De Smet, M. M., Meganck, R., De Geest, R., Norman, U. A., Truijens, F., & Desmet, M. (2020). What “good outcome” means to patients: Understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective. Journal of Counseling Psychology, 67(1), 25–39.
Many researchers consider the randomized controlled trial (RCT) as the best research design for testing medical and psychological treatments. However, critics of the design point to its limitations. For example, in order to collect homogenous samples of patients, researchers may exclude those with complex comorbidities. As a result, patient samples in RCTs may not represent patients one might see in real clinical practice. Also, researchers, and not patients, tend to define the meaning of what is a “good outcome” in these studies. It is possible that researchers and patients may not share the same definition of what it means to have a good outcome from psychotherapy. One key statistical and measurement method that researchers use to define outcomes is the reliable change index, which calculates the degree of change on a symptom scale from pre-treatment to post-treatment relative to the unreliability of the measurement. Using this method, researchers classify patients as “recovered” (reliably changed and passing a clinical cut-off score), “improved” (reliably changed but remaining in the clinical range), “not improved”, or “deteriorated”. However, this commonly used approach does not indicate whether the changes are actually meaningful to the patients. In this study, De Smet and colleagues interviewed patients from a randomized controlled trial of time-limited psychotherapy (16 sessions of CBT vs psychodynamic therapy) for depression who were classified as “recovered” or “improved” at post-treatment based on the reliable change index of a commonly used depression self-report scale. The authors asked how the patients experienced their depression symptom outcome, and what changes the patients valued since the start of therapy. In the original treatment trial of 100 patients, 28 were categorized as “recovered” and 19 patients were categorized as “improved”. During the post-therapy interview, the “recovered” and “improved” patients typically reported a certain degree of improvement in their symptoms. However, the patients categorized as “improved” reported that their gains were unstable from day to day, some reported having relapsed, and half did not feel that they improved at all. None of the “recovered” patients indicated that they felt “cured” of depression. Patients identified three domains of change that they experienced and valued. First, they felt empowered – that is, they had increased self-confidence, greater independence, and new coping skills. Second, they found a personal balance – that is, they had better relationships with loved ones, felt calmer, and had greater insight into their problems. Third, patients tended to identify ongoing struggles despite positive changes in the other domains – that is, certain key problems remained unresolved. “Improved” patients, and even some in the “recovered” group, indicated that their core difficulties had not been altered by the therapy.
Although measurement of symptom change can give a clinician a general sense of how the patient is doing with regard to their symptoms and whether the patient is on track, such measurement may not capture the complexity of patients’ experiences of the therapy and any broader changes they may value. Patients in this trial, especially those classified as “improved”, had varied experiences. Aside from symptom reduction, clinicians should assess what their patients may value, such as: better relationships, greater self-understanding, more self-confidence, and feeling calmer. Most patients, including some who “recovered”, felt that they were engaged in an ongoing struggle, even after therapy. These findings suggest that addressing some of the core difficulties patients face may require longer term psychotherapy.