Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community

PPRNet Blog: May 2016


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


blogDoes Organizational Context Have an Effect on Patient Outcomes?

Falkenström, F., Grant, J., & Holmqvist, R. (2016): Review of organizational effects on the outcome of mental health treatments. Psychotherapy Research, DOI: 10.1080/10503307.2016.1158883

Many psychotherapists treat patients within organizational contexts. These contexts might include university clinics, hospitals, primary care centers, community health centers, or even shared or group private practices. Psychotherapy researchers are often concerned with patient outcomes and predictors of outcomes like patient, therapist, or relationship variables. However, rarely do psychotherapy researchers consider the effects of the larger organizational context within which the psychotherapy is provided. On the other hand, many organizational psychology researchers are interested in organizational culture and management practices but seldom link these directly to patient outcomes. Is there an effect of the organizational context (i.e., culture and climate) on patient outcomes, and can we understand its effects in order to improve outcomes? Falkenstrom and colleagues review this literature. Organizational culture refers to shared norms, beliefs, and expectations in an organization or unit. These can be affected by hierarchical structure (i.e., perceived power differences between professions), managerial principles and styles (e.g., rigid vs lax styles, supportive and active vs undermining, micro-managing, or disengaged), and by technology. Various organizations appear to engender different cultures such that the staff can be more or less committed to the organization strategies and to the work itself. This is the basis of the well known expression: “culture eats strategy for breakfast”. Organizational climate refers to the overall sense of psychological security in a work environment. This may have an impact on workers’ attitudes and performance, and may also affect their willingness to report errors and to problem solve. In their review, Falkenstrom and colleagues found only 19 studies that directly assessed the effects of organizational context on patient mental health outcomes. Differences between organizations appeared to account for between 6% and 60% of patient outcomes. This is a very wide range that may be the result of many differences between studies (i.e., different patient populations, different definitions of outcomes, different definitions and measurements of organizational variables, etc.). However, even at 6%, this represents what most researchers would call a medium and meaningful effect. For example, Falkenstrom and colleagues reviewed specific studies and found that organizational climate (i.e., low conflict, low emotional exhaustion, and high cooperation and job satisfaction) were related to better psychosocial functioning in children placed in state custody. Several other studies showed that high staff turnover, low levels of support from leadership, and low mutual respect among professionals was associated with poorer mental health outcomes for a variety of patient populations. One study found that an intervention to improve organizational culture and climate resulted in improving mental health outcomes among children and adolescents.

Practice Implications

There are surprisingly few studies that look at the relationship between organizational culture and patient outcomes. Although limited, most of the studies point to the effects of organizational culture and climate on staff and on patient outcomes. With increased emphasis on quality control in mental health care, it makes sense for managers, practitioners, researchers and patient groups to carefully consider an organization’s managerial practices, leadership, culture, and climate when looking to improve patient outcomes.

View a copy of the Does Organizational Context Have an Effect on Patient Outcomes? abstract.

Author email: fredrik.falkenstrom@liu.se

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blogOrganizational Factors That Reduce Suicide Rates in the Population

Kapur, N., Ibrahim, S., While, D., Baird, A.,… Appleby, L. (2016). Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. The Lancet Psychiatry. DOI: http://dx.doi.org/10.1016/S2215-0366(16)00063-8.

Suicide is a major cause of death worldwide, and many recent public health efforts have focused on suicide prevention. Many studies have looked at social, psychological, and biological factors that may cause suicide, but few studies have examined the effects of health service contexts on suicide rates. In this large retrospective population-based study, Kapur and colleagues looked at over 19,000 suicides that occurred within England’s health services from 1997 to 2012. This represented 26% of all suicides in England. The researchers: evaluated economic climate, surveyed the clinic administrators and clinicians involved, and they reviewed policy, service, and staffing changes at each time point. Health care in England is organized nationally through the National Health Service, and the government also collected confidential survey data on deaths by suicide between 1997 and 2012. The researchers examined if specific policy changes and organizational factors affected suicide rates. Health system changes such as: (a) implementing the National Institute for Health and Care Excellence depression guidelines, (b) making available crisis and home treatment teams, (c) implementing policies on transfer from youth to adult care and (d) new procedures for managing patients with dual diagnosis were all associated with reduced suicide rates during the study period. One of the most interesting findings was that these changes to the treatment and management of depression, youth, crises, and dual diagnoses were much more effective in reducing suicide rates under two organizational contexts: (1) when non-medical staff turnover was low, and (2) when there was greater reporting of patient safety incidents. Lower staff turnover likely means that patients in those organizations received greater continuity of care and that suicidal or depressed patients were more likely to receive treatment from highly trained and experienced professionals. Greater reporting of patient safety incidents tend to occur in organizations in which the staff feels sufficiently safe and secure to report and discuss negative clinical events without fear of reprisal or punishment. Such reflective practice is likely critical to increasing staff expertise in providing psychological treatment.

Practice Implications

Psychotherapists often do not think about the organizational context within which they work when considering the treatment they provide to those with mental health issues including people who may attempt suicide. Yet many psychotherapists work within an organizational context (e.g., hospitals, group practices, clinics, community health care centers, etc.). The findings from this study indicate that stability in staffing (i.e. low turnover) and working within a system that encourages reporting and discussing negative events likely has a positive impact on mental health outcomes like suicide.

View a copy of the Organizational Factors That Reduce Suicide Rates in the Population abstract.

Author email: nav.kapur@manchester.ac.uk

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blogCommon Factors Across 5 Therapies for Suicidal Patients with Borderline Personality Disorder

Sledge, W., Plukin, E.M., Bauer, S., Brodsky, B.,… Yoemans, F. (2014). Psychotherapy for suicidal patients with borderline personality disorder: An expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation, 1:16. doi:10.1186/2051-6673-1-16.

Treating patients with suicidal ideation and borderline personality disorder (BPD) can cause significant anxiety, concern, anger, and guilt in clinicians. Strong emotional reactions can lead to risky therapeutic interventions, poor clinical decisions, and professional burn out. The outcome of therapy can have serious consequences for such patients. Recently, a panel of 13 experts reviewed the efficacy of the most common treatments for suicidal ideation in BPD. As part of the review, they identified the common factors that may be useful for all clinicians who work with these clients. The five therapies they reviewed included the following. Dialectical behavior therapy, which emphasizes the role of emotional dysregulation and impulsivity in suicide. Treatment includes distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Schema therapy decreases suicide risk by challenging negative thoughts with cognitive and behavioral techniques while using the therapeutic relationship to improve the patient’s capacity to attach to others. Mentalization based therapy works toward improving the patient’s capacity to keep in mind the patient’s own mind and the mind of the other. This encourages new perspectives on relationships and emotion regulation. Transference focused psychotherapy views suicidal behavior in BPD as related to distorted images of the self and others. The treatment emphasizes gaining greater awareness of self in relation to others, and integrating a more realistic experience of the self. Good psychiatric management is an integrative approach that uses both psychodynamic and behavioral concepts. The approach sees BPD as a problem with interpersonal hypersensitivity, but the management tends to be more pragmatic than theoretically based. The expert panel defined six common factors among these treatments. (1) Negotiation of a frame for treatment – in which roles and responsibilities of therapist and patient are defined before the start of treatment, including an explicit crisis plan. (2) Recognition of the patient’s responsibilities within therapy. (3) The therapist having a clear conceptual framework for understanding the disorder that then guides the interventions. (4) Use of the therapeutic relationship to engage the patient and to address suicide actively and explicitly. (5) Prioritizing suicide as a topic whenever it comes up in the therapy. (6) Providing support for the therapist through supervision, consultation, and peer support.

Practice Implications

Suicidal ideation in patients with BPD can have serious consequences for the patient and can be highly stressful for the clinician. This expert panel identified six common features of most major treatment approaches to suicidal ideation in BPD. Even if clinicians are not explicitly trained in any one of the approaches, ensuring that these six factors are present in their work will improve the likelihood that their patients will experience a good outcome.

View a copy of the Common Factors Across 5 Therapies for Suicidal Patients with Borderline Personality Disorder article.

Author email: William.Sledge@yale.edu

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