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Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy, 10(6), 361-373.

Much of psychotherapy research has focused on searching for effective psychotherapies rather than focusing on effective psychotherapists. Research on psychotherapies generally assumes that therapists are equally effective or relatively less important to patient outcomes than the interventions themselves. Therapists in clinical trials are trained to follow a manual in an attempt to reduce the therapists’ impact on patient outcomes, and to focus the study on the specific ingredients of the therapy itself. However, research indicates that the degree to which a therapist follows a manual has little bearing on patient outcomes, and that therapists do differ in terms of their patients’ outcomes. In one large study, between 33% and 65% of therapists was ineffective or harmful. Okiishi and colleagues asked if it is possible to identify highly effective therapists (“super-shrinks”) and highly ineffective therapists (“pseudo-shrinks”) based on their patients’ outcomes. The therapists were 56 men and women who treated 1779 clients in a university counselling centre. Each therapist saw at least 15 clients, so that there was a good sampling of therapists’ outcomes across a variety of clients. Therapists had a range of experience, training, and theoretical orientations. Clients were adults who had moderate to severe problems with anxiety, depression, or adjustment. Outcomes were measured after every session, and the average number of sessions was 5.16 (SD = 7.20). On average clients improved so that their level of distress significantly declined. Therapist characteristics (sex, experience, training background, theoretical orientation) did not predict patient outcomes. However, client change varied significantly, so that some clients improved at a faster rate than others, some did not change, and some got worse. There were no differences between therapists in their clients’ level of distress, so therapists had equivalent caseloads in terms of client initial distress. However, therapists significantly differed from each other in terms of their clients’ outcomes. For example, the top 3 therapists consistently had clients who got better (super-shrinks), and the bottom 3 therapists consistently had clients who got worse (pseudo-shrinks).

Practice Implications

One would hope that a loved one would get to see a “super-shrink” therapist, since these therapists seem to consistently have clients who do well in therapy. But what about the average or “pseudo-shrink” therapist– what can be done to elevate their skills and their patients’ outcomes? We’ve discussed in this blog several things therapists can do to improve their outcomes, including: using progress monitoring in their practice, receiving training focused on deliberate practice, and seeking out specific continuing education around developing, maintaining, and repairing the therapeutic alliance.

Reese, R. J., Duncan, B. L., Bohanske, R. T., Owen, J. J., & Minami, T. (2014). Benchmarking outcomes in a public behavioral health setting: Feedback as a quality improvement strategy. Journal of Consulting and Clinical Psychology, 82(4), 731-742.

Psychotherapy has demonstrated its efficacy in randomized controlled trials. But do these findings in highly controlled studies translate to everyday practice in publicly funded agencies that treat low income clients? Previous research in the US showed that outcomes of treatment-as-usual in public behavioural health agencies are generally not positive, so that only 20 to 35% of clients reliably improved. One approach to improving outcomes is to transport specific evidence-based treatments into practice settings. For example, research on applying CBT for panic and depression in a publicly funded agency resulted in similar outcomes to those achieved in randomized controlled trials. However, an alternative strategy of improving outcomes is to use continuous outcome monitoring, which involves repeated (weekly) measurement of client outcomes with reliable scales, and feedback to therapists on the client’s status relative to previous sessions and relative to other similar clients. Research has demonstrated that this strategy improves client outcomes and reduces the number of clients who deteriorate. In this study, Reese and colleagues examined the outcomes of a large public behavioural health service in the U.S. that treats low-income individuals. The service implemented repeated outcome monitoring of clients with feedback to therapists. Over 5,000 clients mainly with depression, mood, and anxiety disorders were treated by 84 therapists who were licensed at the masters degree or higher. The clients completed the Outcome Rating Scale (a measure of symptom outcome) prior to each session, and the Session Rating Scale (a measure of the therapeutic alliance) after each session. Therapists received two days of training on how to use these measures and on the continuous feedback they were provided in order to improve their treatment of clients and their outcomes. Outcomes from this public behavioural health service were compared to previous large studies in publicly funded settings that implemented specific evidence-based treatments. The findings were similar, with about 42% showing reliable pre- to post-treatment improvement. The results of implementing continuous outcome monitoring with feedback for depressive symptoms were also large and positive (d = 1.34). These effects were similar to benchmarks established in randomized controlled trials of specific psychotherapies.

Practice Implications

Continuous outcome feedback enables therapists to identify clients who are not benefiting
from a given treatment, so that clinicians may collaboratively design different interventions or change their interpersonal stances. The inclusion of outcome monitoring and feedback in this publicly funded psychotherapy system, resulted in outcomes that were: better than what is often seen in such public service settings, equivalent to those public systems that implemented specific evidence based treatments, and similar to those reported in highly controlled randomized trials. The authors concluded that adding routine outcome monitoring and feedback is a viable alternative to transporting specific evidence based treatments to publicly funded psychotherapy programs. The measures used in this study are available free for individuals to use at: betteroutcomesnow.com.

Author email: jeff.reese@uky.edu

Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted events and side effects in cognitive behavior therapy. Cognitive Therapy and Research, 42(3), 219-229.

Unwanted events are negative consequences for clients that may or may not be related to treatment (i.e., events outside of therapy or inside of therapy that may negatively affect clients).  These might include: occupational problems, stigmatization, strains in personal relationships, changes in the social network, patients feeling overwhelmed, undermined self-efficacy, deterioration of symptoms, emergence of new symptoms, suicidality, and others. Side effects refer to negative reactions in clients directly related to appropriately delivered therapy. Research estimates that between 5% and 20% of patients report side effects of psychotherapy. One could argue that side effects may be inevitable even in well-delivered therapy, and therapists who are aware of the potential for side effects may be better equipped to help clients to manage. In this study, Schermuly-Haupt, interviewed 100 psychotherapists who provided CBT in outpatient clinics in Germany about side effects among their clients. All therapists were supervised as part of their work and so the authors assumed the therapy was appropriately delivered. Therapists had on average 5 years of experience and were trained to provide CBT. The interview asked therapists about their most recent treatment case in which the client attended at least 10 sessions. Clients typically had major depression, an anxiety disorder, or a personality disorder, and had attended 28 sessions of therapy on average. During the interview, therapists identified if an unwanted event occurred for a client from a standardized list, and then rated the duration and severity of the effects. They also rated the degree to which the unwanted event was directly related to therapy (i.e., a side effect). Prior to the interview, only 26% of therapists reported their client experienced side effects. However, the interview process found that almost all clients experienced an unwanted event (98%) that may or may have been related to therapy, and 43% experienced at least one side effect that was at least somewhat related to treatment. The most frequent side effects were: “negative wellbeing/distress” (27% of clients), “deterioration of symptoms” (9% of clients) and “strains in family relations” (6% of clients). Of the therapists, 46% rated the side effects as at least moderately severe, and 8.8% of side effects were rated as persistent (lasting more than a month).

Practice Implications

Unwanted events outside of therapy are very common among our clients, but so are side effects from appropriately delivered treatment. Psychotherapy is not always harmless, and it may be best to acknowledge and prepare both clients and therapists for side effects. These may represent ruptures in the alliance that can be managed through alliance-focused therapy, for example. That is, side effects may be caused a mismatch between the goals of a therapist and client, or a disagreement on how to proceed in therapy given what a client needs at the time. Goals and tasks of therapy may need to be renegotiated following the experience of a side effect.

Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., et al. (2016). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of Affective Disorders, 190, 254-263.

There is substantial evidence that short-term psychotherapy is effective for depressive and anxiety disorders, including at follow-up. There are also a few meta-analyses showing the effectiveness of longer term therapy. Although there is research indicating the cost-effectiveness of short-term treatments, less research has evaluated the cost-effectiveness of longer term therapy, and even less research at long term follow-ups. In this study from the Helsinki Psychotherapy Study Group, the authors evaluated the cost-effectiveness of short-term therapy (solution-focused therapy [12 sessions] or short-term dynamic therapy [20 sessions]) versus long term dynamic psychotherapy (2-3 sessions weekly for up to 3 years). Participants (N = 326) with anxiety or mood disorders were randomized to one of the three therapies. Symptoms and work ability were assessed at pre-treatment, post-treatment, and several times during a 5 year follow-up period. A previous publication with this sample showed that long-term treatment resulted in greater recovery with regard to symptoms and work ability (recovery for both outcomes exceeding 60%) compared to short-term treatment (50% recovered). For this study the authors asked: is long-term treatment cost-effective – in other words, is the better outcome from long-term treatment justified by greater cost? Both direct costs (health care utilization) and indirect costs (lost productivity) were calculated in this study using standard econometrics. Long-term therapy cost 3 times as much as short-term treatments. This amount was smaller than expected because those who received short-term treatments had higher auxiliary costs (i.e., the need for other treatments after the short term therapy ended). Shorter therapies were equally cost-effective, but both were more cost-effective than the longer treatment. That is, despite being more effective and requiring less auxiliary treatment, the longer-term therapy was more costly per unit of improvement with regard to symptoms and productivity compared to the shorter treatments.

Practice Implications

From an economic point of view, short-term treatments make the most sense. However, given that many patients needed other treatments after the end of short-term therapy, and given that on average the longer-term therapy was more effective in the long run, a clinician may want to weigh the economics with the specific needs and preferences of each patient.

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.

Practice Implications

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.

Waldinger, R.J. & Schulz, M.S. (2016). The long reach of nurturing family environments: Links with midlife emotion-regulatory styles and late-life security in intimate relationships. Psychological Science. DOI: 10.1177/0956797616661556.

Although, not a psychotherapy study, this research has important implications for psychological treatment of adults, including older adults. This research, drawn from the original Grant study, is extraordinary because the sample is from a 78-year long study of 81 men. The original cohort of over 200 men were first assessed as adolescents and young adults between 1939 and 1942. At that time, the original authors conducted intensive interviews of the adolescents` family experiences and current life situations. These men were re-interviewed in mid-life in the 1960s (aged between 45 and 50 years), which included interviews and assessments of challenges in relationships, work functioning, and physical health. Waldinger and Schulz recently re-interviewed these men and their current partner in late-life (aged between 75 and 85 years), with interviews focusing on their current partner relationship. Raters reviewed audio recordings and notes from all the interviews and coded for: (a) quality of family environment in childhood (distant, hostile vs cohesive, warm) - taken from the first interview; (b) style of regulating emotions (suppressive, maladaptive vs engaged, adaptive) – taken from the midlife interview; and (c) security of attachment with their current partner (secure, comforting vs insecure, anxious) – taken from the late-life interview. The authors found that more nurturing early family environments were significantly linked with late-life attachment security with a partner (r = .23, 95% CI = .01, .45), and early family environment was significantly related to midlife adaptive emotion regulation strategies (r = .29, 95% CI = .06, .50). Also, adaptive emotion regulation strategies in midlife were significantly correlated with greater late-life attachment security (r = .23, 95% CI = .05, .51). These are medium-sized correlations, but they are remarkable because they represent associations between variables that were assessed decades apart. Through a statistical mediation analysis, the authors also reported that adaptiveness of emotion-regulation strategies partially explained why positive childhood family environments may lead to late-life attachment security (accounting for 6% of the variance).

Practice Implications

This compelling study adds to the argument that early family environment shapes the way adults regulate their emotions, which in turn affects how they experience relationships in old age. More securely attached adults were better able to meet two challenges associated with aging: accepting vulnerability in depending on a partner, and accepting the responsibility of being depended upon by that partner. The early family environment indeed has a long reach. Psychotherapy directed at reducing the effects of childhood adversity takes on a heightened meaning in the context of these findings. Treatment for adults who struggle with the consequences of non-nurturing early environments should include improving emotion regulation strategies.