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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.

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.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270-277.

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate (2^nd ed.). New York: Routledge.

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books

In the concluding chapter of their book, Wampold and Imel discuss the evidence and strategies that therapists can use to improve patient outcomes. As indicated in previous PPRNet Blogs, Wampold and Imel concluded that the differences between specific treatment approaches is small. In other words, Wampold and Imel argue that there is no good evidence that one bona fide psychotherapy is more effective than another for most disorders. By “bona fide” treatments, they mean psychotherapy that: provides the client with a plausible theory/explanation of the disorder, delivers a structured intervention based on the plausible theory, and is offered by an effective therapist. The authors also found that contextual factors (e.g., therapeutic alliance, therapist empathy, client expectations) accounted for a sizeable proportion of patient outcomes. A key element in this understanding of effective therapy is the role of the therapist. The authors reviewed various studies and meta analyses that showed that therapists differ widely in their outcomes and in their ability to establish a therapeutic alliance. Unfortunately, therapists tend to be overly-optimistic about their clients’ outcomes. Therapists often do not have quality data on their clients’ progress, and the complexities of the therapeutic work makes it difficult for therapists to keep in mind all aspects of the therapy that is helpful or not helpful to clients. For example, some therapists may be good at establishing an alliance, but they may not be so good at providing a viable treatment structure. Other therapists may be highly empathic with clients who have moderately severe symptoms, but the same therapists may not respond as empathically with more difficult clients. Outcome or process monitoring (i.e., providing therapists with reliable information about the ongoing status of patient symptoms or about the quality of the therapeutic relationship) provides an evidence-based aid in helping therapists to improve their clients’ outcomes.

Practice Implications

Regardless of the type of psychotherapy they use, therapists are responsible for achieving good outcomes for their clients. This includes continually developing therapeutic skills over time. There is some evidence that a reflective attitude towards one’s psychotherapy practice is helpful. Unfortunately, therapists may not be continually improving or reflecting on their practice. This is indicated by research showing that trainees and interns appear to be as competent as experienced clinicians. Therapists need quality information about their clients in order to improve their own practice and clients’ outcomes. But psychotherapy practice is complex, the therapeutic relationship is multifaceted, and clients are variable in their presenting issues and life experiences. All of these make it difficult for any therapist to make accurate decisions in therapy. Progress or process monitoring (i.e., continually measuring outcomes and relationship processes with a psychometrically valid instrument), may be one way for therapists to receive high quality feedback about patient progress in order to improve their psychotherapy practice.

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Change in dysfunctional attitudes or cognitions is one of the specific mechanisms by which cognitive therapy (CT) is thought to be effective in the treatment of depression. In this part of their book, Wampold and Imel discuss the evidence that addresses the specific change mechanisms for CT. The reason they focus on CT is that CT is by far the most researched psychotherapy approach, and there is a substantial number of CT studies that have addressed this issue of change mechanisms. In an early meta analysis, Oei and Free (1995) found a significant relationship between change in cognitions and CT. However, in the same meta analysis, the authors found that CT and non-cognitive therapies did not differ in terms of their effects on cognitions. That is, most treatments, whether CT or not, appeared to change cognitions. In another study, three different interventions (behavioral activation, CT, and CT plus behavioral activation) all resulted in change in cognitions and improved depression. In other words, cognitive interventions do not seem to be needed to alter cognitions and reduce depression. Wampold and Imel argue that nonspecific processes in CT (and other psychotherapies for that matter) are largely responsible for the effectiveness of psychotherapy. For example, there is evidence to suggest that a number of patients show substantial symptom improvement early in treatment before specific cognitive techniques are introduced. Some have argued that this early favourable response is largely due to the effects of client expectations, reassurance, and remoralization rather than the specific procedures of the therapy. Moreover, patients who experience this remoralization early-on may be better at successfully applying techniques taught in CT. A large review of this literature concluded that there was insufficient evidence to support the notion that challenging thoughts was responsible for the positive effects of CT.

Practice Implications

This line of research appears to indicate that the specific practice of challenging thoughts or dysfunctional attitudes is not primarily responsible for patient change in CT. It may be that for any psychological treatment that has a cogent rationale for the disorder and is administered by an acknowledged expert, client progress may be determined largely by contextual factors. These factors may include a therapeutic alliance, client expectations of benefit, and client remoralization, which may in turn allow clients to benefit from the specific interventions of psychological treatments.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

The conduct of psychotherapy trials almost always requires that therapists be adherent and competent in delivering a manualized therapy intervention. Treatment adherence usually refers to the extent to which a therapist used the intervention prescribed by a treatment manual. Therapist competence refers specifically to a therapist’s skill in delivering the therapy. So “competence” in the context of psychotherapy research typically refers only to performing a certain type of treatment. Wampold and Imel argue that these definitions are consistent with a Medical Model of psychotherapy that emphasizes delivering specific active ingredients of a treatment. The Contextual Model of psychotherapy, on the other hand might define a therapist as competent to the extent that the therapist is interpersonally skilled, empathic, and able to engage clients in the actions of the therapy. Wampold and Imel report on a meta analysis of 28 studies conducted by Webb and colleagues (2010) who found a small and non-significant relationship between therapist adherence and patient outcomes (r = .02), and a small and non-significant relationship between therapist competence and patient outcomes (r = .07). Type of treatment (e.g., CBT, IPT, dynamic) did not affect these associations – in other words adherence and competence were not more important to CBT than to other treatments. However, competence seemed to be more important for the treatment of depression (r = .28). Perhaps depression responds better to specific techniques. The finding that competence was generally not related to outcomes was surprising, however generally competence is narrowly defined as how well a therapist delivered the treatment not how well the therapist was able to establish a therapeutic context. Previous researchers concluded that when clients liked working with a therapist, clients got better, and therapists were rated as more competent as a result. A number of studies appear to indicate that therapist competence is really a function of the client’s characteristics not to what the therapist does. For example, clients with more severe personality problems could make a therapist appear less competent, and these clients may have poorer outcomes. If this is the case, it would create a paradoxical situation in which therapists’ appearance of competence (i.e., ability to deliver a manualized intervention well) is largely determined by the client and not by the therapist.

Practice Implications

In contrast to the findings about adherence and competence, the therapeutic alliance is robustly related to patient outcomes. Also in contrast, the size of the alliance-outcome relationship is almost entirely due to the skills of the therapist, not the client’s characteristics. In other words, therapist competence is not a matter of whether they can do a good job of following a manual, but rather therapist competence is likely a matter of creating the right conditions (i.e., interpersonal skill, alliance, empathy, etc.) for delivering evidence-based interventions by which many clients improve. However, some therapists are better at these facilitative interpersonal skills than others.