CONOCIMIENTO DE ALTERNATIVAS PARA LA OBTENCIÓN EL SALDO

The first reference to to the YAVIS criteria is in 1964 (Schofield 1964). In his book Professor Schofield notes the preference o f some therapists to select patients who fulfill the YAVIS criteria over other potential patients. According to the YAVIS criteria, psychotherapy patients tend to be young, verbal, attractive (although this can create problems: Hatfield and Perlmutter 1983) intelligent and successful, additionally they are reported as middle class. Hence one can reflect that the YAVIS criteria are the cornerstones o f a model o f systematic selection o f patients which reflect therapists’ practice, and by definition then such patients become “good” therapy patients.

The difficulty with the YAVIS criteria is that it is a common selection practice o f therapists as opposed to a theoretical framework, i.e. the YAVIS criteria are all cornerstones o f a model that was derived from therapists practice and is not a theory per se. /fence a theoretical framework around the YAVIS criteria is notable by its absence.

This leads to difficulties in research. If the research is based on normal therapeutic practice (in the UK) most patients will be found to be

• Predominantly white North American or Western European.^^ • Mostly middle class

• Usually YAVIS

• Usually paying for their therapy

• Those with few external problems, that might be seen to influence “success” e.g. poverty.

Continued justification o f the YAVIS criteria are difficult to sustain in the light o f a more diverse population seeking therapy, and the therapists’ need to maintain the same population may reflect some o f the unconscious processes o f therapists, we know from anecdotal evidence that therapists tend to choose patients who similar to themselves in some aspects. It might also explain the contradictory results and the lack o f interest in researching other groups (e.g older patients, less verbally adept patients etc).

Therefore only those studies which specifically set out to look at patients who do not fulfill one or more o f these criteria, give us information about the relevance o f the YAVIS criteria.

The well-known large-scale studies which have explored several facets o f therapy have tended not to research ethnic minority patients. The Menninger study patients were all white, middle class or upper middle class with high I.Q.’s with a mean age o f 33:30 (memwomen) (Wallerstein 1989), and the Penn study had only six “black or oriental”

H ere w e are talking abou t research carried out in Britain, obviou sly th e sou th A m erican therapeutic com m unity a lso p ro d u ce s research relevant to its own population.

patients, with only one o f the total sample being less educated than a high school graduate and a mean age o f 26 years (Luborsky et al 1988) (see Table 9a).

The Sheffield Psychotherapy Projects (the first and second projects, Shapiro and Firth 1987) had very stringent symptom and occupational criteria, however they do not report any ethnic minority patients in their first study, while in the second study they note that the patients were “predominantly white Anglo-Saxon”. The mean age o f their sample was older than the other studies at 40 years.

Such lack o f clarity creates difficulties when comparing and contrasting population profiles, presenting issues and outcomes.

Hence the few major studies o f psychotherapy tend to review patients who fulfil the YAVIS criteria because they are part o f the “normal” population seen by therapists and hence are the ones available for research.

Common therapy research may identify certain individual components o f the YAVIS criteria for investigation, e.g. do older patients have equivalent success rates, or whether intelligence is a predictor o f success. However, by varying one factor e.g. age, other factors are influenced certain age groups have certain external concerns that vary through the life cycle. Older patients may be coming to terms with “retirement”, middle aged patients may be deciding on a final career move, younger patients may be worrying about examinations. There may even be age related medical problems.

Young

Therefore the difficulty with measuring age is that it is a continuous variable and although there will be similarities between, say, two twenty year olds, their levels o f maturity (psychological, emotional) as well as their life situation may vary.

Luborsky et al (1988) reviewed eleven studies that related age and outcome and found that older patients tended to have a slightly worse prognosis than younger patients, although the evidence is weak. While Garfield and Bergin (1986) found that age does not seem to be an important variable in relation to continuation o f therapy. It can also be noted that Smith et al (1980) found an overall correlation o f .00 between age and outcome.

Attractive

There is support for good outcome being related to patient attractiveness/ likeability in the literature (Stoler 1963). Stoler notes that successful clients were rated more highly on likability than less successful ones. Garfield and Bergin (1986) review the literature and note that there seems to be a relationship between likability and outcome, but the evidence seems to be “far from clear” (pg 244), and the risk o f providing contaminated research is high when the ratings o f both likability and outcome are completed by the therapist involved.

Verbal

Obviously a verbal therapy requires both participants to be able to communicate meaningfully with each other. There is often reference made to the difficulties in therapy between a middle class therapist and working class patient (see 1.9.4 below). There are also similar difficulties where the two participants speak different languages, and particularly where the patient is speaking in their second language. This may mitigate against a patient being taken on by the therapist

One o f the measures o f verbal abililty is the amount o f post -school qualifications achieved by the research subjects. Many o f the studies cited reflect the bias o f therapists (e.g. the Menninger study researched patients who were mostly middle class with a mean I.Q. o f 124 (Wallerstein 1989), while in the Penn study only one research patient was educated to less than a high school graduate (Luborsky et al 1988)).

Intelligence

Reviewing the literature it is clear that the major research studies have chosen patients who are clearly highly educated (of course, people can be not educated and still intelligent) only the Menninger collated information on I.Q., and as stated above, their figures show a highly intelligent and educated group. Luborsky et al (1988) note that in 5 out o f 7 other studies educational achievements have been shown to relate to improvement with psychotherapy, whilst 6 out o f 9 studies they reviewed showed that higher intellectual functioning was associated with better improvement in psychotherapy, a finding that replicated in the review by Garfield and Bergin (1986).

Successful

“Successful” is a very nebulous concept and can arguably be defined in terms o f social class as defined by occupation: professional people tend to be seen as more successful. Such professional people also have the ability to pay for therapy. Luborsky et al (1988) note that in 5 out o f 7 studies occupational achievements have been shown to relate to improvement with psychotherapy while Sheffield Psychotherapy Project specifically targeted managerial staff (Shapiro and Firth, 1987).

This brief review o f the literature relating to the YAVIS criteria, show the relative paucity o f research into non-YAVIS populations. This difficulty becomes more apparent when researchers try to evaluate a culturally diverse population. There is little research, but obviously applying the same YAVIS criteria cross-culturally will have implications in relation to age (expectations o f people at different ages is different in different cultures, e.g. the notion o f adolescence is a western notion). The notion o f attractiveness and similarity to the therapist may have implications in finding a therapist and starting therapy. Verbal ability in a second, or for some, a third language, may make the process o f therapy more difficult and less responsive to the patient. While, for migrants (and more particularly for asylum seekers and refugees) they might find their intelligence and success assessed on distorted facts (for example a person may a doctor in their home country, and unemployed refugee in Britain).

While reporting the current research facts, the cross cultural aspect needs to be investigated in its own right. To assess a patient on the same factors as a white English population might lead to distortion and thus provide erroneous results.

However, there are patients from a variety o f cultural backgrounds who understand and/or want to use psychotherapy as a treatment option. Such patients may be thought

to have been acculturated into the particular cultural context o f psychotherapy. Questions now to be asked are whether these criteria are universally applicable (i.e. are those who fulfill theYAVIS criteria the only successful patients), are there are any young, middle-class and intelligent ethnic minority people (which, o f course, there are), are they acculturated into the culture o f psychotherapy (or can they be so?) and is psychotherapy an effective treatment for them?