Measurement and psychotherapy. Evidence-based practice and practice-based evidence

Leadership, organizational climate, and working alliance in a children's mental health service system

The goal of this study was to examine the relationships of transformational leadership and organizational climate with working alliance, in a children's mental health service system. Using multilevel structural equation modeling, the effect of leadership on working alliance was mediated by organizational climate. These results suggest that supervisors may be able to impact quality of care through improving workplace climate. Organizational factors should be considered in efforts to improve public sector services. Understanding these issues is important for program leaders, mental health service providers, and consumers because they can affect both the way services are delivered and ultimately, clinical outcomes.

Using early change to predict outcome in cognitive behaviour therapy: exploring timeframe, calculation method, and differences of disorder-specific versus general measures

Early change can predict outcome of psychological treatment, especially in cognitive behavior therapy. However, the optimal operationalization of “early change” for maximizing its predictive ability, and differences in predictive ability of disorder-specific versus general mental health measures has yet to be clarified. This study aimed to investigate how well early change predicted outcome depending on the week it was measured, the calculation method (regression slope or simple subtraction), the type of measures used, and the target disorder. During 10–15 weeks of internet-based cognitive behavior therapy for depression, social anxiety disorder, or panic disorder, weekly ratings were collected through both disorder-specific measures and general measures (Outcome Questionnaire-45 (OQ-45) and Clinical Outcomes in Routine Evaluation-10 (CORE-10)). With outcome defined as the disorder-specific measure, change at week four was the optimal predictor. Slope and subtraction methods performed equally well. The OQ-45 explained 18% of outcome for depression, 14% for social anxiety disorder, and 0% for panic disorder. Corresponding values for CORE-10 were 23%, 29%, and 25%. Specific measures explained 41%, 43%, and 34% respectively: this exceeded the ability of general measures also when they predicted themselves. We conclude that a simple calculation method with a disorder-specific measure at week four seems to provide a good choice for predicting outcome in time-limited cognitive behavior therapy.

Mindfulness-based narrative therapy for depression in cancer patients

Mindfulness-based narrative therapy (MBNT) is a therapeutic intervention for the treatment of depression in cancer patients. In a previous randomized controlled trial, MBNT was found to ameliorate anxiety and depression, improve functional dimensions of quality of life, and enhance treatment adherence. In this review, we describe MBNT and its technical characteristics in the context of other psychotherapeutic interventions for depression in cancer patients. We highlight needed adjustments to other narrative approaches and recommend clinical modifications tailored to the needs of cancer patients that are intended to encompass the client's initial depressive narrative. The narrative construction is supported by emotional regulation and attachment relationships on the one hand and by individual and social linguistic capabilities on the other. Through destabilization of the depressive narrative, MBNT facilitates the emergence of new meanings using both verbal and non-verbal techniques based on mindfulness. The attitude and practice of mindfulness are integrated throughout the therapeutic process. In summary, MBNT makes use of linguistic interventions, promotes mindfulness and emotional regulation, and can be adapted specifically for use with cancer patients.

KEY PRACTITIONER MESSAGE

In this review, we describe mindfulness-based narrative therapy (MBNT) for the treatment of depression in cancer patients. In a previous controlled trial, we found significant benefits of MBNT in terms of reducing depressive symptoms and improving treatment adherence and quality of life in depressed, non-metastatic cancer patients. Narrative construction is socially and neurobiologically derived. MBNT makes use of linguistic interventions, promotes mindfulness and emotional regulation, and can be adapted specifically for use with cancer patients. MBNT is proposed as an interesting and promising intervention, particularly for patients with somatic pathologies.

Evidence-Based Practice & Practice-Based Evidence Applied to Adult, Medical Speech-Language Pathology

In this paper, we review concepts of evidence-based practice (EBP), and provide a discussion of the current limitations of EBP in terms of a relative paucity of efficacy evidence and the limitations of applying findings from randomized controlled clinical trials to individual clinical decisions. We will offer a complementary model of practice-based evidence (PBE) to encourage clinical scientists to design, implement, and evaluate our own clinical practices with high-quality evidence. We will describe two models for conducting PBE: the multiple baseline single-case experimental design and a clinical case study enhanced with generalization and control data probes. Gathering, analyzing, and sharing high-quality data can offer additional support through PBE to support EBP in speech-language pathology. It is our hope that these EBP and PBE strategies will empower clinical scientists to persevere in the quest for best practices.

Partnership for implementation of evidence-based mental health practices in rural federally qualified health centers: theory and methods

BACKGROUND

Mental health and substance abuse are among the most commonly reported reasons for visits to Federally Qualified Health Centers (CHCs), yet only 6.5% of encounters are with on-site behavioral health specialists. Rural CHCs are significantly less likely to have on-site behavioral specialists than urban CHCs. Because of this lack of mental health specialists in rural areas, the most promising approach to improving mental health outcomes is to help rural primary care (PC) providers deliver evidence-based practices (EBPs). Despite the scope of these problems, no research has developed an effective implementation strategy for facilitating the adoption of mental health EBPs for rural CHCs. We sought to describe the conceptual components of an implementation partnership that focuses on the adaption and adoption of mental health EBPs by rural CHCs in Arkansas.

METHODS

We present a conceptual model that integrates seven separate frameworks: (1) Jones and Wells' Evidence-Based Community Partnership Model, (2) Kitson's Promoting Action on Research Implementation in Health Services (PARiHS) implementation framework, (3) Sackett's definition of evidence-based medicine, (4) Glisson's organizational social context model, (5) Rubenstein's Evidence-Based Quality Improvement (EBQI) facilitation process, (6) Glasgow's RE-AIM evaluation approach, and (7) Naylor's concept of shared decision making.

CONCLUSIONS

By integrating these frameworks into a meaningful conceptual model, we hope to develop a successful implementation partnership between an academic health center and small rural CHCs to improve mental health outcomes. Findings from this implementation partnership should have relevance to hundreds of clinics and millions of patients, and could help promote the sustained adoption of EBPs across rural America.

Editors' introduction: Identifying and assessing promising practices for criminal justice clients--California Substance Abuse Research Consortium (SARC) meetings, 2010

Although some practices clearly have stronger supporting evidence than others, a single authoritative list of evidence-based practices (EBPs) that can be applied in the treatment of criminal justice clients does not exist. Nationally, use of EBPs is low, and such practices are generally only implemented under certain circumstances. To clarify these issues, experts from around the nation were invited to California for two research-to-policy meetings focused on EBP identification and implementation. Their presentations and the resulting series of articles in this special theme issue describe the current state of EBP research for criminal justice clients. To advance the field beyond the compilation of EBP lists, which can only represent a partial solution at best, next steps should include a greater focus on quality of implementation, intensity of quality assurance and monitoring, and training for underlying skills and principles.

Introducing the CORE-OM in a South African Context: Validation of the CORE-OM using a South African Student Population Sample

The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was originally introduced as a standardised, practice-based evidence tool for generating effectiveness data by practitioners within the context of routine clinical practice in the United Kingdom's National Health Service (NHS) settings. Following wide application across UK NHS sites the CORE-OM has proven to be a pragmatic measure of both a) gross psychological distress and b) the effectiveness of psychotherapy interventions across client populations, presenting problems, clinical settings and therapy models. However in order for South Africa to benefit from this tool, the CORE-OM must be applicable within a South African context. This requires its validation within South African populations. The aim of this article is to demonstrate the cross-cultural validity of the CORE-OM, using a South African student population sample and in so doing to provide preliminary referential data for use in interpreting CORE-OM scores within English-medium, South African University student counselling centre contexts.

An investigation of the accuracy of therapists' self-assessment of cognitive-behaviour therapy skills

BACKGROUND

The impact of cognitive behavioural therapy (CBT) interventions in routine clinical practice depends on those interventions being delivered competently. Since direct observation or independent assessment of therapists' skills are typically limited in routine clinical practice, the assessment of competence, and thus of the need for further training and/or supervision to improve competence, rests mainly on the individual therapist's self-assessment.

AIMS

To examine the accuracy of therapists' self-assessment of their CBT competence in relation to supervisors' assessments.

METHOD

Self-ratings on the Cognitive Therapy Scale (CTS; Young & Beck, 1980; 1988) from two groups of trainees on established cognitive therapy training courses (n= 64) were compared to supervisors' ratings of the same therapy sessions.

RESULTS

There were moderate correlations between self- and supervisor assessments, and the previously reported over-estimation of CBT skills (Brosan, Reynolds, & Moore, 2008) was not replicated in the current sample. Instead, these groups showed under-estimation of their skills compared to supervisors' ratings, with the less-competent trainees' ratings not being significantly different from their supervisors' and the more competent trainees' ratings being significantly lower than those of their supervisors.

CONCLUSIONS

Several possible explanations of the results are discussed and recommendations for ensuring the integrity of CBT delivered in routine clinical practice are made.

Use of the evidence base in substance abuse treatment programs for American Indians and Alaska Natives: pursuing quality in the crucible of practice and policy

BACKGROUND

A variety of forces are now shaping a passionate debate regarding the optimal approaches to improving the quality of substance abuse services for American Indian and Alaska Native communities. While there have been some highly successful efforts to meld the traditions of American Indian and Alaska Native tribes with that of 12-step approaches, some American Indian and Alaska Natives remain profoundly uncomfortable with the dominance of this Euro-American approach to substance abuse treatment in their communities. This longstanding tension has now been complicated by the emergence of a number of evidence-based treatments that, while holding promise for improving treatment for American Indian and Alaska Natives with substance use problems, may conflict with both American Indian and Alaska Native and 12-step healing traditions.

DISCUSSION

We convened a panel of experts from American Indian and Alaska Native communities, substance abuse treatment programs serving these communities, and researchers to discuss and analyze these controversies in preparation for a national study of American Indian and Alaska Native substance abuse services. While the panel identified programs that are using evidence-based treatments, members still voiced concerns about the cultural appropriateness of many evidence-based treatments as well as the lack of guidance on how to adapt them for use with American Indians and Alaska Natives. The panel concluded that the efforts of federal and state policymakers to promote the use of evidence-based treatments are further complicating an already-contentious debate within American Indian and Alaska Native communities on how to provide effective substance abuse services. This external pressure to utilize evidence-based treatments is particularly problematic given American Indian and Alaska Native communities' concerns about protecting their sovereign status.

SUMMARY

Broadening this conversation beyond its primary focus on the use of evidence-based treatments to other salient issues such as building the necessary research evidence (including incorporating American Indian and Alaska Native cultural values into clinical practice) and developing the human and infrastructural resources to support the use of this evidence may be far more effective for advancing efforts to improve substance abuse services for American Indian and Alaska Native communities.

[Psychotherapy research in the German-speaking community--a bibliometric analysis of three journals]

OBJECTIVES

Psychotherapy research has often been considered a neglected topic in clinical psychology, psychosomatic medicine, and psychiatry because of its massive organizational and financial demands. However, it is unclear whether this assumption actually reflects the research activities in the field.

METHODS

We conducted a bibliometric analysis of the annual volumes for 2008 and 2009 of three clinical journals published in German. All publications referring to facets of psychotherapy research were analysed.

RESULTS

About 30% of the publications dealt with issues of psychotherapy research. Outcome and process studies were about equally distributed. Process research frequently focused on patient variables as outcome predictors. Outcome studies most often presented effectiveness studies with rather small sample sizes.

CONCLUSION

Psychotherapy research is a well-represented and multifaceted field in the German speaking research community. However, the traditional distinction between efficacy and process research among the various schools of psychotherapy research may be hampering further developments in this branch. The government-funded research networks may turn out to be promising approaches to overcoming some of the obstacles of classic psychotherapy research.

Finding the common core: evidence-based practices, clinically relevant evidence, and core mechanisms of change

Improving the quality of children's mental health care can benefit from the adoption of evidence based and evidence informed treatments. However, the promise of moving science into practice is hampered by three core elements that need to be addressed in the current conversation among key stakeholders: (1) expanding our understanding of the clinical relevance of different types of evidence, (2) emphasizing the identification of core mechanisms of change, and (3) re-conceptualizing what evidence-based practice means. This paper focuses on these elements in an attempt to find a common core among stakeholders that may create opportunities for more inclusive conversation to move the field of children's mental health care forward.

Evidence-based practices in addiction treatment: review and recommendations for public policy

The movement in recent years towards evidence-based practice (EBP) in health care systems and policy has permeated the substance abuse treatment system, leading to a growing number of federal and statewide initiatives to mandate EBP implementation. Nevertheless, due to a lack of consensus in the addiction field regarding procedures or criteria to identify EBPs, the optimal processes for disseminating empirically based interventions into real-world clinical settings have not been identified. Although working lists of interventions considered to be evidence-based have been developed by a number of constituencies advocating EBP dissemination in addiction treatment settings, the use of EBP lists to form policy-driven mandates has been controversial. This article examines the concept of EBP, critically reviews criteria used to evaluate the evidence basis of interventions, and highlights the manner in which such criteria have been applied in the addictions field. Controversies regarding EBP implementation policies and practices in addiction treatment are described, and suggestions are made to shift the focus of dissemination efforts from manualized psychosocial interventions to specific skill sets that are broadly applicable and easily learned by clinicians. Organizational and workforce barriers to EBP implementation are delineated, with corresponding recommendations to facilitate successful dissemination of evidence-based skills.

Toward a technology of treatment individualization for young children with autism spectrum disorders

Although the etiology of autism spectrum disorders (ASD) and early development of the ASD are not yet well understood, recent research in the field of autism has heavily emphasized the importance of early intervention (i.e. treatment before the age of 4 years). Currently, several methods have been demonstrated to be efficacious with some children however no treatment completely ameliorates the symptoms of ASD or works for all children with the disorder. The heterogeneity and developmental nature of the disorder make it unlikely that one specific treatment will be best for all children, or will work for any one child throughout his or her educational career. Thus, this paper examines early research validating different technologies for individualizing treatment. A discussion of current research on pre-treatment characteristics associated with differential outcomes in treatment, including child, family, and practitioner variables; and how specific intervention techniques address each of those pre-treatment characteristics is provided. The ultimate goal of this line of research is to enable practitioners to prospectively tailor treatments to specific children and increase the overall rate of positives outcomes for children with autism. Research that furthers understanding of how to match clients with efficacious treatments will decrease the outcome variability that characterizes early intervention research at present, and provide for the most efficient allocation of resources during the critical early intervention time-period. This type of research is in its infancy, but is imperative if we are to determine a priori which treatment method will be most effective for a specific child.

Empirically supported treatments in psychotherapy: towards an evidence-based or evidence-biased psychology in clinical settings?

THE FIELD OF RESEARCH AND PRACTICE IN PSYCHOTHERAPY HAS BEEN DEEPLY INFLUENCED BY TWO DIFFERENT APPROACHES: the empirically supported treatments (ESTs) movement, linked with the evidence-based medicine (EBM) perspective and the "Common Factors" approach, typically connected with the "Dodo Bird Verdict". About the first perspective, since 1998 a list of ESTs has been established in mental health field. Criterions for "well-established" and "probably efficacious" treatments have arisen. The development of these kinds of paradigms was motivated by the emergence of a "managerial" approach and related systems for remuneration also for mental health providers and for insurance companies. In this article ESTs will be presented underlining also some possible criticisms. Finally complementary approaches, that could add different evidence in the psychotherapy research in comparison with traditional EBM approach, are presented.

Systematic reviews to support evidence-based psychiatry: what about schizophrenia?

OBJECTIVE

To assess whether systematic reviews (SRs), the gold standard for scientific research, can offer valuable support in evidence-based psychiatry in the treatment of schizophrenia.

METHODS

We used three database services (Ovid, PubMed and Cochrane) to identify SRs related to schizophrenia, found 163 reviews and grouped them by topic. We then evaluated each study's conclusions and divided them into three groups based on results (ranging from certain to null conclusions).

RESULTS

SRs of pharmacological treatments represented 59% of the studies sampled, only 23% of which had reached certain conclusions. Other clinical topics were less frequently represented and had achieved lower degrees of certainty.

CONCLUSIONS

Only 40 SRs (22 studies investigating pharmacological treatment) provided clear-cut answers to clinical questions examined. Results therefore showed that SRs provide a certain but rather limited contribution to scientific evidence in the field of schizophrenia.

The effectiveness of routinely delivered cognitive behavioural therapy for obsessive-compulsive disorder: a benchmarking study

OBJECTIVES

There is often difficulty in generalizing the results of randomized controlled trials (RCTs) to routine clinical practice given the rigid design features of such studies. The purpose of this study is to describe the effectiveness of routinely delivered, formulation-based cognitive behavioural therapy (CBT) within a publicly funded clinic for adults with obsessive-compulsive disorder (OCD) and offer a comparison against the outcomes achieved in efficacy studies for the same population.

METHOD

Practice-based prospective study. Routine data collected from a National Health Service out-patient clinic for adult clients with OCD is benchmarked against the findings of RCTs. The comparison RCTs were identified using a systematic review methodology.

RESULTS

The mean (95% confidence interval) change in Yale-Brown Obsessive Compulsive Scale score pre- to post-therapy in the Sheffield clinic was 10.2 (7.1 - 13.3), which compares well with changes of 11.4 (10.5 - 12.2) for exposure and response prevention trials, 12.9 (11.2 - 14.7) for cognitive therapy trials, and 10.6 (8.5 - 12.8) for CBT trials. The Sheffield results fell within the benchmarks derived from the included RCTs.

CONCLUSION

These results indicate that CBT for adults with OCD delivered outside the constraints of a clinical trial is equivalently effective but that this conclusion should be tested further on a larger group of patients.

Mind, brain and psychotherapy

There is long-standing debate about superiority of mind over brain, in other words about superiority of mind over matter. And outcome of this debate is going to decide future of psychiatry. The psychiatrists believing in materialism may say that brain is all and by changing neurotransmitters level with new molecules of drugs would cure all illnesses. On the other hand, antipsychiatry activists and some psychotherapists oppose all types of treatment despite of convincing evidence that drug therapy is effective (although sometimes it is not as effective as it claims to be). However, truth lies somewhere in between. Pharmacotherapy and psychotherapy are like two legs of psychiatry and psychiatry cannot walk into a future on one leg. The studies have shown that judicious use of pharmacotherapy along with psychotherapy gives better outcome than any one of them used alone. We must heal dichotomy between mind and brain before we heal the patients.

Balancing rigour and relevance in guideline development for depression: the case for comprehensive cohort studies

PURPOSE

Clinical guidelines for the treatment of depression have not yet realized their potential for improving the delivery of the psychological therapies within national healthcare systems. Current guidelines emphasize treatment efficacy and issues in service delivery are relatively neglected. Hence, there is a hierarchy of evidence in which randomized efficacy trials are given primacy over naturalistic (i.e. practice-based) data. Such a strategy is inadequate to address important questions about best delivery of safe and acceptable psychological therapies and exacerbates divisions between research and practice communities.

METHODS

Selected narrative review.

RESULTS

Both randomized controlled trials and practice-based studies have shortcomings that can be ameliorated by the adoption of practical clinical trials embedded within large cohort studies - that is, comprehensive cohort studies.

CONCLUSIONS

Comprehensive cohort studies have the potential to deliver an evidence base which is both rigorous and relevant. This could satisfy the scientific community as well as allowing practitioners and service users to be fully involved and committed to the process of collecting evidence and implementing guidance. We argue this would be a sound foundation upon which to build an evidence base upon which to develop future clinical guidelines for depression.

Enhancing treatment fidelity in psychotherapy research: novel approach to measure the components of cognitive behavioural therapy for relapse prevention in first-episode psychosis

OBJECTIVES

Establishing treatment fidelity is one of the most important aspects of psychotherapy research. Treatment fidelity refers to the methodological strategies used to examine and enhance the reliability and validity of psychotherapy. This study sought to develop and evaluate a measure specifically designed to assess fidelity to the different therapeutic components (i.e. therapy phases) of the individual intervention of a psychotherapy clinical trial (the EPISODE II trial).

METHOD

A representative sample of sessions stratified by therapy phase was assessed using a specifically developed fidelity measure (Relapse Prevention Therapy-Fidelity Scale, RPT-FS). Each RPT-FS subscale was designed to include a different component/phase of therapy and its major therapeutic ingredients.

RESULTS

The measure was found to be reliable and had good internal consistency. The RPT-FS discriminated, almost perfectly, between therapy phases. The analysis of the therapeutic strategies implemented during the intervention indicated that treatment fidelity was good throughout therapy phases. While therapists primarily engaged in interventions from the appropriate therapeutic phase, flexibility in therapy was evident.

CONCLUSIONS

This study described the development of a brief, reliable and internally consistent measure to determine both treatment fidelity and the therapy components implemented throughout the intervention. This methodology can be potentially useful to determine those components related to therapeutic change.

Significância clínica e mudança confiável na avaliação de intervenções psicológicas

As evidências da efetividade de qualquer intervenção psicológica baseiam-se na demonstração de sua validade interna e externa, usualmente efetuadas por meio de estatística inferencial. Uma alternativa mais recentemente explorada, especialmente no âmbito da pesquisa em psicoterapia, é a demonstração da confiabilidade e significância clínica das mudanças. Dentre os métodos utilizados na produção desses indicadores, destaca-se o desenvolvido por Jacobson e Truax (1991), mais conhecido como "Método JT", ainda com limitada divulgação em nosso meio. Este estudo apresenta, resumidamente, a racional desse método e algumas questões metodológicas e práticas pertinentes ao uso desse método, exemplificando sua aplicabilidade no tratamento de dados de uma intervenção fictícia.

Developing guided self-help for depression using the Medical Research Council complex interventions framework: a description of the modelling phase and results of an exploratory randomised controlled trial

BACKGROUND

Current guidelines for the management of depression suggest the use of guided self-help for patients with mild to moderate disorders. However, there is little consensus concerning the optimal form and delivery of this intervention. To develop acceptable and effective interventions, a phased process has been proposed, using a modelling phase to examine and develop an intervention prior to preliminary testing in an exploratory trial. This paper (a) describes the modelling phase used to develop a guided self-help intervention for depression in primary care and (b) reports data from an exploratory randomised trial of the intervention.

METHODS

A guided self-help intervention was developed following a modelling phase which involved a systematic review, meta synthesis and a consensus process. The intervention was then tested in an exploratory randomised controlled trial by examining (a) fidelity using analysis of taped guided self-help sessions (b) acceptability to patients and professionals through qualitative interviews (c) effectiveness through estimation of the intervention effect size.

RESULTS

Fifty eight patients were recruited to the exploratory trial. Seven professionals and nine patients were interviewed, and 22 tapes of sessions analysed for fidelity. Generally, fidelity to the intervention protocol was high, and the professionals delivered the majority of the specific components (with the exception of the use of feedback). Acceptability to both professionals and patients was also high. The effect size of the intervention on outcomes was small, and in line with previous analyses showing the modest effect of guided self-help in primary care. However, the sample size was small and confidence intervals around the effectiveness estimate were wide.

CONCLUSION

The general principles of the modelling phase adopted in this study are designed to draw on a range of evidence, potentially providing an intervention that is evidence-based, patient-centred and acceptable to professionals. However, the pilot outcome data did not suggest that the intervention developed was particularly effective. The advantages and disadvantages of the general methods used in the modelling phase are discussed, and possible reasons for the failure to demonstrate a larger effect in this particular case are outlined.

Enhancing the Cultural Relevance of Empirically-Supported Mental Health Interventions

Evidence-based practice (EBP) has become a hot topic in clinical social work and other mental health disciplines. Mental health professionals have called attention to the need for clinical decision-making to be based on the best available empirically supported treatments integrated with client preferences, values, and circumstances. This movement has greatly stimulated mental health professionals to develop, test, and adopt efficacious treatments for clients with psychological problems, but what is missing in the literature is the cultural context in which these treatments must be implemented to be effective with racial/ethnic minority populations. Herein, we utilize the culturally centered framework of Bernal, Bonilla and Bellido (1995) to examine its utility in assessing to what extent empirically supported mental health treatments incorporate culturally relevant components.

The effectiveness of psychodynamic-interpersonal therapy (PIT) in routine clinical practice: a benchmarking comparison

AIMS

To investigate the effectiveness of psychodynamic-interpersonal therapy (PIT) in a routine clinical practice setting.

METHODS

Full pre-post data were available on 62 out of a total of 67 patients aged between 19 and 60 years. Patients were seen over a 52-month period (2001-2005) receiving a course of PIT therapy (mean number of sessions = 16.9, median number of sessions = 16). The outcomes were assessed using a range of outcome measures: the 32-item version of the Inventory of Interpersonal Problems (IIP-32), the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and the Beck Depression Inventory - Second Edition (BDI-II). Study data were benchmarked against comparative national and local data.

RESULTS

There were significant pre-post reductions on all measures: IIP-32 effect size (ES) = 0.56; CORE-OM ES = 0.76; BDI-II ES = 0.76. Reliable and clinically significant change was achieved by 34% of clients on the BDI-II and by 40% of clients on the CORE-OM. Clients with high pre-therapy levels of interpersonal problems had poorer outcomes.

CONCLUSION

Benchmarking our results against both national and local comparative data showed that our results were less favourable than those obtained where PIT had been used in efficacy trials, but were comparable with reports of other therapies (including cognitive behavioural therapy (CBT)) in routine practice settings. The results show that PIT can yield acceptable clinical outcomes, comparable to CBT in a routine care setting, within the context of current limitations of the practice-based evidence paradigm.