Blog
The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
This month...
…I blog about client perspectives on psychotherapy failure, therapeutic alliance, and alliance ruptures and resolutions and symptom severity.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
August 2016
Therapists Affect Patient Dropout and Deterioration
Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy. Advanced online publication, DOI: 10.1002/cpp.2028.
Outcomes for patients receiving psychotherapy are generally positive, but not always. For example, patients might drop out of therapy (i.e., unilaterally end therapy). In clinical trials, the average drop out rate is somewhere between 17% and 26% of patients. Also, patients might deteriorate during therapy (i.e., show a reliable negative change in symptoms from pre- to post-therapy). On average, about 8.2% of patients show a reliable deterioration after therapy. In this large study from a practice-based research network in the UK, Saxon and colleagues were interested in estimating the effect that therapists had on patient drop out and deterioration. Therapist effects refer to differences between therapists and the effects of this difference on patient outcomes. The authors were also interested in whether therapist effects predicted negative outcomes after controlling for therapist case-mix (i.e., patient variables like severity of symptoms, risk of self harm). Their study included 85 therapists who treated more than 10,000 adult patients over a 10-year period. Each therapist saw between 30 and 468 patients at one of 14 sites in the UK. About half of patients had moderate to severe depressive symptoms, and/or moderate to severe anxiety symptoms prior to starting therapy. Outcomes were measured with a reliable and valid psychometric instrument at pre- and post-treatment. The proportion of patients who dropped out of therapy was 33.8%. Patients who dropped out attended an average of 2.8 sessions (SD = 1.91), whereas treatment completers attended an average of 6.1 sessions (SD = 2.68). About 23.5% of therapists had drop out rates that were significantly worse than average. These below average therapists (n = 13) had 49% of their patients drop out, whereas above average therapists (n = 20) had only 12% of their patients drop out. Most patients who completed therapy improved (72.2%), but about 7.2% of patients deteriorated to some degree. The average therapist (i.e., 74% of therapists) had 4.6% of their patients who got worse, whereas below average therapists (i.e., 4.7% of therapists) had up to 14.9% of their patients who got worse. That is, almost 3 times as many patients deteriorated with below average therapists.
Practice Implications
We know from previous studies that the type and amount of therapist training or theoretical orientation are not predictive of patient outcomes. However, previous research does suggest that therapists’ lack of empathy, negative countertransference, over-use of transference interpretations, and disagreement with patients about therapy process was associated with negative outcomes. Patient safety concerns might necessitate below average therapists to be identified and provided with greater support, supervision, and training.
July 2016
Is it Feasible to Have a Nationally Funded Psychotherapy Service?
Community and Mental Health Team, Health and Social Care Information Centre (2015). Psychological therapies; Annual report on the use of IAPT services: England 2014/15.
There have been calls from mental health professional organizations and by the media to provide publicly funded psychotherapy in Canada. Rates of common mental disorders in Canada are high, such that about 20% of the population will personally experience a mental illness in their lifetime. In 1998, the estimated direct and indirect economic cost of mental illness in Canada was $7.9 billion (all figures are in Canadian dollars). Current estimates of costs to fund a public psychotherapy service in Canada may be about $1 billion to $2.8 billion – which far outweighs the cost. Most outpatient psychotherapy in Canada is provided by professionals in private practice who charge somewhere between $100 and $200 per session, costing Canadians nearly $1 billion per year. Some people are fortunate to have workplace insurance that covers some but not all of the costs, but most people in Canada do not have insurance and so they pay out of pocket or they go untreated. Research shows us that approximately 13 to 18 sessions are needed for 50% of clients to get better with psychotherapy. Which means that even with an insurance plan, many Canadians who need psychotherapy will find it to be a financial burden. Since 2008, the National Health Service in England implemented the Improving Access to Psychotherapies (IAPT) services to provide publicly funded psychotherapy to the population. The psychological treatments provided through IAPT are evidence-based (e.g., CBT, interpersonal psychotherapy, brief dynamic psychotherapy for depression). For mild to moderate problems, individuals get low intensity interventions first (i.e., self help, internet based interventions), followed by more intensive psychotherapy if needed. Treatment outcomes are measured from pre- to post-treatment with valid standardized measures of depression and anxiety. At post-treatment, patients are categorized as reliably deteriorated, not changed, improved, and recovered. The goal of the IAPT is to achieve 50% recovery rates among patients. In their online 2014-15 annual report, the IAPT service reported that it treated over 400,000 patients in that year. 44.8% of patients were rated as reliably recovered – that is over 180,000 mentally ill patients improved and no longer had a mental illness. Reliable improvement was seen in 60.8% of patients – this included recovered patients plus those who still had a disorder but were feeling significantly better than when they started. Recovery was highest for people 65 years and older (57.8%). Rates of recovery were similar for depression (44.6%) and anxiety (47.8%) disorders, and between men and women. Waiting times for treatment was less than 28 days for 66.0% of patients.
Practice Implications
The experience in England with the IAPT is instructive for Canada. The IAPT service provides evidence-based psychological therapies within a publicly funded national health service. The IAPT approached its target of 50% of patients recovering from mental illness, and over 60% of patients were reliably improved. Waiting times were low for most patients. Given the experience in England’s National Health Service, the implementation of a national strategy for psychotherapy appears to be feasible and effective. Will political leaders in Canada be able to see the financial and human value of publicly funded psychotherapy?
June 2016
Is Therapist Effectiveness a Stable Characteristic?
Kraus, D. R., Bentley, J. H., Alexander, P. C., Boswell, J. F., Constantino, M. J., Baxter, E. E., & Castonguay, L. G. (2016). Predicting therapist effectiveness from their own practice-based evidence. Journal of Consulting and Clinical Psychology, 84(6), 473-483.
There is lots of evidence that there are differences between therapists in their patients’ outcomes. Some studies estimate that 5% to 7% of patient outcomes can be attributed to differences between therapists’ abilities and style of delivering treatment. But most of these studies measured outcomes only once, and so they could not estimate if therapist effects are stable across time. Further, many of these studies used only a global measure of patient distress as an outcome and did not measure domain-specific outcomes (e.g., depression, anxiety, mania, alcohol dependence, etc.). In this study by Krauss and colleagues, 59 therapists who treated 3,540 patients were included. Therapists had on average 10 years of experience and were from a variety of professions (psychologists, psychiatrists, social workers, counsellors etc.). The settings included mental health clinics, independent practice, hospitals, and others. The authors went to some effort to control for case-mix variables such as client problem difficulty, length of treatment, caseload size, and other variables. Client outcomes were measured for 12 different domains ranging from depression to sexual dysfunction to substance abuse. First, outcomes were assessed for 30 patients of each therapist, and then these were compared to outcomes of the same therapist’s next 30 patients. Therapists were classified as “exceptional”, “average”, or “below average” based on their patients’ outcomes. Fifty-seven percent of therapists who were rated as exceptional with the first 30 patients were likely to remain exceptional or above average with the next 30 patients. In other words, effective therapists tended to remain effective over time. Therapists had better patient outcomes when it came to depression, suicidality, and substance abuse, but therapists tended not to have as good outcomes when it came to mania, and sexual functioning.
Practice Implications
Effective therapists tend to remain effective over time for particular client problem areas. However, therapists are seldom effective for more than 4 or 5 client presenting problems, and less than 10 % of therapists are effective with all client problem areas. Therefore patients with differing problems are likely to achieve better or worse outcomes depending on the particular therapist and his or her strengths. Therapists can regularly assess patient outcomes and use that information to help with continuing education to improve their practice for a particular problem area.
Are Therapists Uniformly Effective Across Patient Outcomes?
Nissen-Lie, H. A., Goldberg, S. B., Hoyt, W. T., Falkenström, F., Holmqvist, R., Nielsen, S. L., & Wampold, B. E. (2016). Are therapists uniformly effective across patient outcome domains? A study of therapist effectiveness in two different treatment contexts. Journal of Counseling Psychology. Advance online publication.
What characterizes more or less effective therapists? Are some therapists more effective for certain types of client mental health problems? In this study by Nissen-Lie and colleagues the authors look at whether therapists are skilled across patient problem domains. They conducted two studies with over 6000 patients and almost 200 therapists. Patients were assessed with common outcome measures of mental health domains that included: social functioning, work functioning, relationship functioning and symptom distress. Therapists included psychologists and social work professionals (70%) and trainees (30%) who saw at least 10 patients each. Theoretical orientations ranged from CBT, psychodynamic, and supportive psychotherapy. Patients were symptomatic at the start of therapy and primarily had problems with anxiety and depression. Patient symptoms on average improved so that psychotherapy had a moderate to large effect. Therapists did not differ in caseload mix regarding client severity. The authors reported that the client mental health domains (i.e., symptom severity, work functioning, social functioning, and interpersonal functioning) were relatively distinct or unrelated areas (i.e., the domains were largely uncorrelated). The authors then calculated change scores for each client domain area and used these change scores in a multilevel factor analysis. They wanted to see if a therapist’s clients achieved greater change in one client domain versus in another client domain. The results showed that if clients of a therapist changed in one domain (e.g., depression) then that outcome was highly related to change in another domain (e.g., interpersonal functioning). In other words, if a therapist was effective (or ineffective) in reducing client symptoms, then that therapist was also likely effective (or ineffective) in reducing, work, social, and relationship problems.
Practice Implications
The results support the notion of therapist uniformity in terms of client outcome domains. In other words effective therapists tend to be effective with many types of client problems (but perhaps not all client problems – see my blog this month of the Kraus et al. (2016) study). The authors argue that effective therapists have three key qualities: flexibility in adapting treatments to clients, sensitivity to differences between clients, and responsiveness to clients’ reactions to therapeutic interventions. That is, effective therapists are willing and able to self correct when required.
May 2016
Organizational 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.
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.
April 2016
Nonimproved Patients View Their Psychotherapy
Werbart, A., Von Below, C., Brun, J., & Gunnarsdottir, H. (2015). “Spinning one’s wheels”: Nonimproved patients view their psychotherapy. Psychotherapy Research, 25, 546-564.
The rate of patients who experience no change after receiving psychotherapy is about 35% to 40% in clinical trials. Further, about 5% to 10% get worse after treatment. So, in spite of the fact that psychotherapy is effective in general, a sizeable minority of patients do not benefit. There is also evidence that patients’ perception of therapy differs greatly from their therapists’. Therapists are often inaccurate in identifying or predicting patient outcomes, and patients’ judgements tend to better correspond with treatment outcomes. In this study, Werbart and colleagues evaluated outcomes of 134 patients who had elevated symptoms. The average age of patients was 22.4 years (range 18 – 26), so many were young adults. Almost all received a diagnosis ranging from depressive disorders, anxiety disorders, or personality disorders. The predominant treatment was psychoanalytic. Of the 134 patients, many experienced large improvements by the end of treatment. However, 20 patients remained clinically distressed and did not improve or deteriorated after receiving psychotherapy. The authors interviewed these 20 patients at termination and at three-year follow-up using a semi-structured interview. The interview asked patients for their experiences of therapy. The researchers transcribed the interviews and coded the transcripts using a known method of qualitative analysis called “grounded theory”. Three main themes related to poor outcomes were identified by these patients. (1) The therapy or therapist – in which: therapists were perceived by patients as passive or reticent, patients felt distant from the therapist, and patients did not understand the therapy method. (2) Outcomes of therapy – in which: the patient expected more from therapy, and symptoms and emotional problems remained in the “impaired” range at the end of treatment. (3) The impact of life circumstances – referring to negative impacts of events outside of the therapy.
Practice Implications
This is a small but unique study that interviewed patients who did not benefit from psychotherapy about their experiences of the treatment and therapist. Nonimproved patients described their therapist generally as too passive, distant, and uninvolved in the work of therapy. These patients described difficulty understanding the therapeutic method and the nature of the therapeutic relationship. The findings highlight the importance of the therapeutic alliance. To have a good alliance, patients and therapists have to agree on the tasks of therapy, agree on the goals that the therapy should achieve for the patient, and there should be a mutual liking or bond between patient and therapist. Those patients whose therapists pay attention to and foster a good alliance are more likely to experience good outcomes.