Practice-Based Psychotherapy Research
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PPRNet Blog: February 2013


Giorgio A. TascaAt 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 pprnet@toh.on.ca.

Giorgio A. Tasca


blogWhat To Do When a Patient Might be Suicidal

Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments, Psychotherapy, 49, 81-89.

The journal Psychotherapy regularly publishes Practice Reviews, which are clinician-friendly practical articles that are based on the best current evidence. Recently, James Fowler published a Practice Review on suicide risk assessment. The assessment, management, and treatment of suicidal patients are some of the most stressful events in clinical practice. However, there is very little that is clear in the evidence base to help clinicians to make accurate assessments about suicide risk. Assessing suicide risk factors tends to result in making an inordinate number of false-positive predictions (i.e., deciding that a patient will attempt suicide when in fact the patient will not attempt suicide). Making false positive suicide predictions might be seen by some as desirable because doing so represents a conservative course of action. However, a clinician acting as if a patient will suicide when he or she will not can lead to unintended negative consequences for the therapeutic alliance and for the patient’s future trust in health professionals. Fowler suggests an assessment approach in which efforts are made to enhance therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. The list of protective factors (e.g., supportive social contacts, religious beliefs, therapeutic contacts) and risk factors (e.g., past suicide attempts) based on the most current evidence are presented in the article in easy to read tables. Fowler also presents a list of clinician resources for suicide assessment and facts with handy web site addresses. For example, Fowler suggests the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) that incorporates the risk and protective factors with the best evidence base.

Practice Implications

Most methods of predicting suicide risk result in false positives (i.e., predicting suicide when suicide will not occur). Though conservative, a false positive prediction of suicide risk can have a negative impact on therapeutic alliance and patients’ future trust in health care providers. Evidence-based assessments of risk and protective factors may help. A free SAFE-T pocket guide is available to download at the Substance Abuse and Mental Health Services Administration (SAMHSA) web site: http://store.samhsa.gov/product/SMA09-4432.

View the What To Do When a Patient Might be Suicidal article abstract.
Author email: cfowler@menninger.edu

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blogDoes Participating in Research Have a Negative Effect on Psychotherapy?

Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F., Driessen, E., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 49, 276-290.

One of the main reasons that some clinicians do not participate in research is that they argue that doing so will have a negative impact on the therapeutic relationship, the therapy process, and patient outcomes. Although I have heard this from clinicians of many theoretical orientations, this opinion is perhaps most strongly held by some colleagues with a psychodynamic orientation. I identify with psychodynamic theory and practice, so this opinion about research held by some of my colleagues has been very disconcerting to me. Up to now, the best I could say in defense of practice-based research of psychodynamic therapy was to talk about my own experiences, which have been highly positive and rewarding. A recent meta analysis by Town and colleagues from Dalhousie University changes all that. (First, a note about meta analysis. Meta analysis is a statistical way of combining the effects of many studies, each of which has a number of participants, into a common metric called an effect size. By combining studies, the end result is more meaningful and more reliable than the results of any single study on its own.). The meta analysis by Town and colleagues had 45 independent samples and over 1600 patients. Results indicated that psychodynamic treatments for a variety of disorders (e.g., depression, anxiety, personality disorders) showed a significant large positive treatment effect – this is not new. What is new is that compared to conditions in which no research-specific protocols were introduced, conditions that did use research protocols were no different in terms of patient outcomes up to one year post treatment. There was even a significant small positive effect of these research protocols on outcomes from post treatment to one year post treatment. Research-specific protocols included video recordings of therapy sessions, therapists following treatment manuals, fidelity checks to make sure therapists were accurately doing psychodynamic therapy, and psychometric measurements of processes and outcomes

Practice Implications

Research protocols do not have a negative impact on psychodynamic therapy outcomes. Perhaps research protocols should be introduced into all therapies to improve longer term outcomes in addition to studying therapy procedures and processes that work.

View the Does Participating in Research Have a Negative Effect on Psychotherapy? article abstract.
Author email: joel.town@dal.ca

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blogIncreasing Attendance in Psychotherapy

Oldham, M., Kellett, S., Miles, E., & Sheeran, P. (2012). Interventions to increase attendance at psychotherapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology, 80, 928-939.

A great deal of clinical time can be wasted because of patient nonattendance at scheduled psychotherapy appointments. The financial costs of nonattendance are also high, and patients who need help but do not attend are not receiving help. Premature termination from psychotherapy is associated with poor outcomes. Previous reviews reported that premature termination rates in regular clinical practice ranged from 40% to 46.8%. Clearly this is a big problem for many psychotherapists and patients. Oldham and colleagues (2012) conducted a meta analysis of interventions to increase psychotherapy attendance. Their meta analysis included 33 randomized controlled trials (RCTs) representing 4422 patients. Interventions had a significant moderate effect on reducing premature termination and increasing attendance. Effective interventions included: giving patients a choice of appointment times, giving patients a choice of therapists, motivational enhancement interventions, preparing patients prior to psychotherapy on what to expect, attendance reminders, and providing information on how to make the best use of therapy. Participants with single diagnoses made better use of interventions than those with multiple diagnoses.

Practice Implications

Psychotherapists can improve attendance in psychotherapy by providing patients with choice of appointment times and therapists, by taking the time to prepare patients prior to therapy for what to expect in treatment and how to best make use of therapy, using motivational interventions, and by providing appointment reminders.

View the Increasing Attendance in Psychotherapy article abstract.
Author email: s.kellett@sheffield.ac.uk or p.sheeran@sheffield.ac.uk

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