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Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337.

In 2014, Tracey and colleagues caused a stir when they claimed that there was no evidence of expertise in psychotherapy (see my July, 2014 blog). They defined expertise as increased quality of performance that is gained with additional experience – and they concluded that psychotherapy research has not provided evidence that therapist performance improves with experience. The issue is important because differences between therapists account for over 5% of patient outcomes. This seems small, but it is larger than variance in outcomes accounted for by the use of empirically supported treatments (0% - 4%), and almost as large as the variance accounted for by client-rated alliance (5% - 15%). Across a wide variety of professions (e.g., music, medicine, chess, sports), professionals’ engagement in deliberate practice results in improvement and superior performance. However, there is little evidence of this in psychotherapy. In this article by Chow and colleagues, the authors look specifically at “deliberate practice” defined as individualized training activities to improve one’s performance through repetition and refinement. To be effective, deliberate practice has to be focused on achieving specific targets and guided by conscious monitoring of outcomes over a long period of time. The authors collected a sample of 69 therapists who worked across a number of organizations and practice areas, and these therapists provided data related to 4,850 patients. Seventeen of the 69 therapists who treated 1,632 clients also provided data on professional development activities. Therapists were multidisciplinary (i.e., counsellors, psychologists, marital therapists, social workers, psychotherapists) with an average of over 8 years of experience, who worked mainly in private practice or within the national health service in the U.K., and who primarily treated adult patients with depression or anxiety disorders. Patient outcomes were measured repeatedly with a valid standardized scale, and deliberate practice was self reported by therapists using a measure that asked about the frequency and time therapists engaged in 25 activities outside of work aimed at improving therapeutic skills. On average, clients improved by the end of treatment and the effect was large (d = 1.22). As expected therapists differed in their patient outcomes (i.e., some therapists were reliably more effective than others). Therapist demographic variables, theoretical orientation, years of experience, and practice setting were not related to patient outcomes. However, the amount of time in deliberate practice activities was associated with a reduction in client distress. Compared to the less effective therapists (2.62 hrs/wk in deliberate practice), the best performing therapists (7.39 hrs/wk in deliberate practice) spent about 2.81 times more time on deliberate practice. Therapists rated the following deliberate practice activities as the most relevant to their patients’ outcomes: reviewing challenging cases, attending training workshops, reflecting on past sessions, and reflecting on what to do in future sessions.

Practice Implications

Although this is a single study with a relatively small sample of therapists, it is one of those rare studies to assess the effects of therapist deliberate practice on patient outcomes. As is the case with other professions, reviewing one’s performance can play an important role in identifying errors, altering course, and remediating problems. As Tracey and colleagues indicated, therapists need good quality information in order to learn from their errors and make adjustments so that clients can improve. Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes especially for at-risk cases. Chow and colleagues go further to suggest targeted learning by using standardized clients within training and supervision contexts. Deliberate practice is not only for newer or less experienced therapists, since experienced therapists also vary in their ability to engage and help clients. Highly effective therapists spend more time engaging in activities outside of their practice specifically aimed at improving their performance.

Erekson, D.M., Lambert, M.J., & Egget, D.L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology.

The dose-response model of psychotherapy suggests that a single session is like a “dose” of therapy, and that each session adds to a cumulative response by the client. For example, research indicates that between 13 and 18 sessions are required for 50% of patients to improve significantly, but with diminishing returns for clients after 18 sessions. In this very large study in a naturalistic setting, Erekson and colleagues studied the question of the effects of the “dose” or quantity of therapy a little differently. What if the spacing or frequency of sessions rather than the total number of sessions was important to patient outcomes? That is, if psychotherapy reinforces adaptive behaviors, then less learning might occur if time between sessions increases. With greater time between sessions clients may miss timely support from a therapist, and the therapeutic alliance may not be as solid. Erekson examined the impact of session frequency in a very large sample of university students (N = 21,488) seen by therapists (N = 303) for individual therapy lasting about 50 minutes per session. Clients typically received between 6 and 21 weeks of therapy. The data were collected at a counselling center over a 17-year period. Therapist orientations included CBT, psychodynamic, existential, and integrative. Patient outcomes were measured after each session with a reliable measure that allows one to evaluate if a client recovered from symptoms, reliably improved but did not recover, or reliably deteriorated. The authors found that compared to less frequent sessions (approximately every 2 weeks), more frequent sessions (approximately weekly) was associated with faster improvement and faster recovery. The statistical models predicted that 50% of individuals being seen weekly would reliably improve in 8 sessions, whereas 50% those seen every 2 weeks would reliably improve in 12 sessions. That is, clients seen every two weeks required 50% more sessions to achieve the same level of improvement as clients seen every week.

Practice Implications

Clients that are seen weekly may have a better therapeutic experience and develop a better therapeutic alliance with their therapists, which may in turn result in faster improvements. More frequent meetings may suggest to clients that their needs are important to the therapist. Institutions may have the opinion that lower session frequency is a way of saving resources, but in the end patients seen less frequently may require more therapy to achieve outcomes at the same rate as patients seen more frequently. Higher frequency of sessions may increase the efficiency of the psychotherapy and possibly reduce the amount of resources invested by the institution to improve patient mental health outcomes.

Stiles, W.B., Barkham, M., & Wheeler, S. (2015). Duration of psychological therapy: Relation to recover and improvement rates in UK routine practice. British Journal of Psychiatry, 207, 115-122.

In this very large study from the UK National Health Service (NHS), Stiles and colleagues assessed whether more therapy is better. That is, do people continue to get better with more sessions or do patients reach a certain level of improvement and terminate therapy regardless of number of sessions. The “dose-effect model” of psychotherapy suggests that patients continue to improve with more sessions, although the rate of improvement slows down after 18 sessions. However, large naturalistic studies from the UK health system show that patients have similar rates of recovery regardless of the number of sessions they attend (i.e., up to 20 sessions). These findings suggest that patient improvement may follow a good-enough or “responsive regulation model” of improvement, in which patients responsively regulate the number of sessions that they need. This could have implications for policies regarding how many sessions are prescribed to patients. In this study, Stiles and colleagues drew data from the NHS data base of over 26,000 adult patients who were seen by 1,450 therapists. These were patients who provided enough reliable outcome data, who attended 40 or fewer sessions, and who had a planned ending. Many patients had multiple problems including anxiety, depression, bereavement, and trauma and abuse. Patients who were selected for the study had initial symptom scores in the clinical range. The most common therapy approaches included integrative, psychodynamic, CBT, and supportive. Patient “recovery” was defined as no longer scoring in the clinical range at the end of therapy. Patient “improvement” was defined as a reliable drop in symptom scores on a psychometric measure. Patients received an average of 8.3 sessions, 60% recovered, and an additional 19% improved but did not recover. Rates of reliable improvement were negatively correlated (r = -.58) with number of sessions, and the effect was large. That is, patients who stayed in therapy longer had lower rates of recovery. These patients were more symptomatic at the outset.

Practical Implications

The results of this very large naturalistic study suggest that therapists and clients should regularly monitor improvement and adjust the treatment duration based on whether clients improve to a satisfactory level. The authors refer to this as “responsive regulation” of treatment duration. In practice, this means that therapists and clients end treatment when patients have improved to a “good-enough” level, which is likely balanced against costs and alternatives. These findings should encourage therapists and agencies to shift their attention away from prescribing a pre-specified length of treatment at the beginning of therapy towards evaluating on an ongoing basis what constitutes good-enough gains for each client.

Owen, J., Adelson, J., Budge, S., Wampold, B., Kopta, M., Minami, T., & Miller, S. (2015). Trajectories of change in psychotherapy. Journal of Clinical Psychology, 71(9), 817–827.

Knowing the rate, or the trajectory, or the shape of client change across sessions of therapy can inform our understanding of how patients change, our policies of how many sessions to provide clients, and our clinical decisions if clients are no longer improving. The most popular models of client change across sessions include the “dose-effect model” and the “good-enough level model”. The dose-effect suggests that the more therapy patients receive the more they improve but, at a certain point, more sessions result in diminishing returns. In the August, 2013 PPRNet blog, I reviewed a chapter suggesting that 17% to 50% partially improve after about 7 sessions, and 50% patients fully recover after receiving about 21 sessions of therapy. Dose effect models might encourage some agencies to provide only the average number of sessions so that most patients will improve. The good-enough level model, on the other hand suggests that patients stay in therapy for varying lengths of time, and the number of sessions is determined by the point at which they feel better. In this study by Owen and colleagues, the authors take a different approach by looking at the patterns or trajectories of change that represent how and at what rate patients improve over time. In this very large study, they gathered session-by-session outcome data for over 10,000 clients seen at 47 treatment centres by over 500 different therapists. Client presenting problems and therapy orientations varied. Owen and colleagues identified 3 classes of patient change trajectories by using advanced statistical modeling of general distress outcomes across 5 to 25 sessions of therapy (average = 9.4 sessions). The largest class, representing 75% of clients, typified those who rapidly improved to session 5 and whose improvement plateaued to session 11, after which they improved again. This was called the “early and late change” class. The second largest class of patients, representing almost 20% of the sample, showed consistent linear change across the sessions. This was called the “slow and steady change” class. The third class of clients, representing about 5% of the sample, showed an initial decline in functioning up to session 5, followed by a steady improvement up to session 9, and then a plateau in improvement after session 9. This was called the “got worse before they got better” class.  This last group of clients had the most severe symptoms at the outset.

Practice Implications

This study indicates that one size does not fit all when it comes to how rapidly and in what manner patients change. “Early and late change” patients improve early on and then show another round of improvement later on in therapy. “Slow and steady” change patients show mild but consistent improvement across sessions of therapy. And those whose symptoms are more severe at the outset may “get worse before they get better”. This means that it may not be feasible to set an average fixed number of sessions for all patients, but rather therapists and agencies must rely on indices of reliable or good-enough change to determine optimal therapy length for each client. For example, “early and late change” patients may be working on different issues at different stages of therapy. Whereas clients who “show slow and steady” change may need to be in therapy longer before they realize sufficient improvement. For those patients with more severe symptoms who “get worse before they get better”, the therapy initially may be difficult but may ultimately induce change in the long run. In this case, therapists may need to provide enough of the current therapeutic approach before considering a change in the course of therapy.

Author email: Jesse.owen@louisville.edu

Farrell, N.R. & Deacon, B.J. (2015). The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists. Journal of Behavior Therapy and Experimental Psychiatry. DOI: 10.1016/j.jbtep.2015.08.004

The American Psychological Association defines evidence-based practice (EBP) in psychotherapy as based on: (a) research evidence, (b) clinical expertise, and (c) client characteristics and preferences. We know for example, that clients who receive their preferred treatments better engage with therapy, drop out at a lower rate, and achieve better symptom outcomes. However, we know very little about clients’ preferences for the relative importance of the therapeutic relationship with an empathic therapist versus the scientific merit of the treatment they receive. We do know that therapists generally prefer research on the therapeutic relationship, and that therapists may place greater value on relationship issues versus research support for the treatments they provide. In this study Farrell and Deacon sample 200 members of the community about the relative importance of the relationship with a therapist versus the scientific basis of the treatment. The authors also surveyed a similar number of therapists about what therapists thought clients would prefer (relationship vs research evidence) in psychotherapy. Not surprisingly, community members rated both the therapeutic relationship and research evidence highly when indicating what they preferred should they receive psychotherapy. However, the authors found that members of the community rated the therapeutic relationship much more highly than they rated research evidence (d = 1.24). But the difference shrank (d = .24) when it came to treating panic disorder or obsessive compulsive disorder. Therapists tended to under-estimate the importance of community members’ preferences for scientific evidence for psychotherapy. The under-estimation was greater for therapists who placed less value on research. In other words, therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to members of the general public.

Practice Implications

This is by no means a perfect study. As readers of this blog know, I prefer to write about meta analyses, which are much more reliable than findings from a single study. However, it is quite rare to have a study on a large sample of members of the community, let alone one that asks about their perceptions and preferences about psychotherapy. The findings from this study suggest that members of the community highly value the therapeutic relationship and factors like therapist empathy. However, members of the community also place much faith in the scientific evidence that supports the use of psychotherapy. The preference for both a good therapeutic relationship coupled with research evidence may be very important to most people who may seek therapy. Therapists, particularly those who place less weight on research, should keep in mind that clients value the scientific evidence for psychotherapy.

Author email: bdeacon@uow.edu.au

Abbass, A., Kisely, S., Rasic, D., Town, J.M., & Johansson, R. (2015). Long-term healthcare cost reduction with Intensive Short-term Psychodynamic Psychotherapy in tertiary psychiatric care. Journal of Psychiatric Research, http://dx.doi.org/10.1016/j.jpsychires.2015.03.001

Several years ago Lazar (2010) published a book detailing the cost-effectiveness of psychotherapy for a variety of disorders. That is, her systematic review found that on most economic indicators (lost income, decreased disability, decreased health utilization) psychotherapy resulted in an immediate cost reduction over and above the cost of the treatment. In this study from Halifax, Canada, Abbass and colleagues looked at the effects of psychotherapy, specifically of Intensive Short-term Dynamic Psychotherapy (ISTDP), on the long-term reduction in hospital costs and physician visits. Abass and colleagues argue that adverse childhood events are an important determinant of adult mental health problems and of increased costs to the health system likely because of the consequence of problems with emotion regulation. Psychotherapies like ISTDP specifically address issues that are a consequence of childhood maltreatment and so might reduce some of the consequent health care costs. Abbass and colleagues provided ISTDP to 890 patients in the Halifax health care system who were referred to the psychotherapy service from emergency departments, physicians, and mental health providers. These patients’ outcomes were compared to 192 patients not seen by the clinic for various reasons. Most common diagnoses of the total sample were: somatoform disorder, anxiety disorder, personality disorder, and depressive disorder. Participant completed measures of psychological distress, and the research team were able to access provincial health usage data tracked over 3 years. Fifty eight therapists of various skill levels (psychiatrists, psychologists, family physicians, trainees) provided ISTDP. The average patient attended 7.3 sessions which cost $708 (estimated by salaries in 2006). Patients receiving psychotherapy had physician and hospital costs that decreased from $3,224 to $4759 in Canadian dollars per year over three years (again in 2006 dollars). Patients in the control condition not receiving ISTDP showed health care costs that increased from $368 to $2,663 per year. These trajectories of health care costs were significantly different. Yearly physician and health care costs for patients prior to being treated with ISTDP were greater than those of the general Canadian population, but 3 years post ISTDP their health care costs were less than the general Canadian population. In addition, compared to control patients those treated with psychotherapy showed a significant reduction in psychological distress.

Practice Implications

This study by Abbass and colleagues demonstrates that short term psychotherapy provided to a broad range of patients and targeting health and illness behaviors related to problems with emotion regulation can reduce health care costs. These reductions in hospital and physician visits occurred in the short term and were sustained over several years. Some patients may require longer treatment, but the evidence suggests that short term interventions should be tried first.

Author email: allan.abbass@dal.ca