language and cultural groups; different
if necessary diagnostic groups; clinical/non-clinical populations
Reliability: reproducibility (inter-rater reliability or testretest reliability)

Yes = 1 No = 0 9 = Unable to determine N/A = Not applicable to measure
5 Methods employed to collect reliability data Information on (a) methods of sample accrual and
sample size; (b) characteristics of sample; (c) testing
instrument
6 Well-argued rationale to support the design of
the study and the interval between the first and
subsequent administration to support the
assumption that the population is stable
7 Information on testretest reliability and inter-
rater reliability based on intraclass correlation
coefficients
8 For item response theory applications: information
on the comparability of the item parameter
estimates and on measurement precision over
repeated administrations
Validity Yes = 1 No = 0 9 = Unable to determine

N/A = not applicable to measure
9 Rationale supporting the particular mix of evidence
presented for the intended cases
10 Clear description of the methods employed to Information on (a) methods of sample accrual and
collect validity data sample size; (b) characteristics of sample; (c) testing
instrument
11 Composition of the sample used to examine validity
(in detail)
12 Above data for each major population of interest
36 FIGURE 3 Rating tool for appraisal of clientpractitioner interaction tests and measures
13 For construct validity, present hypotheses tested

and data related to the tests
14 Clear rationale and support for the choice of

criteria measures
Responsiveness (change over time or differences between groups)

15 Evidence on the changes in scores of the
instrument
16 Longitudinal data that compare a group that is

expected to change with a group that is expected
to remain stable
17 Population(s) on which responsiveness has been
tested, including the time intervals of assessment,
interventions or measures involved in evaluating
change, and the populations assumed to be stable
Acceptability: respondent burden Yes = 1 No = 0 9 = Unable to determine

18 Information on average and range of the time
needed to complete the instrument
19 Information on reading and comprehension level
20 Information on any special requirements or

requests made of respondent
21 Level of missing data and refusal rates and the

reasons for both
22 Provide evidence that the instrument places no This criterion is only applicable to instruments that
undue physical or emotional strain on the have excessive amounts of missing data
respondent
23 Indicate when or under what circumstances their
instrument is not suitable for respondents
Feasibility: administrative burden Yes = 1 No = 0 9 = Unable to determine

24 Information about any resources required for
administration of the instrument, such as the
need for special or specific computer hardware
or software to administer, score or analyse the
instrument
FIGURE 3 Rating tool for appraisal of clientpractitioner interaction tests and measures (contd) 37

For interviewer-administered instruments

25 Document the average time and range of time
required of a trained interviewer to administer the
instrument in face-to-face interviews, by telephone
or with computer-assisted formats/applications,
as appropriate
26 Indicate the amount of training and level of
education or professional expertise and experience
needed by administrative staff to administer,
score or otherwise use the instrument
27 Indicate the availability of scoring instructions
Cultural and language adaptations or translations Yes = 1 No = 0 9 = Unable to determine

28 Describe methods to achieve linguistic equivalence.
Steps are (a) at least two forward translations;
(b) at least one backward translation to the source
language that yields a pooled forward translation;
(c) a review of translated versions by lay and
expert panels with revisions; (d) field tests to
provide evidence of comparability
29 Describe methods to achieve conceptual
equivalence. Steps are (a) assessment of content
validity of the measure in each cultural or language
group to which the measure is to be applied;
(b) item response theory and confirmatory factor
analysis to evaluate cross-cultural equivalence
through examination of differential item functioning
30 Identify and explain any significant differences
between the original and translated versions
31 Explain how inconsistencies were reconciled
Precision (degree to which one can assign easily understood meaning to an instruments quantitative scores)
32 Description of the rationale for selection of external
criteria or populations for purposes of comparison
and interpretability of data
33 Information regarding the ways in which data from
the instrument should be (or have been) reported
and displayed
34 Cite meaningful benchmarks (comparative or
normative data) to facilitate interpretation of the
scores
FIGURE 3 Rating tool for appraisal of clientpractitioner interaction tests and measures (contd)
38
Conclusions and the measure has been cited in the Web of Science.
The authors would advise that all measures that
recommendations have been excluded on the positive evidence on
The hallmark of systematic reviews is an validity rule, but which have been cited at least
adherence to a set of agreed procedures supported once in the Web of Science (excluding self-
by documentation detailing the decision-making citations) are worthy of consideration.
process. Such procedures have been pivotal in
developing the rigour for the discipline. In the Some common problems were identified
authors opinion, there needs to be a similar associated with applying systematic appraisal
priority given to the development of criteria to clientpractitioner interaction measures.
clientpractitioner interaction measures and a In the authors opinion, a tool needs to be
detailed protocol for doing this, and researchers developed to assess primary studies associated
need to establish an agenda to shape up measure with measures, akin to tools currently available for
research in order for it to emulate the rigour of a appraisal of intervention studies. Such a move
systematic approach. would ensure that practitioners and researchers
involved in therapeutic activities could have more
Because the application of systematic review confidence in the use and selection of
techniques to rating instruments is still very clientpractitioner interaction measures.
recent, there should be some caution in how the
current inventory of measures is used. Although With regard to the field of clientpractitioner
the measures in Table 14 (p. 28) have been interactions, it is essential that measures are
critically appraised and found to have met the subject to quality-control procedures. When
minimum standard of psychometric data, if the aggregating results across studies it is necessary
measure has not been cited at least once in the not only that the same measures are used,
Web of Science (excluding self-citations), a larger but also that these measures have been proven
research evidence base may be needed before it to meet established, acceptable criteria. The
can be used with confidence as a research tool. importance of clientpractitioner interaction
Although this should be part of the process of research lies in its ability to determine and
methodologically rigorous research, this delineate the change mechanisms in therapy due
recommendation is being drawn up in an effort to to the therapeutic relationship. Using measures
offset the tendency noted earlier for new, that do not meet criteria has implications for
underused measures to populate the field of hypothesis testing in this field. The use of
research into clientpractitioner interactions. psychometrically sound measures will ensure that
researchers and practitioners will be able to
The reader is also referred to the list of excluded determine reliably what leads to outcome and will
measures (Table 15), paying particular attention to enable new models of therapy to be successfully
the reason for exclusion and the number of times developed.
39

Acknowledgements
his project was funded by the NIHR HTA University of Manchester) was a grantholder on
T R&D Programme (project number 06/90/05). the project and provided advice on the interim
report. Kate Bonsall (Research Assistant,
The views and opinions expressed therein are University of Leeds) data extracted and conducted
those of the authors and do not necessarily reflect qualitative data analysis on articles in the
those of the funder. preparation of the conceptual map, conducted
data extraction on the articles relating to the
Contribution of authors measures and summarised psychometric
Jane Cahill (Research Officer) managed the information on the measures. Kanan Pandya
research project and had a primary role in the (Research Assistant, University of Leeds) data
drafting and critical revision of the manuscript at extracted and conducted qualitative data analysis
all stages. Michael Barkham (Professor of on articles in the preparation of the conceptual
Counselling and Clinical Psychology) contributed map. Clare Doherty (Research Assistant,
to the writing and critical reworking of the draft at University of Leeds) conducted data extraction on
all stages of development and was responsible for the articles relating to the measures and
the general supervision of the research group. summarised psychometric information on the
Gillian Hardy (Professor of Clinical and measures. Helen Ashworth (Clerical Support,
Occupational Psychology) developed and wrote up University of Leeds) provided administrative
the conceptual map. Simon Gilbody (Senior support on the project. Martin Gill (Faculty Team
Lecturer in Psychiatry) oversaw methodological Librarian, University of Leeds) assisted in the
aspects of the project including literature searches design of electronic search strategies. Susan
and application of systematic review techniques. Mottram (Faculty Team Librarian, University of
David Richards (Professor of Mental Health Leeds) assisted in the design of electronic search
Nursing) contributed to the development of the strategies.
conceptual map and its validation. Peter Bower
(Senior Research Fellow) contributed to the Papers published elsewhere relating to
development of the conceptual map and its this research
validation. Kerry Audin (Research Officer) co- Hardy GE, Cahill J, Barkham M. Models of
rated the measures and assisted in the writing and the therapeutic relationship and prediction
critical revision of the manuscript, including its of outcome: a research perspective. In
preparation for submission. Janice Connell Gilbert P, Leahy RL, editors. The therapeutic
(Research Officer) developed the Access Database relationship in the cognitive behavioural
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Screening for speech and language
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Systematic reviews of wound care diabetes mellitus: a rapid and systematic
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and cost-effectiveness of irinotecan, effectiveness of brief psychological economic evaluation.
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Effectiveness and cost-effectiveness of consultations on disease management focused on individual womens
acute hospital-based spinal cord injuries and satisfaction in inflammatory bowel physical and psychological health
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Prioritisation of health technology The effectiveness of diagnostic tests for Estimating implied rates of discount in
assessment. The PATHS model: the assessment of shoulder pain due to healthcare decision-making.
methods and case studies. soft tissue disorders: a systematic review. By West RR, McNabb R,
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Systematic review of isolation policies in Clinical effectiveness and costs of the Involving consumers in research and
the hospital management of methicillin- Sugarbaker procedure for the treatment development agenda setting for the
resistant Staphylococcus aureus: a review of of pseudomyxoma peritonei. NHS: developing an evidence-based
the literature with epidemiological and By Bryant J, Clegg AJ, Sidhu MK, approach.
economic modelling. Brodin H, Royle P, Davidson P. By Oliver S, Clarke-Jones L,
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the regulation of long-term hypnotic No. 16
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drug use. A multi-centre randomised controlled
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multiple sclerosis: a systematic review.
Thompson J, Tomeny M. coronary bypass grafting versus
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percutaneous transluminal coronary
No. 41 No. 9
Improving the evaluation of therapeutic angioplasty with stenting for proximal
The inclusion of reports of randomised stenosis of the left anterior descending
trials published in languages other than interventions in multiple sclerosis:
development of a patient-based measure coronary artery.
English in systematic reviews.
of outcome. By Reeves BC, Angelini GD, Bryan
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The impact of screening on future No. 10 Does early magnetic resonance imaging
health-promoting behaviours and health A systematic review and economic influence management or improve
beliefs: a systematic review. evaluation of magnetic resonance outcome in patients referred to
By Bankhead CR, Brett J, Bukach C, cholangiopancreatography compared secondary care with low back pain?
Webster P, Stewart-Brown S, Munafo M, with diagnostic endoscopic retrograde A pragmatic randomised controlled
et al. cholangiopancreatography. trial.
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Volume 8, 2004 Chilcott J, Thomas S, Blakeborough T, MGC, Vale L, Scott NW, Campbell MK,
Walters SJ, et al. et al.
No. 1
What is the best imaging strategy for No. 11 No. 18
acute stroke? The clinical and cost-effectiveness of
The use of modelling to evaluate new
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drugs for patients with a chronic
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Delaney BC, Barton PM, Deeks JJ, et al. Clinical effectiveness and cost- economic evaluation of the clinical and
effectiveness of neonatal screening for cost-effectiveness of newer drugs for
No. 3 inborn errors of metabolism using treatment of mania associated with
The effectiveness and cost-effectiveness tandem mass spectrometry: a systematic bipolar affective disorder.
of microwave and thermal balloon
review. By Bridle C, Palmer S, Bagnall A-M,
endometrial ablation for heavy
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menstrual bleeding: a systematic review
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By Garside R, Stein K, Wyatt K, No. 13 Liquid-based cytology in cervical
Round A, Price A. Clinical effectiveness and cost- screening: an updated rapid and
No. 4 effectiveness of pioglitazone and systematic review and economic
A systematic review of the role of rosiglitazone in the treatment of analysis.
bisphosphonates in metastatic disease. type 2 diabetes: a systematic By Karnon J, Peters J, Platt J,
By Ross JR, Saunders Y, Edmonds PM, review and economic Chilcott J, McGoogan E, Brewer N.
Patel S, Wonderling D, Normand C, et al. evaluation.
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capecitabine (Xeloda ) for locally No. 14 for health improvement.
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Effectiveness and efficiency of guideline trial of appropriately trained midwives Autoantibody testing in children with
dissemination and implementation and paediatric senior house newly diagnosed type 1 diabetes
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Clinical effectiveness and cost- The Social Support and Family Health Provision, uptake and cost of cardiac
effectiveness of prehospital intravenous Study: a randomised controlled trial and rehabilitation programmes: improving
fluids in trauma patients. economic evaluation of two alternative services to under-represented groups.
By Dretzke J, Sandercock J, Bayliss S, forms of postnatal support for mothers By Beswick AD, Rees K, Griebsch I,
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By Dndar Y, Boland A, Strobl J, a systematic review. No. 43
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outpatient procedures within cohorts
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multicentre randomised trial comparing No. 35 C, Bayliss S, Adi Y, Wilson JS, et al.
abdominal, vaginal and laparoscopic Coronary artery stents: a rapid systematic
review and economic evaluation. No. 45
methods of hysterectomy. Systematic review and economic
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evaluation of a long-acting insulin
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information analysis in complex health in decision-analytic modelling in health No. 46
economic models: developments on the technology assessment. Supplementation of a home-based
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modified-release dipyridamole in the economic evaluation.
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Measurement of health-related quality A randomised controlled comparison of
No. 1
of life for people with dementia: alternative strategies in stroke care.
Randomised controlled multiple
development of a new instrument By Kalra L, Evans A, Perez I,
treatment comparison to provide a
(DEMQOL) and an evaluation of Knapp M, Swift C, Donaldson N.
cost-effectiveness rationale for the
current methodology.
selection of antimicrobial therapy in No. 19
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acne. The investigation and analysis of critical
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No. 11 Taylor-Adams S, Vincent C.
No. 2 Clinical effectiveness and cost-
Do the findings of case series studies effectiveness of drotrecogin alfa No. 20
vary significantly according to (activated) (Xigris) for the treatment of Potential use of routine databases in
methodological characteristics? severe sepsis in adults: a systematic health technology assessment.
By Dalziel K, Round A, Stein K, review and economic evaluation. By Raftery J, Roderick P, Stevens A.
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No. 21
Shepherd J, Hartwell D, Cave C,
Clinical and cost-effectiveness of newer
No. 3 et al.
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Improving the referral process for
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familial breast cancer genetic No. 12 modelling study.
counselling: findings of three A methodological review of how By Woodroffe R, Yao GL, Meads C,
randomised controlled trials of two heterogeneity has been examined in Bayliss S, Ready A, Raftery J, et al.
interventions. systematic reviews of diagnostic test
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Roderick P. evaluation of alendronate, etidronate,
No. 4 risedronate, raloxifene and teriparatide
Randomised evaluation of alternative for the prevention and treatment of
No. 13
electrosurgical modalities to treat postmenopausal osteoporosis.
Cervical screening programmes: can
bladder outflow obstruction in men with By Stevenson M, Lloyd Jones M,
automation help? Evidence from
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systematic reviews, an economic analysis
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and a simulation modelling exercise
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of the cost-effectiveness of palliative interventions on health outcomes and
therapies for patients with inoperable No. 14 costs in adults and children with difficult
oesophageal cancer. Laparoscopic surgery for inguinal asthma.
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Bond J, Griffin SM. effectiveness and economic evaluation. Candy B, Noble MJ, Harrison BDW, et al.
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Impact of computer-aided detection An evaluation of the costs, effectiveness
prompts on the sensitivity and specificity No. 15 and quality of renal replacement
of screening mammography. Clinical effectiveness, tolerability and therapy provision in renal satellite units
By Taylor P, Champness J, Given- cost-effectiveness of newer drugs for in England and Wales.
Wilson R, Johnston K, Potts H. epilepsy in adults: a systematic review By Roderick P, Nicholson T, Armitage
and economic evaluation. A, Mehta R, Mullee M, Gerard K, et al.
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AB, Campbell MK, Clemens FJ,
A randomised controlled trial to systematic review and economic
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compare the cost-effectiveness of evaluation.
No. 8 tricyclic antidepressants, selective By Wilson J, Connock M, Song F, Yao
Lay publics understanding of equipoise serotonin reuptake inhibitors and G, Fry-Smith A, Raftery J, et al.
and randomisation in randomised lofepramine.
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controlled trials. Indirect comparisons of competing
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Clinical and cost-effectiveness of effectiveness of immediate angioplasty Cost-effectiveness of alternative
electroconvulsive therapy for depressive for acute myocardial infarction: strategies for the initial medical
illness, schizophrenia, catatonia and systematic review and economic management of non-ST elevation acute
mania: systematic reviews and economic evaluation. coronary syndrome: systematic review
modelling studies. By Hartwell D, Colquitt J, Loveman and decision-analytical modelling.
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Outcomes of electrically stimulated The causes and effects of socio- The effectiveness of the Heidelberg
gracilis neosphincter surgery. demographic exclusions from clinical Retina Tomograph and laser diagnostic
By Tillin T, Chambers M, Feldman R. trials. glaucoma scanning system (GDx) in
By Bartlett C, Doyal L, Ebrahim S, detecting and monitoring glaucoma.
No. 29 Davey P, Bachmann M, Egger M, By Kwartz AJ, Henson DB,
The effectiveness and cost-effectiveness et al. Harper RA, Spencer AF,
of pimecrolimus and tacrolimus for McLeod D.
atopic eczema: a systematic review and No. 39
economic evaluation. Is hydrotherapy cost-effective? A No. 47
By Garside R, Stein K, Castelnuovo E, randomised controlled trial of combined Clinical and cost-effectiveness of
Pitt M, Ashcroft D, Dimmock P, et al. hydrotherapy programmes compared autologous chondrocyte implantation
with physiotherapy land techniques in for cartilage defects in knee joints:
No. 30 children with juvenile idiopathic systematic review and economic
Systematic review on urine albumin arthritis. evaluation.
testing for early detection of diabetic By Epps H, Ginnelly L, Utley M, By Clar C, Cummins E, McIntyre L,
complications. Southwood T, Gallivan S, Sculpher M, Thomas S, Lamb J, Bain L, et al.
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No. 40 Systematic review of effectiveness of
No. 31 different treatments for childhood
A randomised controlled trial and cost-
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et al. thromboembolism: systematic
patients with chronic low back pain.
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By Thomas KJ, MacPherson H,
No. 41 anticoagulation, dextran and regional
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Displaced intracapsular hip fractures anaesthesia as thromboprophylaxis.
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No. 33 comparison of reduction and fixation, Halls H, Jackson D, Collins R,
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Group (BROSG) randomised controlled behaviour therapy clinical trials in defiant disorder, in children.
trial to compare the effectiveness and central Scotland. By Dretzke J, Frew E, Davenport C,
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The effectiveness and cost-effectiveness No. 1
No. 35 of dual-chamber pacemakers compared The clinical and cost-effectiveness of
Conceptual framework and systematic with single-chamber pacemakers for donepezil, rivastigmine, galantamine
review of the effects of participants and bradycardia due to atrioventricular and memantine for Alzheimers
professionals preferences in randomised block or sick sinus syndrome: disease.
controlled trials. systematic review and economic By Loveman E, Green C, Kirby J,
By King M, Nazareth I, Lampe F, evaluation. Takeda A, Picot J, Payne E,
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No. 36 No. 2
The clinical and cost-effectiveness of No. 44 FOOD: a multicentre randomised trial
implantable cardioverter defibrillators: Newborn screening for congenital heart evaluating feeding policies in patients
a systematic review. defects: a systematic review and admitted to hospital with a recent
By Bryant J, Brodin H, Loveman E, cost-effectiveness analysis. stroke.
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mental health nurses for anxiety, The clinical and cost-effectiveness of left The clinical effectiveness and cost-
depression and life difficulties among ventricular assist devices for end-stage effectiveness of computed tomography
general practice patients. The CPN-GP heart failure: a systematic review and screening for lung cancer: systematic
study. economic evaluation. reviews.
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No. 4 No. 12 No. 20

A systematic review of the effectiveness A series of systematic reviews to inform A systematic review of the clinical
and cost-effectiveness of neuroimaging a decision analysis for sampling and effectiveness and cost-effectiveness of
assessments used to visualise the treating infected diabetic foot enzyme replacement therapies for
seizure focus in people with refractory ulcers. Fabrys disease and
epilepsy being considered for By Nelson EA, OMeara S, Craig D, mucopolysaccharidosis type 1.
surgery. Iglesias C, Golder S, Dalton J, By Connock M, Juarez-Garcia A, Frew
By Whiting P, Gupta R, Burch J, et al. E, Mans A, Dretzke J, Fry-Smith A, et al.
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et al. No. 13 No. 21
Randomised clinical trial, observational Health benefits of antiviral therapy for
No. 5 study and assessment of cost- mild chronic hepatitis C: randomised
Comparison of conference abstracts effectiveness of the treatment of varicose controlled trial and economic
and presentations with full-text veins (REACTIV trial). evaluation.
articles in the health technology By Michaels JA, Campbell WB, By Wright M, Grieve R, Roberts J,
assessments of rapidly evolving Brazier JE, MacIntyre JB, Palfreyman Main J, Thomas HC on behalf of the
technologies. SJ, Ratcliffe J, et al. UK Mild Hepatitis C Trial Investigators.
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Walley T, Haycox A, Williamson PR. No. 22
No. 14
Pressure relieving support surfaces: a
The cost-effectiveness of screening for
No. 6 randomised evaluation.
oral cancer in primary care.
Systematic review and evaluation of By Nixon J, Nelson EA, Cranny G,
methods of assessing urinary By Speight PM, Palmer S, Moles DR,
Iglesias CP, Hawkins K, Cullum NA, et al.
incontinence. Downer MC, Smith DH, Henriksson M
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KR, Turner DA, Sutton AJ, Chapple C, A systematic review and economic
No. 15 model of the effectiveness and cost-
et al.
Measurement of the clinical and cost- effectiveness of methylphenidate,
No. 7 effectiveness of non-invasive diagnostic dexamfetamine and atomoxetine for the
The clinical effectiveness and cost- testing strategies for deep vein treatment of attention deficit
effectiveness of newer drugs for children thrombosis. hyperactivity disorder in children and
with epilepsy. A systematic review. By Goodacre S, Sampson F, Stevenson adolescents.
By Connock M, Frew E, Evans B-W, M, Wailoo A, Sutton A, Thomas S, et al. By King S, Griffin S, Hodges Z,
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Systematic review of the effectiveness
No. 8 and cost-effectiveness of HealOzone No. 24
Surveillance of Barretts oesophagus: for the treatment of occlusal pit/fissure The clinical effectiveness and cost-
exploring the uncertainty through caries and root caries. effectiveness of enzyme replacement
systematic review, expert workshop and By Brazzelli M, McKenzie L, Fielding therapy for Gauchers disease:
economic modelling. S, Fraser C, Clarkson J, Kilonzo M, a systematic review.
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No. 9 Randomised controlled trials of
Topotecan, pegylated liposomal conventional antipsychotic versus new No. 25
doxorubicin hydrochloride and Effectiveness and cost-effectiveness of
atypical drugs, and new atypical drugs
paclitaxel for second-line or subsequent salicylic acid and cryotherapy for
versus clozapine, in people with
treatment of advanced ovarian cancer: a cutaneous warts. An economic decision
schizophrenia responding poorly
systematic review and economic model.
to, or intolerant of, current drug
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et al.
et al. No. 26
No. 10 A systematic literature review of the
Evaluation of molecular techniques No. 18 effectiveness of non-pharmacological
in prediction and diagnosis of Diagnostic tests and algorithms used in interventions to prevent wandering in
cytomegalovirus disease in the investigation of haematuria: dementia and evaluation of the ethical
immunocompromised patients. systematic reviews and economic implications and acceptability of their
By Szczepura A, Westmoreland D, evaluation. use.
Vinogradova Y, Fox J, Clark M. By Rodgers M, Nixon J, Hempel S, By Robinson L, Hutchings D, Corner
Aho T, Kelly J, Neal D, et al. L, Beyer F, Dickinson H, Vanoli A, et al.
No. 11
Screening for thrombophilia in high-risk No. 19 No. 27
situations: systematic review and cost- Cognitive behavioural therapy in A review of the evidence on the effects
effectiveness analysis. The Thrombosis: addition to antispasmodic therapy for and costs of implantable cardioverter
Risk and Economic Assessment of irritable bowel syndrome in primary defibrillator therapy in different patient
Thrombophilia Screening (TREATS) care: randomised controlled groups, and modelling of cost-
study. trial. effectiveness and costutility for these
By Wu O, Robertson L, Twaddle S, By Kennedy TM, Chalder T, groups in a UK context.
Lowe GDO, Clark P, Greaves M, McCrone P, Darnley S, Knapp M, By Buxton M, Caine N, Chase D,
420 et al. Jones RH, et al. Connelly D, Grace A, Jackson C, et al.
No. 28 No. 37 No. 46

Adefovir dipivoxil and pegylated Cognitive behavioural therapy in Etanercept and efalizumab for the
interferon alfa-2a for the treatment of chronic fatigue syndrome: a randomised treatment of psoriasis: a systematic
chronic hepatitis B: a systematic review controlled trial of an outpatient group review.
and economic evaluation. programme. By Woolacott N, Hawkins N,
By Shepherd J, Jones J, Takeda A, By ODowd H, Gladwell P, Rogers CA, Mason A, Kainth A, Khadjesari Z,
Davidson P, Price A. Hollinghurst S, Gregory A. Bravo Vergel Y, et al.
No. 29 No. 38 No. 47
An evaluation of the clinical and cost- A comparison of the cost-effectiveness of Systematic reviews of clinical decision
effectiveness of pulmonary artery five strategies for the prevention of non- tools for acute abdominal pain.
catheters in patient management in steroidal anti-inflammatory drug-induced By Liu JLY, Wyatt JC, Deeks JJ,
intensive care: a systematic review and a gastrointestinal toxicity: a systematic Clamp S, Keen J, Verde P, et al.
randomised controlled trial. review with economic modelling.
By Harvey S, Stevens K, Harrison D, By Brown TJ, Hooper L, Elliott RA, No. 48
Young D, Brampton W, McCabe C, et al. Payne K, Webb R, Roberts C, et al. Evaluation of the ventricular assist
device programme in the UK.
No. 30 No. 39
By Sharples L, Buxton M, Caine N,
Accurate, practical and cost-effective The effectiveness and cost-effectiveness
Cafferty F, Demiris N, Dyer M,
assessment of carotid stenosis in the UK. of computed tomography screening for
et al.
By Wardlaw JM, Chappell FM, coronary artery disease: systematic
Stevenson M, De Nigris E, Thomas S, review. No. 49
Gillard J, et al. By Waugh N, Black C, Walker S, A systematic review and economic
McIntyre L, Cummins E, Hillis G. model of the clinical and cost-
No. 31 effectiveness of immunosuppressive
Etanercept and infliximab for the No. 40
What are the clinical outcome and cost- therapy for renal transplantation in
treatment of psoriatic arthritis: children.
a systematic review and economic effectiveness of endoscopy undertaken
by nurses when compared with doctors? By Yao G, Albon E, Adi Y, Milford D,
evaluation. Bayliss S, Ready A, et al.
By Woolacott N, Bravo Vergel Y, A Multi-Institution Nurse Endoscopy
Hawkins N, Kainth A, Khadjesari Z, Trial (MINuET).
No. 50
Misso K, et al. By Williams J, Russell I, Durai D,
Amniocentesis results: investigation of
Cheung W-Y, Farrin A, Bloor K, et al.
anxiety. The ARIA trial.
No. 32
No. 41 By Hewison J, Nixon J, Fountain J,
The cost-effectiveness of testing for
The clinical and cost-effectiveness of Cocks K, Jones C, Mason G, et al.
hepatitis C in former injecting drug
oxaliplatin and capecitabine for the
users.
adjuvant treatment of colon cancer:
By Castelnuovo E, Thompson-Coon J,
systematic review and economic Volume 11, 2007
Pitt M, Cramp M, Siebert U, Price A,
evaluation.
et al. No. 1
By Pandor A, Eggington S, Paisley S,
No. 33 Tappenden P, Sutcliffe P. Pemetrexed disodium for the treatment
Computerised cognitive behaviour of malignant pleural mesothelioma:
No. 42 a systematic review and economic
therapy for depression and anxiety A systematic review of the effectiveness
update: a systematic review and evaluation.
of adalimumab, etanercept and By Dundar Y, Bagust A, Dickson R,
economic evaluation. infliximab for the treatment of
By Kaltenthaler E, Brazier J, Dodd S, Green J, Haycox A, et al.
rheumatoid arthritis in adults and an
De Nigris E, Tumur I, Ferriter M, economic evaluation of their cost- No. 2
Beverley C, et al. effectiveness. A systematic review and economic
No. 34 By Chen Y-F, Jobanputra P, Barton P, model of the clinical effectiveness and
Cost-effectiveness of using prognostic Jowett S, Bryan S, Clark W, et al. cost-effectiveness of docetaxel in
information to select women with breast combination with prednisone or
No. 43
cancer for adjuvant systemic therapy. prednisolone for the treatment of
Telemedicine in dermatology:
By Williams C, Brunskill S, Altman D, hormone-refractory metastatic prostate
a randomised controlled trial.
Briggs A, Campbell H, Clarke M, cancer.
By Bowns IR, Collins K, Walters SJ,
et al. By Collins R, Fenwick E, Trowman R,
McDonagh AJG.
Perard R, Norman G, Light K,
No. 35 No. 44 et al.
Psychological therapies including Cost-effectiveness of cell salvage and
dialectical behaviour therapy for alternative methods of minimising No. 3
borderline personality disorder: perioperative allogeneic blood A systematic review of rapid diagnostic
a systematic review and preliminary transfusion: a systematic review and tests for the detection of tuberculosis
economic evaluation. economic model. infection.
By Brazier J, Tumur I, Holmes M, By Davies L, Brown TJ, Haynes S, By Dinnes J, Deeks J, Kunst H,
Ferriter M, Parry G, Dent-Brown K, et al. Payne K, Elliott RA, McCollum C. Gibson A, Cummins E, Waugh N, et al.
No. 36 No. 45 No. 4

Clinical effectiveness and cost- Clinical effectiveness and cost- The clinical effectiveness and cost-
effectiveness of tests for the diagnosis effectiveness of laparoscopic surgery for effectiveness of strontium ranelate for
and investigation of urinary tract colorectal cancer: systematic reviews and the prevention of osteoporotic
infection in children: a systematic review economic evaluation. fragility fractures in postmenopausal
and economic model. By Murray A, Lourenco T, women.
By Whiting P, Westwood M, Bojke L, de Verteuil R, Hernandez R, Fraser C, By Stevenson M, Davis S,
Palmer S, Richardson G, Cooper J, et al. McKinley A, et al. Lloyd-Jones M, Beverley C. 421

No. 5 No. 13 No. 21

A systematic review of quantitative and A systematic review and economic The clinical effectiveness and cost-
qualitative research on the role and evaluation of epoetin alfa, epoetin beta effectiveness of treatments for children
effectiveness of written information and darbepoetin alfa in anaemia with idiopathic steroid-resistant
available to patients about individual associated with cancer, especially that nephrotic syndrome: a systematic review.
medicines. attributable to cancer treatment. By Colquitt JL, Kirby J, Green C,
By Raynor DK, Blenkinsopp A, By Wilson J, Yao GL, Raftery J, Cooper K, Trompeter RS.
Knapp P, Grime J, Nicolson DJ, Bohlius J, Brunskill S, Sandercock J,
Pollock K, et al. et al. No. 22
A systematic review of the routine
No. 6 No. 14 monitoring of growth in children of
Oral naltrexone as a treatment for A systematic review and economic primary school age to identify
relapse prevention in formerly evaluation of statins for the prevention growth-related conditions.
opioid-dependent drug users: of coronary events. By Fayter D, Nixon J, Hartley S,
a systematic review and economic By Ward S, Lloyd Jones M, Pandor A, Rithalia A, Butler G, Rudolf M, et al.
evaluation. Holmes M, Ara R, Ryan A, et al.
By Adi Y, Juarez-Garcia A, Wang D, No. 23
Jowett S, Frew E, Day E, et al. No. 15 Systematic review of the effectiveness of
A systematic review of the effectiveness preventing and treating Staphylococcus
No. 7 and cost-effectiveness of different aureus carriage in reducing peritoneal
Glucocorticoid-induced osteoporosis: models of community-based respite catheter-related infections.
a systematic review and costutility care for frail older people and their By McCormack K, Rabindranath K,
analysis. carers. Kilonzo M, Vale L, Fraser C, McIntyre L,
By Kanis JA, Stevenson M, By Mason A, Weatherly H, Spilsbury et al.
McCloskey EV, Davis S, Lloyd-Jones M. K, Arksey H, Golder S, Adamson J,
et al. No. 24
No. 8
The clinical effectiveness and cost of
Epidemiological, social, diagnostic and
No. 16 repetitive transcranial magnetic
economic evaluation of population
Additional therapy for young children stimulation versus electroconvulsive
screening for genital chlamydial
with spastic cerebral palsy: therapy in severe depression:
infection.
a randomised controlled trial. a multicentre pragmatic randomised
By Low N, McCarthy A, Macleod J,
By Weindling AM, Cunningham CC, controlled trial and economic
Salisbury C, Campbell R, Roberts TE,
Glenn SM, Edwards RT, Reeves DJ. analysis.
et al.
By McLoughlin DM, Mogg A,
No. 17 Eranti S, Pluck G, Purvis R, Edwards D,
No. 9
Screening for type 2 diabetes: literature et al.
Methadone and buprenorphine for the
review and economic modelling.
management of opioid dependence:
By Waugh N, Scotland G, No. 25
a systematic review and economic
McNamee P, Gillett M, Brennan A, A randomised controlled trial and
evaluation.
Goyder E, et al. economic evaluation of direct versus
By Connock M, Juarez-Garcia A,
indirect and individual versus group
Jowett S, Frew E, Liu Z, Taylor RJ,
No. 18 modes of speech and language therapy
et al.
The effectiveness and cost-effectiveness for children with primary language
No. 10 of cinacalcet for secondary impairment.
Exercise Evaluation Randomised Trial hyperparathyroidism in end-stage By Boyle J, McCartney E, Forbes J,
(EXERT): a randomised trial comparing renal disease patients on dialysis: a OHare A.
GP referral for leisure centre-based systematic review and economic
exercise, community-based walking and evaluation. No. 26
advice only. By Garside R, Pitt M, Anderson R, Hormonal therapies for early breast
By Isaacs AJ, Critchley JA, Mealing S, Roome C, Snaith A, cancer: systematic review and economic
See Tai S, Buckingham K, Westley D, et al. evaluation.
Harridge SDR, et al. By Hind D, Ward S, De Nigris E,
No. 19 Simpson E, Carroll C, Wyld L.
No. 11 The clinical effectiveness and
Interferon alfa (pegylated and cost-effectiveness of gemcitabine for No. 27
non-pegylated) and ribavirin for the metastatic breast cancer: a systematic Cardioprotection against the toxic
treatment of mild chronic hepatitis C: review and economic evaluation. effects of anthracyclines given to
a systematic review and economic By Takeda AL, Jones J, Loveman E, children with cancer: a systematic
evaluation. Tan SC, Clegg AJ. review.
By Shepherd J, Jones J, Hartwell D, By Bryant J, Picot J, Levitt G,
Davidson P, Price A, Waugh N. No. 20 Sullivan I, Baxter L, Clegg A.
A systematic review of duplex
No. 12 ultrasound, magnetic resonance No. 28
Systematic review and economic angiography and computed tomography Adalimumab, etanercept and infliximab
evaluation of bevacizumab and angiography for the diagnosis for the treatment of ankylosing
cetuximab for the treatment of and assessment of symptomatic, lower spondylitis: a systematic review and
metastatic colorectal cancer. limb peripheral arterial disease. economic evaluation.
By Tappenden P, Jones R, Paisley S, By Collins R, Cranny G, Burch J, By McLeod C, Bagust A, Boland A,
422 Carroll C. Aguiar-Ibez R, Craig D, Wright K, et al. Dagenais P, Dickson R, Dundar Y, et al.
No. 29 No. 37 No. 46

Prenatal screening and treatment A randomised controlled trial Drug-eluting stents: a systematic review
strategies to prevent group B examining the longer-term outcomes of and economic evaluation.
streptococcal and other bacterial standard versus new antiepileptic drugs. By Hill RA, Boland A, Dickson R,
infections in early infancy: cost- The SANAD trial. Dndar Y, Haycox A, McLeod C,
effectiveness and expected value of By Marson AG, Appleton R, Baker GA, et al.
information analyses. Chadwick DW, Doughty J, Eaton B, et al.
By Colbourn T, Asseburg C, Bojke L, No. 47
Philips Z, Claxton K, Ades AE, et al. No. 38 The clinical effectiveness and cost-
Clinical effectiveness and cost- effectiveness of cardiac resynchronisation
No. 30 effectiveness of different models (biventricular pacing) for heart failure:
Clinical effectiveness and cost- of managing long-term oral systematic review and economic model.
effectiveness of bone morphogenetic anticoagulation therapy: a systematic By Fox M, Mealing S, Anderson R,
proteins in the non-healing of fractures review and economic modelling. Dean J, Stein K, Price A, et al.
and spinal fusion: a systematic By Connock M, Stevens C, Fry-Smith A,
review. Jowett S, Fitzmaurice D, Moore D, et al. No. 48
By Garrison KR, Donell S, Ryder J, Recruitment to randomised trials:
Shemilt I, Mugford M, Harvey I, No. 39 strategies for trial enrolment and
et al. A systematic review and economic participation study. The STEPS study.
model of the clinical effectiveness and By Campbell MK, Snowdon C,
No. 31 cost-effectiveness of interventions for Francis D, Elbourne D, McDonald AM,
A randomised controlled trial of preventing relapse in people with Knight R, et al.
postoperative radiotherapy following bipolar disorder.
breast-conserving surgery in a By Soares-Weiser K, Bravo Vergel Y, No. 49
minimum-risk older population. The Beynon S, Dunn G, Barbieri M, Duffy S, Cost-effectiveness of functional
PRIME trial. et al. cardiac testing in the diagnosis and
By Prescott RJ, Kunkler IH, Williams management of coronary artery disease:
No. 40 a randomised controlled trial.
LJ, King CC, Jack W, van der Pol M,
Taxanes for the adjuvant treatment of The CECaT trial.
et al.
early breast cancer: systematic review By Sharples L, Hughes V, Crean A,
No. 32 and economic evaluation. Dyer M, Buxton M, Goldsmith K, et al.
Current practice, accuracy, effectiveness By Ward S, Simpson E, Davis S,
and cost-effectiveness of the school Hind D, Rees A, Wilkinson A. No. 50
entry hearing screen. Evaluation of diagnostic tests when
No. 41 there is no gold standard. A review of
By Bamford J, Fortnum H, Bristow K,
The clinical effectiveness and cost- methods.
Smith J, Vamvakas G, Davies L, et al. effectiveness of screening for open angle By Rutjes AWS, Reitsma JB,
glaucoma: a systematic review and Coomarasamy A, Khan KS,
No. 33
economic evaluation. Bossuyt PMM.
The clinical effectiveness and
By Burr JM, Mowatt G, Hernndez R,
cost-effectiveness of inhaled insulin
Siddiqui MAR, Cook J, Lourenco T, No. 51
in diabetes mellitus: a systematic
et al. Systematic reviews of the clinical
effectiveness and cost-effectiveness of
By Black C, Cummins E, Royle P, No. 42 proton pump inhibitors in acute upper
Philip S, Waugh N. Acceptability, benefit and costs of early gastrointestinal bleeding.
screening for hearing disability: a study By Leontiadis GI, Sreedharan A,
No. 34
of potential screening tests and Dorward S, Barton P, Delaney B,
Surveillance of cirrhosis for
models. Howden CW, et al.
hepatocellular carcinoma: systematic
By Davis A, Smith P, Ferguson M,
review and economic analysis.
Stephens D, Gianopoulos I. No. 52
By Thompson Coon J, Rogers G,
A review and critique of modelling in
Hewson P, Wright D, Anderson R, No. 43 prioritising and designing screening
Cramp M, et al. Contamination in trials of educational programmes.
interventions. By Karnon J, Goyder E, Tappenden P,
No. 35 By Keogh-Brown MR, Bachmann
The Birmingham Rehabilitation Uptake McPhie S, Towers I, Brazier J, et al.
MO, Shepstone L, Hewitt C, Howe A,
Maximisation Study (BRUM). Home- Ramsay CR, et al. No. 53
based compared with hospital-based
An assessment of the impact of the
cardiac rehabilitation in a multi-ethnic No. 44 NHS Health Technology Assessment
population: cost-effectiveness and Overview of the clinical effectiveness of Programme.
patient adherence. positron emission tomography imaging By Hanney S, Buxton M, Green C,
By Jolly K, Taylor R, Lip GYH, in selected cancers. Coulson D, Raftery J.
Greenfield S, Raftery J, Mant J, et al. By Facey K, Bradbury I, Laking G,
Payne E.
No. 36
A systematic review of the clinical,
Volume 12, 2008
No. 45
public health and cost-effectiveness The effectiveness and cost-effectiveness of No. 1
of rapid diagnostic tests for the carmustine implants and temozolomide A systematic review and economic
detection and identification of for the treatment of newly diagnosed model of switching from non-
bacterial intestinal pathogens in high-grade glioma: a systematic review glycopeptide to glycopeptide antibiotic
faeces and food. and economic evaluation. prophylaxis for surgery.
By Abubakar I, Irvine L, Aldus CF, By Garside R, Pitt M, Anderson R, By Cranny G, Elliott R, Weatherly H,
Wyatt GM, Fordham R, Schelenz S, et al. Rogers G, Dyer M, Mealing S, et al. Chambers D, Hawkins N, Myers L, et al. 423

No. 2 No. 10 No. 18

Cut down to quit with nicotine Payment to healthcare professionals for Structural neuroimaging in psychosis:
replacement therapies in smoking patient recruitment to trials: systematic a systematic review and economic
cessation: a systematic review of review and qualitative study. evaluation.
effectiveness and economic analysis. By Raftery J, Bryant J, Powell J, By Albon E, Tsourapas A, Frew E,
By Wang D, Connock M, Barton P, Kerr C, Hawker S. Davenport C, Oyebode F, Bayliss S, et al.
Fry-Smith A, Aveyard P, Moore D.
No. 11 No. 19
No. 3 Cyclooxygenase-2 selective non-steroidal Systematic review and economic analysis
A systematic review of the effectiveness anti-inflammatory drugs (etodolac, of the comparative effectiveness of
of strategies for reducing fracture risk in meloxicam, celecoxib, rofecoxib, different inhaled corticosteroids and
children with juvenile idiopathic etoricoxib, valdecoxib and lumiracoxib) their usage with long-acting beta2
arthritis with additional data on long- for osteoarthritis and rheumatoid agonists for the treatment of chronic
term risk of fracture and cost of disease arthritis: a systematic review and asthma in adults and children aged
management. economic evaluation. 12 years and over.
By Thornton J, Ashcroft D, ONeill T, By Chen Y-F, Jobanputra P, Barton P, By Shepherd J, Rogers G, Anderson R,
Elliott R, Adams J, Roberts C, et al. Bryan S, Fry-Smith A, Harris G, et al. Main C, Thompson-Coon J, Hartwell D,
No. 12 et al.
Does befriending by trained lay workers No. 20
effectiveness of central venous catheters
improve psychological well-being and Systematic review and economic analysis
treated with anti-infective agents in
quality of life for carers of people of the comparative effectiveness of
preventing bloodstream infections:
with dementia, and at what cost? different inhaled corticosteroids and
a systematic review and economic
A randomised controlled trial. their usage with long-acting beta2
evaluation.
By Charlesworth G, Shepstone L, By Hockenhull JC, Dwan K, Boland agonists for the treatment of chronic
Wilson E, Thalanany M, Mugford M, A, Smith G, Bagust A, Dndar Y, et al. asthma in children under the age
Poland F. of 12 years.
No. 13 By Main C, Shepherd J, Anderson R,
No. 5 Stepped treatment of older adults on Rogers G, Thompson-Coon J, Liu Z, et al.
A multi-centre retrospective cohort study laxatives. The STOOL trial.
comparing the efficacy, safety and cost- By Mihaylov S, Stark C, McColl E, No. 21
effectiveness of hysterectomy and Steen N, Vanoli A, Rubin G, et al. Ezetimibe for the treatment of
uterine artery embolisation for the hypercholesterolaemia: a systematic
No. 14 review and economic evaluation.
treatment of symptomatic uterine
A randomised controlled trial of By Ara R, Tumur I, Pandor A,
fibroids. The HOPEFUL study.
cognitive behaviour therapy in Duenas A, Williams R, Wilkinson A, et al.
By Hirst A, Dutton S, Wu O, Briggs A,
adolescents with major depression
Edwards C, Waldenmaier L, et al.
treated by selective serotonin reuptake No. 22
No. 6 inhibitors. The ADAPT trial. Topical or oral ibuprofen for chronic
Methods of prediction and prevention By Goodyer IM, Dubicka B, knee pain in older people. The TOIB
of pre-eclampsia: systematic reviews of Wilkinson P, Kelvin R, Roberts C, study.
accuracy and effectiveness literature with Byford S, et al. By Underwood M, Ashby D, Carnes D,
economic modelling. No. 15 Castelnuovo E, Cross P, Harding G, et al.
By Meads CA, Cnossen JS, Meher S, The use of irinotecan, oxaliplatin and
Juarez-Garcia A, ter Riet G, Duley L, No. 23
raltitrexed for the treatment of
et al. A prospective randomised comparison
advanced colorectal cancer: systematic
of minor surgery in primary and
No. 7 secondary care. The MiSTIC trial.
By Hind D, Tappenden P, Tumur I,
The use of economic evaluations in By George S, Pockney P, Primrose J,
Eggington E, Sutcliffe P, Ryan A.
NHS decision-making: a review and Smith H, Little P, Kinley H, et al.
empirical investigation. No. 16
By Williams I, McIver S, Moore D, Ranibizumab and pegaptanib for the No. 24
Bryan S. treatment of age-related macular A review and critical appraisal of
degeneration: a systematic review and measures of therapistpatient
No. 8 economic evaluation. interactions in mental health settings.
Stapled haemorrhoidectomy By Colquitt JL, Jones J, Tan SC, By Cahill J, Barkham M, Hardy G,
(haemorrhoidopexy) for the treatment Takeda A, Clegg AJ, Price A. Gilbody S, Richards D, Bower P, et al.
of haemorrhoids: a systematic review
and economic evaluation. No. 17
By Burch J, Epstein D, Baba-Akbari A, Systematic review of the clinical
Weatherly H, Fox D, Golder S, et al. effectiveness and cost-effectiveness of
64-slice or higher computed
No. 9 tomography angiography as an
The clinical effectiveness of diabetes alternative to invasive coronary
education models for Type 2 diabetes: angiography in the investigation of
a systematic review. coronary artery disease.
By Loveman E, Frampton GK, By Mowatt G, Cummins E, Waugh N,
Clegg AJ. Walker S, Cook J, Jia X, et al.
424

Programme
Director, Deputy Director,
Professor Tom Walley, Professor Jon Nicholl,
Director, NHS HTA Programme, Director, Medical Care Research
Department of Pharmacology & Unit, University of Sheffield,
Therapeutics, School of Health and Related
University of Liverpool Research
Prioritisation Strategy Group

Members
Chair, Professor Bruce Campbell, Dr Edmund Jessop, Medical Dr Ron Zimmern, Director,
Professor Tom Walley, Consultant Vascular & General Adviser, National Specialist, Public Health Genetics Unit,
Director, NHS HTA Programme, Surgeon, Royal Devon & Exeter Commissioning Advisory Group Strangeways Research
Department of Pharmacology & Hospital (NSCAG), Department of Laboratories, Cambridge
Therapeutics, Health, London
Professor Robin E Ferner,
University of Liverpool
Consultant Physician and Professor Jon Nicholl, Director,
Director, West Midlands Centre Medical Care Research Unit,
for Adverse Drug Reactions, University of Sheffield,
City Hospital NHS Trust, School of Health and
Birmingham Related Research
HTA Commissioning Board

Members
Programme Director, Professor Deborah Ashby, Professor Jenny Donovan, Professor Ian Roberts,
Professor Tom Walley, Professor of Medical Statistics, Professor of Social Medicine, Professor of Epidemiology &
Director, NHS HTA Programme, Department of Environmental Department of Social Medicine, Public Health, Intervention
Department of Pharmacology & and Preventative Medicine, University of Bristol Research Unit, London School
Therapeutics, Queen Mary University of of Hygiene and Tropical
University of Liverpool London Professor Freddie Hamdy, Medicine
Professor of Urology,
Chair, University of Sheffield
Professor Ann Bowling, Professor Mark Sculpher,
Professor Jon Nicholl,
Professor of Health Services Professor Allan House, Professor of Health Economics,
Director, Medical Care Research
Research, Primary Care and Professor of Liaison Psychiatry, Centre for Health Economics,
Unit, University of Sheffield,
Population Studies, University of Leeds Institute for Research in the
School of Health and Related
University College London Social Services,
Research
Professor Sallie Lamb, Director, University of York
Deputy Chair, Professor John Cairns, Warwick Clinical Trials Unit,
Dr Andrew Farmer, Professor of Health Economics, University of Warwick
University Lecturer in General Professor Kate Thomas,
Public Health Policy,
Practice, Department of Professor Stuart Logan, Professor of Complementary
London School of Hygiene
Primary Health Care, Director of Health & Social and Alternative Medicine,
and Tropical Medicine,
University of Oxford Care Research, The Peninsula University of Leeds
London
Medical School, Universities of
Professor Nicky Cullum, Exeter & Plymouth Professor David John Torgerson,
Director of Centre for Evidence Director of York Trial Unit,
Professor Miranda Mugford, Department of Health Sciences,
Based Nursing, Department of Professor of Health Economics,
Health Sciences, University of University of York
University of East Anglia
Dr Jeffrey Aronson, York
Reader in Clinical Dr Linda Patterson, Professor Hywel Williams,
Pharmacology, Department of Professor Jon Deeks, Consultant Physician, Professor of
Clinical Pharmacology, Professor of Health Statistics, Department of Medicine, Dermato-Epidemiology,
Radcliffe Infirmary, Oxford University of Birmingham Burnley General Hospital University of Nottingham
425
Current and past membership details of all HTA committees are available from the HTA website (www.hta.ac.uk)

Health Technology Assessment Programme
Diagnostic Technologies & Screening Panel

Members
Chair, Dr Paul Cockcroft, Consultant Dr Jennifer J Kurinczuk, Dr Margaret Somerville,

Dr Ron Zimmern, Director of Medical Microbiologist and Consultant Clinical Director of Public Health
the Public Health Genetics Unit, Clinical Director of Pathology, Epidemiologist, National Learning, Peninsula Medical
Strangeways Research Department of Clinical Perinatal Epidemiology Unit, School, University of Plymouth
Laboratories, Cambridge Microbiology, St Mary's Oxford
Hospital, Portsmouth Dr Graham Taylor, Scientific
Dr Susanne M Ludgate, Director & Senior Lecturer,
Professor Adrian K Dixon, Clinical Director, Medicines & Regional DNA Laboratory, The
Professor of Radiology, Healthcare Products Regulatory Leeds Teaching Hospitals
University Department of Agency, London
Ms Norma Armston,
Radiology, University of Professor Lindsay Wilson
Freelance Consumer Advocate,
Cambridge Clinical School Mr Stephen Pilling, Director, Turnbull, Scientific Director,
Bolton
Centre for Outcomes, Centre for MR Investigations &
Dr David Elliman, Consultant in
Professor Max Bachmann, Research & Effectiveness, YCR Professor of Radiology,
Community Child Health,
Professor of Health Care Joint Director, National University of Hull
Islington PCT & Great Ormond
Interfaces, Department of Collaborating Centre for Mental
Street Hospital, London
Health Policy and Practice, Health, University College Professor Martin J Whittle,
University of East Anglia Professor Glyn Elwyn, London Clinical Co-director, National
Research Chair, Centre for Co-ordinating Centre for
Professor Rudy Bilous Health Sciences Research, Mrs Una Rennard, Womens and Childhealth
Professor of Clinical Medicine & Cardiff University, Department Service User Representative,
Consultant Physician, of General Practice, Cardiff Oxford Dr Dennis Wright,
The Academic Centre, Consultant Biochemist &
South Tees Hospitals NHS Trust Professor Paul Glasziou, Dr Phil Shackley, Senior Clinical Director,
Director, Centre for Lecturer in Health Economics, The North West London
Ms Dea Birkett, Service User Evidence-Based Practice, Academic Vascular Unit, Hospitals NHS Trust,
Representative, London University of Oxford University of Sheffield Middlesex
Pharmaceuticals Panel
Members
Chair, Professor Imti Choonara, Dr Jonathan Karnon, Senior Dr Martin Shelly,

Professor Robin Ferner, Professor in Child Health, Research Fellow, Health General Practitioner,
Consultant Physician and Academic Division of Child Economics and Decision Leeds
Director, West Midlands Centre Health, University of Science, University of Sheffield
for Adverse Drug Reactions, Nottingham Mrs Katrina Simister, Assistant
City Hospital NHS Trust, Dr Yoon Loke, Senior Lecturer Director New Medicines,
Birmingham Professor John Geddes, in Clinical Pharmacology, National Prescribing Centre,
Professor of Epidemiological University of East Anglia Liverpool
Psychiatry, University of
Oxford Ms Barbara Meredith, Dr Richard Tiner, Medical
Lay Member, Epsom Director, Medical Department,
Mrs Barbara Greggains, Association of the British
Non-Executive Director, Dr Andrew Prentice, Senior Pharmaceutical Industry,
Greggains Management Ltd Lecturer and Consultant London
Obstetrician & Gynaecologist,
Dr Bill Gutteridge, Medical Department of Obstetrics &
Adviser, National Specialist Gynaecology, University of
Commissioning Advisory Group Cambridge
Ms Anne Baileff, Consultant (NSCAG), London
Nurse in First Contact Care, Dr Frances Rotblat, CPMP
Southampton City Primary Care Mrs Sharon Hart, Delegate, Medicines &
Trust, University of Consultant Pharmaceutical Healthcare Products Regulatory
Southampton Adviser, Reading Agency, London
426
Therapeutic Procedures Panel

Members
Chair, Professor Matthew Cooke, Dr Simon de Lusignan, Dr John C Pounsford,
Professor Bruce Campbell, Professor of Emergency Senior Lecturer, Primary Care Consultant Physician,
Consultant Vascular and Medicine, Warwick Emergency Informatics, Department of Directorate of Medical Services,
General Surgeon, Department Care and Rehabilitation, Community Health Sciences, North Bristol NHS Trust
of Surgery, Royal Devon & University of Warwick St Georges Hospital Medical
Exeter Hospital School, London Dr Karen Roberts, Nurse
Mr Mark Emberton, Senior Consultant, Queen Elizabeth
Lecturer in Oncological Dr Peter Martin, Consultant Hospital, Gateshead
Urology, Institute of Urology, Neurologist, Addenbrookes
University College Hospital Hospital, Cambridge
Dr Vimal Sharma, Consultant
Professor Paul Gregg, Professor Neil McIntosh, Psychiatrist/Hon. Senior
Professor of Orthopaedic Edward Clark Professor of Child Lecturer, Mental Health
Surgical Science, Department of Life & Health, Department of Resource Centre, Cheshire and
Dr Mahmood Adil, Deputy
General Practice and Primary Child Life & Health, University Wirral Partnership NHS Trust,
Regional Director of Public
Care, South Tees Hospital NHS of Edinburgh Wallasey
Health, Department of Health,
Manchester Trust, Middlesbrough
Professor Jim Neilson, Professor Scott Weich,
Dr Aileen Clarke, Ms Maryann L Hardy, Professor of Obstetrics and Professor of Psychiatry,
Consultant in Public Health, Lecturer, Division of Gynaecology, Department of Division of Health in the
Public Health Resource Unit, Radiography, University of Obstetrics and Gynaecology, Community, University of
Oxford Bradford University of Liverpool Warwick
Disease Prevention Panel

Members
Chair, Dr Elizabeth Fellow-Smith, Professor Yi Mien Koh, Dr Carol Tannahill, Director,
Dr Edmund Jessop, Medical Medical Director, Director of Public Health and Glasgow Centre for Population
Adviser, National Specialist West London Mental Health Medical Director, London Health, Glasgow
Commissioning Advisory Group Trust, Middlesex NHS (North West London
(NSCAG), London Strategic Health Authority), Professor Margaret Thorogood,
Mr Ian Flack, Director PPI London Professor of Epidemiology,
Forum Support, Council of University of Warwick,
Ethnic Minority Voluntary Ms Jeanett Martin, Coventry
Sector Organisations, Director of Clinical Leadership
Stratford & Quality, Lewisham PCT, Dr Ewan Wilkinson,
London Consultant in Public Health,
Dr John Jackson, Royal Liverpool University
General Practitioner, Dr Chris McCall, General Hospital, Liverpool
Newcastle upon Tyne Practitioner, Dorset
Mrs Veronica James, Chief Dr David Pencheon, Director,

Mrs Sheila Clark, Chief Officer, Horsham District Age Eastern Region Public Health
Executive, St Jamess Hospital, Concern, Horsham Observatory, Cambridge
Portsmouth
Professor Mike Kelly, Dr Ken Stein, Senior Clinical
Mr Richard Copeland, Director, Centre for Public Lecturer in Public Health,
Lead Pharmacist: Clinical Health Excellence, Director, Peninsula Technology
Economy/Interface, National Institute for Health Assessment Group,
Wansbeck General Hospital, and Clinical Excellence, University of Exeter,
Northumberland London Exeter
427
Health Technology Assessment Programme
Expert Advisory Network

Members
Professor Douglas Altman, Professor Carol Dezateux, Professor Stan Kaye, Cancer Professor Chris Price,
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Medicine, Centre for Statistics Epidemiology, London Medical Oncology, Section of Biochemistry, University of
in Medicine, University of Medicine, Royal Marsden Oxford
Oxford Dr Keith Dodd, Consultant Hospital & Institute of Cancer
Paediatrician, Derby Research, Surrey Professor William Rosenberg,
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Director, Centre for Health Mr John Dunning, Dr Duncan Keeley, Consultant Physician, University
Services Research, University of Consultant Cardiothoracic General Practitioner (Dr Burch of Southampton, Southampton
Newcastle upon Tyne, School of Surgeon, Cardiothoracic & Ptnrs), The Health Centre,
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Newcastle upon Tyne Hospital NHS Trust, Cambridge Professor of Medical Neurology,
Dr Donna Lamping, Department of Clinical
Professor Andrew Bradbury, Mr Jonothan Earnshaw, Neurosciences, University of
Research Degrees Programme
Professor of Vascular Surgery, Consultant Vascular Surgeon, Edinburgh
Director & Reader in Psychology,
Solihull Hospital, Birmingham Gloucestershire Royal Hospital,
Health Services Research Unit,
Gloucester Dr Susan Schonfield, Consultant
London School of Hygiene and
Mr Shaun Brogan, in Public Health, Hillingdon
Professor Martin Eccles, Tropical Medicine, London
Chief Executive, Ridgeway PCT, Middlesex
Primary Care Group, Aylesbury Professor of Clinical
Effectiveness, Centre for Health Mr George Levvy, Dr Eamonn Sheridan,
Services Research, University of Chief Executive, Motor Consultant in Clinical Genetics,
Mrs Stella Burnside OBE, Neurone Disease Association,
Chief Executive, Newcastle upon Tyne Genetics Department,
Northampton St Jamess University Hospital,
Regulation and Improvement
Professor Pam Enderby, Leeds
Authority, Belfast Professor James Lindesay,
Professor of Community
Rehabilitation, Institute of Professor of Psychiatry for the Professor Sarah Stewart-Brown,
Ms Tracy Bury,
General Practice and Primary Elderly, University of Leicester, Professor of Public Health,
Project Manager, World
Care, University of Sheffield Leicester General Hospital University of Warwick,
Confederation for Physical
Therapy, London Division of Health in the
Professor Gene Feder, Professor Professor Julian Little, Community Warwick Medical
of Primary Care Research & Professor of Human Genome School, LWMS, Coventry
Professor Iain T Cameron,
Development, Centre for Health Epidemiology, Department of
Professor of Obstetrics and
Sciences, Barts & The London Epidemiology & Community Professor Ala Szczepura,
Gynaecology and Head of the
Queen Marys School of Medicine, University of Ottawa Professor of Health Service
School of Medicine,
University of Southampton Medicine & Dentistry, London Research, Centre for Health
Professor Rajan Madhok, Services Studies, University of
Mr Leonard R Fenwick, Consultant in Public Health, Warwick
Dr Christine Clark,
Chief Executive, Newcastle South Manchester Primary
Medical Writer & Consultant
upon Tyne Hospitals NHS Trust Care Trust, Manchester Dr Ross Taylor,
Pharmacist, Rossendale
Senior Lecturer, Department of
Mrs Gillian Fletcher, Professor Alexander Markham, General Practice and Primary
Professor Collette Clifford,
Antenatal Teacher & Tutor and Director, Molecular Medicine Care, University of Aberdeen
Professor of Nursing & Head of
President, National Childbirth Unit, St Jamess University
Research, School of Health
Trust, Henfield Hospital, Leeds Mrs Joan Webster,
Sciences, University of
Consumer member, HTA
Birmingham, Edgbaston, Professor Jayne Franklyn,
Professor Alistaire McGuire, Expert Advisory Network
Birmingham Professor of Medicine,
Professor of Health Economics,
Department of Medicine,
Professor Barry Cookson, London School of Economics
University of Birmingham,
Director, Laboratory of Queen Elizabeth Hospital,
Healthcare Associated Infection, Dr Peter Moore,
Edgbaston, Birmingham Freelance Science Writer, Ashtead
Health Protection Agency,
London Dr Neville Goodman,
Dr Andrew Mortimore, Public
Consultant Anaesthetist,
Dr Carl Counsell, Clinical Health Director, Southampton
Southmead Hospital, Bristol
Senior Lecturer in Neurology, City Primary Care Trust,
Department of Medicine & Professor Robert E Hawkins, Southampton
Therapeutics, University of CRC Professor and Director of
Aberdeen Medical Oncology, Christie CRC Dr Sue Moss, Associate Director,
Research Centre, Christie Cancer Screening Evaluation
Professor Howard Cuckle, Hospital NHS Trust, Manchester Unit, Institute of Cancer
Professor of Reproductive Research, Sutton
Epidemiology, Department of Professor Allen Hutchinson,
Paediatrics, Obstetrics & Director of Public Health & Mrs Julietta Patnick,
Gynaecology, University of Deputy Dean of ScHARR, Director, NHS Cancer Screening
Leeds Department of Public Health, Programmes, Sheffield
University of Sheffield
Dr Katherine Darton, Professor Robert Peveler,
Information Unit, MIND Professor Peter Jones, Professor Professor of Liaison Psychiatry,
The Mental Health Charity, of Psychiatry, University of Royal South Hants Hospital,
London Cambridge, Cambridge Southampton
428
HTA
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J Cahill, M Barkham, G Hardy, S Gilbody,
Therapistpatient interactions in mental health settings

D Richards, P Bower, K Audin and J Connell
Feedback
The HTA Programme and the authors would like to know
your views about this report.
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(http://www.hta.ac.uk) is a convenient way to publish
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We look forward to hearing from you.
June 2008
The National Coordinating Centre for Health Technology Assessment,

Alpha House, Enterprise Road
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NHS R&D HTA Programme
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HTA
Fax: +44 (0) 23 8059 5639 Email: hta@hta.ac.uk
http://www.hta.ac.uk ISSN 1366-5278

A Review and Critical Appraisal of 2008

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Health Technology Assessment 2008; Vol. 12: No.

A review and critical appraisal of

J Cahill, M Barkham, G Hardy, S Gilbody,

Therapistpatient interactions in mental health settings

The National Coordinating Centre for Health Technology Assessment,

How to obtain copies of this and other HTA Programme reports.

Contact details are as follows:

How do I get a copy of HTA on CD?

J Cahill,1* M Barkham,2 G Hardy,2 S Gilbody,3

* Corresponding author. Present address: Institute of Psychological Sciences,

Declared competing interests of authors: none

Published June 2008

This report should be referenced as follows:

Cahill J, Barkham M, Hardy G, Gilbody S, Richards D, Bower P, et al. A review and

Health Technology Assessment is indexed and abstracted in Index Medicus/MEDLINE,

Queens Printer and Controller of HMSO 2008. All rights reserved.

3 Review to identify candidate measures of Acknowledgements .................................... 41

5 Results ........................................................ 25 Appendix 6 Database access extraction

Appendix 9 Content description of Health Technology Assessment reports

Appendix 10 Psychometric properties of Health Technology Assessment

ACL Adjective Check List MSA multidimensional scale analysis

ADHD attention deficit hyperactivity NA not applicable

IIP Inventory of Interpersonal SD standard deviation

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Objectives Data extraction

Methods I Data analysis

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Review of therapistpatient measures Three developmental processes were identified

Data extraction Psychometric status

Recommendations for further base of existing measures rather than

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Accept*; Adherence (medical model); Agreement; Alliance; Attachment

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Patient factors Establishing a

Contextual Framework Developing a

FIGURE 1 Conceptual map 7

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Empathy, warmth and Expectancies

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TABLE 3 Maintaining the relationship

Threats Processes Objectives

Therapist behaviour Self-reflection

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These relationship objectives are not separate, Cohesion

Therapy context Broader context

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Summary The map is intended as an organising framework,

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Reference lists of articles on therapistpatient Working list of measures

any patient populations presenting with any MEDLINE

All measures that had at least one reliability study

BOX 2 Fitzpatrick criteria

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TABLE 8 Key psychometric attributes138

FAQ, frequently asked question.

Data extraction For reasons of practicality and optimal use of

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TABLE 9 Coding instructions for quality assessment

Fitzpatrick criteria Coding Explanation

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TABLE 10 Number of primary articles associated with candidate measures