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.

May 2016

Does Organizational Context Have an Effect on Patient Outcomes?

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.

April 2016

Patient Experience of Negative Effects of Psychotherapy

Crawford, M.J., Thana, L., Farquharson, L., Palmer, L., Hancock, E.... Parry, G.D. (2016). Patient experience of negative effects of psychological treatment: results of a national survey. British Journal of Psychiatry, 208, 260-265.

There is lots of evidence that psychotherapy is effective for a wide variety of disorders. However, a number of studies report that between 5% and 10% of patients report higher levels of symptoms following treatment compared to when they started. Although the side effects and negative outcomes in pharmacological treatment studies are routinely reported, negative outcomes in psychological treatment studies are rarely reported and investigated. In this very large survey, Crawford and colleagues analysed data from an audit of state funded psychological therapies for depression and anxiety in England and Wales. Adult patients from 220 centers were invited to complete an anonymous service-user questionnaire that asked about their experiences of the processes and outcomes of psychotherapy. Some of the questions asked if clients experienced a “lasting bad effect” from the treatment. Nearly 15,000 individuals responded to the survey. More than half (51%) were treated with cognitive behavioral therapy, and most clients received only one treatment, which was predominantly individual therapy. Most (74.35%) received fewer than 10 sessions. Of the respondents, 763 (5.23%) reported that therapy had a “lasting bad effect”, and an additional 7.70% were “unsure” whether they experienced a lasting bad effect. People over 65 years old were less likely to have a lasting negative effect, and those from minority ethnic groups and non-heterosexuals were more likely to report lasting bad effects. In addition, those who did not know what type of therapy they received were more likely to have lasting bad effects.

Practice Implications

A substantial minority of patients reported lasting negative effects from their psychological treatment. With approximately a million Canadians receiving outpatient psychological treatment of one form or another each year, these findings imply that thousands of patients could have experienced a lasting negative effect. The findings suggest that psychotherapists need to be highly sensitive to cultural and ethnic minority issues and acquire cultural competence. The same is true when treating non-heterosexuals. Clinicians should also make sure to provide sufficient information to patients about the type of treatment they are receiving as part of the informed consent process. Attending to these issues may reduce the likelihood of therapeutic alliance ruptures that may be related to lasting negative effects.
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.

March 2016

Does Clinician Confidence Lead to Accurate Clinical Judgement?

Miller, D.J., Spengler, E.S., & Spengler, P.M. (2015). A meta-analysis of confidence and judgement accuracy in clinical decision making. Journal of Counseling Psychology, 62, 553-567.

People can make errors in judgements based on decision making rules that are biased. Clinicians also may be prone to making such errors. In their Nobel Prize winning work, Kahneman and Tversky outlined a number of heuristics (i.e., mental shortcuts) that lead to cognitive biases, which in turn affect accuracy of decisions. For example, when making a differential diagnosis clinicians may: rely too heavily on only one piece of information which may be the most available (e.g., “I vividly remember a patient with conversion disorder who had the same history”); or ignore that a particular event (e.g., conversion disorder) is very rare; or seek confirming rather than disconfirming evidence (e.g., the patient has PTSD symptoms that can explain some symptoms). Complicating these biases is the tendency for clinicians to be over-confident. For example, in one study the average psychotherapist rated their performance as better than 80% of their peers, and no therapist rated him or herself in the lower 50^th percentile among peers. In their meta analysis, Miller and colleagues reviewed 36 studies of the relationship between clinician confidence ratings and accuracy of decisions among 1,485 clinicians. The authors were particularly interested in the overconfidence bias, which occurs when individuals report higher confidence in their judgments than is warranted by their actual accuracy. For example, studies have assessed the impact of clinician confidence on clinical accuracy in: detecting random responding on a psychological test, diagnosing a brain disorder verified by medical test using neuropsychological test data, predicting future violence and recidivism in offenders, and patient progress in psychotherapy. Most studies find that clinicians are quite confident in their judgments. But, is this confidence warranted? Miller and colleagues’ meta analysis found a significant but small (r = .15) association between confidence and accuracy. This suggests that clinician confidence is only slightly indicative of decision-making accuracy. The effect was a little larger for more experienced clinicians (r = .25), indicating that more experience and training resulted in somewhat more consistency between a clinician’s confidence and their clinical accuracy. Further, higher confidence leads to poorer accuracy when clinicians have to make repeated decisions without feedback, when feedback is not written, and when an event is rare.

Practice Implications

Clinicians, like everyone else, are sometimes subject to making errors when they only look at confirming evidence, when they rely only on their own memory rather than objective data, and when they are over-confident. Accuracy can be increased when clinicians use decision-making aids that provide quality corrective feedback. Aids to help in decision making might include the use of: objective standardized test data, repeated measurements with feedback to assess patient progress in psychotherapy, and actively looking for disconfirming evidence before making a clinical judgement. As the authors conclude, confidence is not a good substitute for accuracy.

February 2016

Patients’ Experiences of Clinicians’ Crying During Psychotherapy

Tritt, A., Kelly, J., & Waller, G. (2015). Patients’ experiences of clinicians’ crying during psychotherapy for eating disorders. Psychotherapy, 52(3), 373-380.

Psychotherapy can be an emotionally intensive experience for both patients and therapists. In a large survey, more than 70% of therapists reported having cried in therapy, and 30% cried during the past month. Therapists who cried almost always saw the experience as positive or neutral (99.2%) for the patient and the therapeutic relationship. Do clients feel the same way about therapists who cry? In this study, Tritt and colleagues surveyed 188 adult patients with an eating disorder who were recently in psychotherapy. Of those, 107 (56.9%) reported that their therapist had cried during therapy. There was no association between frequency of therapist crying and therapist age, patient diagnosis, or type of psychotherapy (i.e., manual-based or not). Therapists who cried a moderate amount were seen by clients as having a positive demeanor (i.e., happy, firm, consistent), whereas therapists who cried more extremely were rated by clients as having a more negative demeanor (i.e., anxious, angry, bored). If therapists who cried were generally perceived by clients to have a positive demeanor, then therapist crying had a positive impact on therapy. That is, clients reported a greater respect for the therapist, greater willingness to express emotions, and higher willingness to undertake therapy in the future. However, if therapists who cried were generally perceived by clients to have a negative demeanor, then therapist crying had a negative impact on therapy. That is, clients were less willing to express emotions in therapy and to undertake therapy in the future. Further, if the therapist who cried was rated as having a negative demeanor, the client experienced more self blame, assumed that there was something wrong in the therapist’s life, and that the therapist and client did not share the same perspective on the client’s life and treatment.

Practice Implications

This small but unique and interesting survey sheds some light on clients’ experiences of therapists who cry during therapy. More than half of clients experienced their therapist crying during therapy. In contrast to surveys of therapists who tend to evaluate therapist crying as exclusively positive or neutral, this survey found that many but not all clients experienced therapist crying as positive. It depends on how the client perceives the therapist as a person. Therapists who are seen by clients as happy, firm, and consistent may assume that patients will experience their crying as a positive indicator of the therapeutic relationship. However, therapists who are seen by clients as anxious, bored, or angry cannot assume that clients will see their tears as being positive for therapy.

January 2016

Deliberate Practice in Highly Effective Therapists

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.

This month...

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May 2016

Practice Implications

April 2016

Practice Implications

Practice Implications

March 2016

Practice Implications

February 2016

Practice Implications

January 2016

Practice Implications

Psychotherapy Practice Research Network (PPRNet)