Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: March 2017
At the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.
About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.
Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.
At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.
If you have ideas for an article to review or a topic you would like to see covered, please send me an email at email@example.com.
Giorgio A. Tasca
Goldberg, S.B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W.T., Whipple, J.L., Miller, S.D., & Wampold, B.E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53, 367-375.
There is a lot of evidence that psychotherapy is effective – a result that has been demonstrated in randomized trials and in naturalistic setting. As I have noted numerous times in this Blog, psychotherapy is as effective as medications but without the side effects and with longer lasting results. However, there is room for improvement, especially in the effectiveness of individual therapists. Health care organizations are increasingly interested in quality improvement, which refers to efforts to make changes in practice that will lead to better patient outcomes, better care, and better professional development. One approach to quality improvement in medicine has been through audit and feedback – which involves measuring a clinician’s practice, comparing the clinician’s outcomes to professional standards, and giving the clinician feedback. In psychotherapy, the analogue is routine outcome monitoring in which patient progress is monitored with standardized measures throughout therapy, and therapists receive ongoing feedback on each patient’s progress relative to the average patient with that disorder. We know that therapists tend not to improve in terms of patient outcomes with experience alone, and some authors argue that one of the things that therapists are missing is good quality information about their clients’ progress. What would happen if an agency or organization decided to make it a priority to provide therapists with quality information about client progress? This paper by Goldberg and colleagues is a case study in which an agency deliberately created a culture of quality feedback and professional development to improve therapist expertise, therapist intentional practice, and client outcomes. The case study is of a community mental health agency in Alberta. Over 5,000 clients were seen by 153 therapists over a 7 year period (2008 to 2015) as part of the study. Clients received at least three sessions of therapy (mean = 6.53 sessions, SD = 5.02), and had a range of disorders typically seen in a mental health clinic. Therapists included 49.7% licensed or provisionally licensed professionals at the masters or doctoral level from different professions (e.g., social work, psychology, pastoral counselling), and 50.3% practicum students. Throughout the 7 years of the study, therapists saw an average of 33.52 clients (SD = 26.24). In 2008, the agency required the staff to collect outcome measures of all clients before each session (although patient scores were not tied to staff performance evaluations). This policy change caused a 40% turnover in clinical staff within 4 months (clearly a large minority of therapists did not want to participate in this new clinic directive)! These staff positions were replaced and staffing was stable after that point. In addition to requiring clinicians to provide measures on all patients (although patients could decline to participate), the agency provided monthly clinical consultations with an external consultant as a means of professional development. During these consultations, clinicians were encouraged to bring cases that were not progressing well in order to get feedback on their most challenging patients. Discussions were organized around therapeutic alliance, i.e., clarifying goals and preferences, and ways of facilitating engagement. The overall results showed a significant decline in distress among patients over the course of treatment. Of most interest was that therapists on average showed a significant improvement in their outcomes over time. That is, contrary to research showing that therapists do not improve over time when left to their own devices, therapists in this agency that received feedback and professional education around difficult cases did improve significantly.
The findings of this study indicate that psychotherapists can improve over time if they receive quality information about client progress, and if they receive professional development that is tied to this information (i.e., concrete suggestions for ways of working with difficult clients). In other words, it is possible for therapist to develop expertise over time under some conditions. A significant challenge in this case study was that a number of therapists left the agency due to the quality improvement efforts. Some therapists are sensitive to or feel threatened by outcome monitoring. However, therapists who remained or who were subsequently hired by the agency showed a reliable increase in their expertise and client outcomes as a result of deliberate intentional practice, quality feedback about client progress, and concrete professional development focused on the therapeutic alliance.
.Dalgadilo, J., Dawson, A., Gilbody, S., & Bohnke, J.R. (2017). Impact of long-term medical conditions on the outcomes of psychological therapy for depression and anxiety. British Journal of Psychiatry, 210, 47-53.
Twenty percent of people have long-term medical conditions, and this percentage rises to 58% for people over 60. These long-term conditions account for approximately 70% of health care costs in the UK. The most prevalent long-term conditions in the population include: hypertension, chronic pain, gastrointestinal disorders, asthma, diabetes, heart disease, and chronic obstructive pulmonary disease. Do these conditions reduce the outcomes of psychological therapies? Dalgadilo and colleagues conducted a large study in the UK of patients who accessed publicly funded psychological services. The authors looked at what impact long-medical problems had on psychological intervention outcomes. Patients accessing the public system in the UK received stepped care - so that they were first given self help followed by a second step of intensive psychotherapy, if they needed it. The sample for the study included over 28,000 patients with a mean age of just over 38 years. About 23.2% had a long-term condition. Sixty-eight percent only received the low intensity self help, and 32% required the intensive psychotherapy. Those with long-term conditions, compared to those without long-term conditions, tended to report higher levels of distress and lower quality of life at the outset. Long-term conditions that were associated with poorer psychological intervention outcomes included: chronic pain, chronic obstructive pulmonary disorder, severe mental health problems, and diabetes. The effects were small (d = .20) to medium (d = .50) sized (confidence intervals not reported). Those with long-term conditions were more likely to receive high intensity psychotherapy after the self help. However, poorer outcomes for those with long-term conditions, compared to those without long-term conditions, were still apparent after they received the intensive psychotherapy.
Compared to those without long-term medical conditions, those with long-term conditions have a higher level of impairment to start with and tend to finish therapy with greater depression and anxiety. The study points to the need to integrate psychological therapies in medical practices - especially for those with long-term medical conditions. Certain conditions like chronic pain, and having multiple conditions increase psychological distress and likely reduce patient mental health outcomes.
Click here for a copy of the abstract.Author email: firstname.lastname@example.org
Gueorguieva, R., Chekroud, A.M., & Krystal, J.H. (2017). Trajectories of relapse in randomised, placebo-controlled trials of treatment discontinuation in major depressive
disorder: An individual patient-level data meta-analysis. Lancet Psychiatry, http://dx.doi.org/10.1016/S2215-0366(17)30038-X.
Individuals with a history of depression who get better have a 30% to 50% chance of relapse in the first year. That is, major depression tends to take a recurrent course, so that about a third to half of patients who initially improve will then experience a re-emergence of symptoms. In this meta-analysis, Gueorguieva and colleagues looked at whether they could identify classes of patients who respond differently to antidepressant medications depending on whether they discontinued or continued with the medications after symptoms improved. The meta-analysis included over 1,400 patients from four studies of duloxetine or fluoxetine (i.e., Cymbalta or Prozac) who participated in a discontinuation trial. A discontinuation trial design involves randomly assigning patients who respond positively to the medication either (1) to stay on the effective medication or (2) to discontinue the treatment and receive a placebo. Such a design gives us an estimate of the advantage of maintenance versus discontinuation of medications to reduce relapse of depression in the longer term. Gueorguieva and colleagues found that 33% of those in the medication continuation condition relapsed (i.e., 33% those who responded well to the initial trial of medications and who then continued with medications had a recurrence of depressive symptoms). By contrast, 46% of those in the placebo/medication discontinuation condition relapsed (i.e., 46% of those who responded well to the initial trial of medications and who then received a placebo had a recurrence of depressive symptoms). In other words, continuation of antidepressant medications resulted in a small 13% reduction in relapse rates compared to continuation with a placebo.
This meta analysis indicates that continuing with antidepressant medications after depressive symptoms remit provides only a modest level of protection against a relapse of depression. Thus continuation with antidepressants after symptoms improve may not be worth it for patients who struggle with medication side effects and complications, or who cannot afford continuation of the medications. There is growing evidence that psychotherapy is effective for preventing relapse, likely because psychotherapy teaches patients ways of coping and interacting with others that allows them to manage life stresses more effectively after the treatment is over.