The Contribution of Therapist Effects to Patient Dropout and Deterioration in the Psychological Therapies

Disentangling the Therapist Effect: Clustering Therapists by Using Different Treatment Outcomes

Previous studies have shown that therapists' performance varies, known as therapist effects, and have indicated that therapists who excel in one treatment outcome may not necessarily be effective in other outcomes. This observational naturalistic study aimed to enhance our understanding of therapist effects and the assessment of therapists' performance in different areas. The study included 68 therapists and 5,582 clients from a large mental health facility. Information about their learning activities was available for a subsample of 49 therapists. Separate multilevel analyses were conducted for treatment outcomes, including case mix-corrected OQ-45 change scores, dropout rates, referrals to other facilities, treatment duration, and client satisfaction ratings. A hierarchical cluster analysis was performed to identify groups of therapists based on their performance across various treatment outcomes. Additionally, differences in therapist characteristics among the clusters identified were examined. Therapist effects varied across different outcomes, ranging from small (2.6% for OQ-45 change) to moderate (6.5% for number of sessions). The cluster analysis revealed four distinct clusters of therapists with specific profiles. They had performance differences in certain areas but not in others. This exploratory study supports the notion that therapists exhibit diverse profiles regarding treatment outcomes. These findings are significant for future investigations of therapist effects that aim to identify the characteristics of effective therapists and in the context of personalizing treatment for clients.

Love yourself as a therapist, doubt yourself as an institution? Therapist and institution effects on outcome, treatment length, and dropout

OBJECTIVE

Research suggests that some therapists achieve better outcomes than others. However, an overlooked area of study is how institution differences impact patient outcomes independent of therapist variance. This study aimed to examine the role of institution and therapist differences in adult outpatient psychotherapy.

METHOD

The study included 1428 patients who were treated by 196 therapists at 10 clinics. Two- and three-level hierarchical linear regression models were employed to investigate the effects of therapists and institutions on three dependent patient variables: (1) symptom change, (2) treatment duration, and (3) dropout. Level three explanatory variables were tested.

RESULTS

The results showed that therapist effects (TE) were significant for all three types of treatment outcome (7.8%-18.2%). When a third level (institution) was added to the model, the differences between therapists decreased, and significant institution effects (IE) were found: 6.3% for symptom change, 10.6% for treatment duration, and 6.5% for dropout. The exploratory analyses found no predictors able to explain the systematic variation at the institution level.

DISCUSSION

TE on psychotherapy outcomes remain a relevant factor but may have been overestimated in previous studies due to not properly distinguishing them from differences at the institution level.

Is there a prospective association between psychological distress as measured by the CORE-OM and treatment attendance and treatment duration? A follow-up study at a Norwegian Community Mental Health Centre

BACKGROUND

Feasible and reliable methods for identifying factors associated with treatment duration and treatment attendance in mental health services are needed. This study examined to what degree the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the start of treatment is associated with treatment attendance and treatment duration.

METHODS

Outpatients (N = 124) at a community mental health centre in Norway completed the 34-item CORE-OM questionnaire addressing the domains of subjective well-being, problems and symptoms, functioning and risk at the start of treatment. The CORE-OM subscales and the 'all' items total scale were used as predictor variables in regression models, with treatment duration, number of consultations attended, treatment attendance (number of therapy sessions attended divided by number of sessions offered) and termination of treatment (planned versus unplanned) as outcome variables.

RESULTS

Higher CORE-OM subscale scores and the 'all' scale were associated with longer treatment duration. No association was found between CORE-OM scales and number of therapy sessions, treatment attendance (sessions attended/offered) or whether the patients unexpectedly ended treatment.

CONCLUSION

Higher patient-reported psychological distress as measured by the CORE-OM at the start of treatment was prospectively associated with treatment duration but not with treatment attendance or drop-out of treatment. The findings imply that patients with higher initial psychological distress need longer treatment but that treatment attendance may be related to factors other than the severity of distress.

Scaling up the task-sharing of psychological therapies: A formative study of the PEERS smartphone application for supervision and quality assurance in rural India

Measurement-based peer supervision is one strategy to assure the quality of psychological treatments delivered by non-mental health specialist providers. In this formative study, we aimed to 1) describe the development and 2) examine the acceptability and feasibility of PEERS (Promoting Effective mental healthcare through peER Supervision)-a novel smartphone app that aims to facilitate registering and scheduling patients, collecting patient outcomes, rating therapy quality and assessing supervision quality-among frontline treatment providers delivering behavioral activation treatment for depression. The PEERS prototype was developed and tested in 2021, and version 1 was launched in 2022. To date, 215 treatment providers (98% female; ages 30-35) in Madhya Pradesh and Goa, India, have been trained to use PEERS and 65.58% have completed the supplemental, virtual PEERS course. Focus group discussions with 98 providers were examined according to four themes-training and education, app effectiveness, user experience and adherence and data privacy and safety. This yielded commonly endorsed facilitators (e.g., collaborative learning through group supervision, the convenience of consolidated patient data), barriers (e.g., difficulties with new technologies) and suggested changes (e.g., esthetic improvements, suicide risk assessment prompt). The PEERS app has the potential to scale measurement-based peer supervision to facilitate quality assurance of psychological treatments across contexts.

First impressions matter: The influence of initial assessments on psychological treatment initiation and subsequent dropout

OBJECTIVE

This study investigated if patients' experience of an initial assessment may be associated with outcome expectations, and with subsequent treatment attendance.

METHOD

The sample comprised n = 6051 patients with depression/anxiety disorders, nested within k = 148 assessing therapists. Multilevel modelling (MLM) was used to examine therapist effects on treatment initiation and subsequent dropout, adjusting for patient-level characteristics. We tested associations between early outcome expectancy measured at an initial assessment with attendance at a first therapy session, and with dropout after initiation. Variability in mean expectancy ratings in the caseloads of assessing therapists was examined using the intracluster correlation coefficient (ICC).

RESULTS

Therapist effects partly explained the variance in treatment initiation and dropout. Pre-treatment outcome expectations significantly predicted treatment initiation but not dropout for the subgroup of patients who started treatment. Approximately 16% of variability in mean expectancy ratings was explained by therapist effects (ICC = 0.159) after controlling for patient-level covariates.

CONCLUSIONS

Patients assessed by some therapists are more likely to have higher outcome expectations, which influences their decision to initiate treatment thereafter. Once patients start therapy, early expectancy measured at assessment no longer influences their attendance, but the "first impression" from an initial assessment does influence their subsequent likelihood of dropout.

Therapeutic frameworks in integration sessions in substance-assisted psychotherapy: A systematised review

Serotonergic psychedelics and related substances have been explored as potential adjuncts in substance-assisted psychotherapy (SAPT) for treating various disorders. SAPT can be divided into three phases: preparation, administration and integration. Integration is commonly defined as the comprehension and effective application of insights from psychedelic experiences into everyday life. However, there is limited research regarding the most appropriate therapeutic approach during SAPT. In this article, we discuss the current evidence for different therapeutic frameworks for integration sessions when serotonergic psychedelics and entactogens are used as adjuncts to psychotherapy. We conducted a systematised review of the literature following PRISMA guidelines and searched PsycINFO, MEDLINE and Cochrane Library databases. The final synthesis included 75 clinical trials, mixed-methods investigations, treatment manuals, study protocols, quasi-experiments, qualitative investigations, descriptive studies, opinion papers, reviews, books and book chapters, published until 11 November 2022. The effects that various therapeutic approaches for integration sessions have on therapeutic outcomes have not been investigated by means of rigorous research. Most of the available evidence we retrieved was not supported by empirical data, thus limiting any conclusive statements regarding appropriate therapeutic frameworks for integration sessions for SAPT. Current clinical studies have used a range of therapeutic frameworks with the majority drawing from the humanistic-experiential tradition. While integration is regarded as crucial for the safe application of SAPT, there is currently an insufficient evidence base to suggest that any type of therapy is effective for guiding integration sessions. A systematic investigation of different therapeutic frameworks for integration and additional therapy-related factors is needed.

Client predictors of therapy dropout in a primary care setting: a prospective cohort study

BACKGROUND

Therapy dropout poses a major challenge. Considerable research has been conducted on predictors of dropout, however none in the context of primary mental health services in Norway. The purpose of this study was to investigate which client characteristics can predict dropout from the service Prompt Mental Health Care (PMHC).

METHODS

We performed a secondary analysis of a Randomized Controlled Trial (RCT). Our sample consisted of 526 adult participants receiving PMHC-treatment in the municipalities of Sandnes and Kristiansand, between November 2015 to August 2017. Using logistic regression, we investigated the association between nine client characteristics and dropout.

RESULTS

The dropout rate was 25.3%. The adjusted analysis indicated that older clients had a lower odds ratio (OR) of dropping out compared to younger clients (OR = 0.43, [95% CI = 0.26, 0.71]). Moreover, clients with higher education had a lower odds ratio of dropping out compared to clients with lower levels of education (OR = 00.55, 95% CI [0.34, 0.88]), while clients who were unemployed were more likely to drop-out as compared the regularly employed (OR = 2.30, [95% CI = 1.18, 4.48]). Finally, clients experiencing poor social support had a higher odds ratio of dropping out compared to clients who reported good social support (OR = 1.81, [95% CI = 1.14, 2.87]). Sex, immigrant background, daily functioning, symptom severity and duration of problems did not predict dropout.

CONCLUSION

The predictors found in this prospective study might help PMHC-therapists identify clients at risk of dropout. Strategies for preventing dropout are discussed.

Fostering practice-based evidence through routine outcome monitoring in a university psychotherapy service for common mental health problems: a protocol for a naturalistic, observational study

INTRODUCTION

Data-informed psychotherapy and routine outcome monitoring are growing as referents in psychotherapy research and practice. In Ecuador, standardised web-based routine outcome monitoring systems have not been used yet, precluding data-driven clinical decisions and service management. Hence, this project aims at fostering and disseminating practice-based evidence in psychotherapy in Ecuador by implementing a web-based routine outcome monitoring system in a university psychotherapy service.

METHODS AND ANALYSES

This is a protocol for an observational naturalistic longitudinal study. Progress and outcomes of treatment in the Centro de Psicología Aplicada of the Universidad de Las Américas in Quito, Ecuador will be examined. Participants will be adolescents and adults (≥11 years) seeking treatment, as well as therapists and trainees working at the centre between October 2022 and September 2025. Clients' progress will be monitored by a range of key variables: psychological distress, ambivalence to change, family functioning, therapeutic alliance and life satisfaction. Sociodemographic information and satisfaction with treatment data will be collected before and at the end of treatment, respectively. Also, semi-structured interviews to explore therapists' and trainees' perceptions, expectations and experiences will be conducted. We will analyse first contact data, psychometrics of the measures, reliable and clinically significant change, outcome predictors as well as trajectories of changes. Moreover, we will conduct a framework analysis for the interviews.

ETHICS AND DISSEMINATION

The protocol for this study was approved by the Human Research Ethics Committee of the Pontificia Universidad Católica del Ecuador (#PV-10-2022). The results will be disseminated in peer-reviewed scientific articles, at conferences and in workshops.

TRIAL REGISTRATION NUMBER

NCT05343741.

Telephone treatments in Improving Access to Psychological Therapies services: an analysis of use and impact on treatment uptake

BACKGROUND

There is debate about how best to increase access to psychological therapy and deliver mental healthcare effectively and efficiently at a national level. One trend is the increased use of the telephone to deliver therapy. However, there is the potential to disadvantage certain patient groups and/or impact on uptake of help. This study aims to answer three questions: (i) Which factors are associated with being offered an assessment by telephone? (ii) Which factors are associated with attendance at assessment? and (iii) What is the impact of an assessment by telephone on subsequent treatment appointment?

METHODS

Routine outcome data was provided by seven UK Improving Access to Psychological Therapy services. The analysis sample comprised 49,923 patients who referred to 615 general practices in 2017. Multilevel modelling, including service and GP practice as random factors, was used to answer the three research questions.

RESULTS

The offer of an initial assessment by telephone was strongly associated with local service configuration. Patient self-referral, a shorter wait, greater age and lower deprivation were associated with attendance at assessment and subsequent treatment session. Telephone mode assessment had no impact on the uptake of the assessment but may influence the uptake of further treatment if this was also by telephone. The practitioner carrying out the assessment had a significant effect on subsequent treatment uptake.

CONCLUSION

Offering telephone assessments does not have a negative impact on uptake of assessment and services may benefit by facilitating and integrating telephone assessments into their systems. The COVID-19 pandemic has accelerated the use of telephone and other remote means of delivery, and results from this study can inform services to consider how best to re-configure post-pandemic.

Reconstructing dropout: Building from multiple definitions, therapist effects, and center effects

Objective: The literature regarding dropout from psychotherapy has suffered from issues of diverse operationalization of the construct. Some have called for a more uniform definition to aid in generalization across research; this study aimed to assess the viability of such a definition by examining the rate of occurrence for three distinct definitions simultaneously. In addition, therapist and center level variances are explored to further understand the differences between definitions.

Method: We compared the prevalence rates and overlap of three distinct operationalizations of dropout (based on last session attendance, therapist judgment, and symptom change) using data gathered from a national practice research network (N = 2977). Higher-order therapist and center-level effects were assessed for each definition.

Results: There was very little overlap among definitions, with less than one percent of clients simultaneously meeting criteria for all three definitions. Additionally, therapist and center effects were found for each definition, especially notable for therapist-rated and last-session attendance definitions of dropout.

Conclusion: Rather than a singular definition of dropout, these results instead suggest that multiple, specific, and unique definitions more accurately depict clinical reality, and future research might benefit from uncovering predictors of different "classes" of dropouts and examining the different practices of therapists and centers.

Therapist Interpersonal Behavior: An Investigation of Various Constructs and Underlying Abilities

<b><i>Objective:</i></b> Psychotherapists differ in their treatment effectiveness as measured by the therapy outcome of their patients. One possible factor for therapist effects seems to be the therapists’ interpersonal skills. Therapist assessments of interpersonal skills have demonstrated sufficient predictive validity, but little is known about underlying skills and related constructs. The purpose of the present study is to compare the different constructs of interpersonal skills with each other and to investigate possible underlying abilities. <b><i>Study Population and Methods:</i></b> In this exploratory study, the concept of interpersonal skills was investigated using three survey methods (questionnaires, computer tests, and assessments) and comparing two measurements each. For this purpose, 6 measures of interpersonal skills were collected from 20 prospective psychotherapists as well as 28 psychology students (total <i>N</i> = 48). Alongside more traditional methods, the correlations and overlaps of the constructs were examined using partial and Bayesian networks. <b><i>Results:</i></b> Moderate to high correlations are found within the self-report measures. The assessments, however, did not correlate with self-report measures nor with computer tests. <b><i>Discussion and Conclusion:</i></b> The similarities in the self-assessments indicate stable self-concepts of interpersonal skills, which, however, cannot be explained by the underlying skills nor by the observer-based evaluations. The marginal correlation between the assessments also indicates that interpersonal, therapy-related abilities must be interpreted in a situation-specific manner.

Associations between therapist factors and treatment efficacy in randomized controlled trials of trauma-focused cognitive behavioral therapy for children and youth: A systematic review and meta-analysis

Previous research suggests that the effect of therapist factors on patient outcomes is significant. Yet, to date, no reviews have explored the potential effects of therapist characteristics on treatment outcomes for children and youth with posttraumatic stress disorder (PTSD). This systematic review and meta-analysis aimed to summarize the professional characteristics of trial therapists delivering trauma-focused cognitive behavioral interventions (TF-CBT) for child PTSD in clinical trials and understand the association between treatment efficacy and therapist factors. Systematic searches for randomized controlled trials (RCTs) published through November 3, 2020, were conducted; 40 RCTs were included in the full review. PTSD treatment outcome data were extracted from each publication along with any available data regarding trial therapists. Subgroup analyses were conducted to compare the outcomes of interventions conducted by different types of therapists. All therapist groups yielded significant effects for TF-CBT relative to active and passive control conditions, with the largest effect size, Hedges' g = -1.11, for RCTs that used clinical psychologists and psychiatrists. A significant moderating effect was found when comparing the treatment outcomes of clinical psychologists and psychiatrists versus other professionals, p = .044; however, this effect was no longer apparent when only studies with an active control arm were included. Further moderator analyses demonstrated no significant differences regarding therapists' educational and professional backgrounds and PTSD treatment outcomes. The current RCT evidence for TF-CBT for children and youth with PTSD does not suggest that therapist educational or professional background influences treatment efficacy. Limitations and implications for future research are discussed.

Fairburn C. EMPOWER: Toward the Global Dissemination of Psychosocial Interventions

Even before the COVID-19 pandemic, the needs for care of persons with mental illness remained largely unmet worldwide, testifying to the inadequacy of current approaches to mental health care and their unsuitability for the rising demand. One hurdle to improved access to quality care is the reliance on expensive specialist providers, particularly for the delivery of psychosocial interventions. This article describes EMPOWER, a not-for-profit program that builds on the clinical science demonstrating the effectiveness of brief psychosocial interventions for a range of psychiatric conditions; implementation science demonstrating the effectiveness of delivery of these interventions by non-specialist providers (NSPs); and pedagogical science demonstrating the effectiveness of digital approaches for training and quality assurance. The EMPOWER program leverages digital tools for training and supervising NSPs, designing competency-based curricula, assessing treatment-specific competencies, implementing measurement-based peer supervision for support and quality assurance, and evaluating impacts to enhance the effectiveness of the delivery system.

Rapid transition from in-person to videoconferencing psychotherapy in a counselor training clinic: A safety and feasibility study during the COVID-19 pandemic

Due to the COVID-19 pandemic, many counselor training clinics rapidly transitioned in-person (IP) services to videoconferencing psychotherapy (VCP). Because VCP is a relatively new technology, more research is needed to establish whether this delivery format is a safe and acceptable substitute for IP services in counselor training clinics. The purpose of this study is to explore questions related to how clients perceive VCP versus IP in terms of credibility and expectancy. Results from this investigation demonstrate that clients who participate in VCP, without first meeting their counselor in person, may initially question the credibility and effectiveness of VCP. However, results demonstrated improvement, in both groups, across the duration of therapy. These findings provide both initial support for the safety of VCP in counselor training clinics and justification for further research.

Automated evaluation of psychotherapy skills using speech and language technologies

With the growing prevalence of psychological interventions, it is vital to have measures which rate the effectiveness of psychological care to assist in training, supervision, and quality assurance of services. Traditionally, quality assessment is addressed by human raters who evaluate recorded sessions along specific dimensions, often codified through constructs relevant to the approach and domain. This is, however, a cost-prohibitive and time-consuming method that leads to poor feasibility and limited use in real-world settings. To facilitate this process, we have developed an automated competency rating tool able to process the raw recorded audio of a session, analyzing who spoke when, what they said, and how the health professional used language to provide therapy. Focusing on a use case of a specific type of psychotherapy called "motivational interviewing", our system gives comprehensive feedback to the therapist, including information about the dynamics of the session (e.g., therapist's vs. client's talking time), low-level psychological language descriptors (e.g., type of questions asked), as well as other high-level behavioral constructs (e.g., the extent to which the therapist understands the clients' perspective). We describe our platform and its performance using a dataset of more than 5000 recordings drawn from its deployment in a real-world clinical setting used to assist training of new therapists. Widespread use of automated psychotherapy rating tools may augment experts' capabilities by providing an avenue for more effective training and skill improvement, eventually leading to more positive clinical outcomes.

Investigation of Therapist Effects on Patient Engagement in Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.

Therapist Interventions and Skills as Predictors of Dropout in Outpatient Psychotherapy

The current study employed machine learning to investigate whether the inclusion of observer-rated therapist interventions and skills in early sessions of psychotherapy improved dropout prediction beyond intake assessments. Patients were treated by postgraduate clinicians at a university outpatient clinic. Psychometric instruments were assessed at intake and therapeutic interventions and skills in the third session were routinely rated by independent observers. After variable preselection, an elastic net algorithm was used to build two dropout prediction models, one including and one excluding observer-rated session variables. The best model included observer-rated variables and was significantly superior to the model including intake variables only. Alongside intake variables, two observer-rated variables significantly predicted dropout: therapist use of feedback and summaries and treatment difficulty. Although not retained in the final prediction model, the observer-rated use of cognitive techniques was also significantly correlated with dropout. Observer ratings of therapist interventions and skills in early sessions of psychotherapy improve predictors of dropout from psychotherapy beyond intake variables alone. Future research could work toward personalizing dropout predictions to the specific dyad, thereby improving their validity and aiding therapists to recognize and react to increased dropout risk.

No self-serving bias in therapists' evaluations of clients' premature treatment termination: An approximate replication of Murdock et al. (2010)

In an often‐cited study, Murdock et al. (2010) found that therapists are more likely to attribute premature treatment termination to client characteristics than to themselves, a finding that the authors interpreted in terms of a self‐serving bias (SSB). We replicated and extended the study of Murdock et al. (2010, study 2). Psychologists and psychotherapists (N = 91) read two case vignettes about premature treatment terminations of clients that, in a between‐subjects set‐up, were either described as own clients or other therapists' clients. Next, participants used three attribution subscales (blaming therapist, client and situation) to evaluate potential causes for the premature terminations. This way, we tested whether participants would manifest SSB. We also investigated whether therapists' scores on self‐confidence and need for closure were linked to SSB tendencies. Unlike Murdock et al. (2010), we found no overall SSB. However, a stronger need for closure was related to more SSB tendencies (i.e., less endorsement of ‘blame therapist’ attributions) in the own‐client condition (r = −.35, p < .05, r² = .12), but not in the other‐therapist's‐client condition (r = .17, p = .27). Our results suggest that SSB is not a ubiquitous phenomenon when therapists evaluate premature termination problems and that their willingness to attend to their own role depends to some extent on their need for closure.

Blending Cognitive Analytic Therapy With a Digital Support Tool: Mixed Methods Study Involving a User-Centered Design of a Prototype App

BACKGROUND

Patients can struggle to make good use of psychotherapy owing to deficits in awareness, and digital technologies that support awareness are at a premium. Currently, when patients participate in cognitive analytic therapy (CAT), the technology supporting relational awareness work involves completion of paper-based worksheets as between-session tasks.

OBJECTIVE

We aimed to design, with therapists and patients, a prototype digital mobile app. This was to help patients better engage in the "recognition" phase of the CAT treatment model by providing an unobtrusive means for practicing relational awareness with dynamic feedback on progress.

METHODS

A national online survey was conducted with CAT therapists (n=50) to determine readiness for adoption of a mobile app in clinical practice and to identify core content, functionality, and potential barriers to adoption. A prototype mobile app based on data and existing paper-based worksheets was built. Initial face-to-face user testing of the prototype system was completed with three therapists and three CAT expatients.

RESULTS

Among the therapists surveyed, 72% (36/50) reported not currently using any digital tools during CAT. However, the potential value of a mobile app to support patient awareness was widely endorsed. Areas of therapist concern were data security, data governance, and equality of access. These concerns were mirrored during subsequent user testing by CAT therapists. Expatients generated additional user specifications on the design, functionality, and usability of the app. Results from both streams were integrated to produce five key changes for the reiteration of the app.

CONCLUSIONS

The user-centered design process has enabled a prototype CAT-App to be developed to enhance the relational awareness work of CAT. This means that patients can now practice relational awareness in a much more unobtrusive manner and with ongoing dynamic feedback of progress. Testing the acceptability and feasibility of this technological innovation in clinical practice is the next stage in the research process, which has since been conducted and has been submitted. The important challenges of data protection and governance must be navigated in order to ensure implementation and adoption if the CAT-App is found to be acceptable and clinically effective.

Therapist effects on dropout in couple therapy

Marriage and family therapy scholars have argued that therapists play a crucial role in successful couple therapy, yet little research has empirically documented that the therapist in couple therapy has a significant impact on outcomes. Known as the study of therapist effects, this study sought to assess the amount of variance attributed to the therapist in couple therapy outcomes. Using dropout as the outcome variable, this study analyzed data from 1,192 couples treated by 90 masters and doctoral student therapists at a university-based training clinic. Results from multilevel analysis indicated that therapists in the sample accounted for 9.4% of the variance in couple dropout while controlling for initial couple impairment. Therapist gender and therapist experience did not significantly predict variability in therapist effects. These findings give promise to future research on therapist effects in couple therapy and encourage exploration into which therapist characteristics and behaviors contribute to successful clinical outcome.

[Psychotherapy Trainees' Experience of Alliance-Focused Training as a Part of Psychotherapy Training - A Qualitative Analysis]

Interpersonal competencies of therapists in dealing with alliance ruptures is related to therapeutic success. Therefore, it is of particular importance to learn and to train these competencies. A method which was developed specially for this purpose is the Alliance-Focused Training (AFT). Seven psychotherapy trainees participated in the AFT. In semi-structured interviews pre- and post-AFT, they were asked about their expectations from and experiences with the training. The transcriptions of the interviews were analyzed using the Consensual Qualitative Research (CQR) method. Before the AFT, participants showed ambivalent attitudes and fears mainly towards self-revelation. After the training, they mainly described personal development and progress in learning to deal with alliance ruptures. Video recordings of therapy sessions, role plays and training of metacommunikation skills were experienced as being helpful and practice related. The results indicate that the AFT has a great potential for improving competencies of psychotherapists.

Improvement in Psychodynamic Psychotherapy for Depression: A Qualitative Study of the Patients' Perspective

The patient's perspective on improvement in psychotherapy is crucial for tailoring the therapy he or she is receiving. The present study aimed at exploring the factors aiding and the patients' experiences of improvement in time-limited psychodynamic psychotherapy for depression. Semi-structured, in-depth interviews were conducted with ten adult patients who received up to 28 sessions of manualized psychodynamic psychotherapy in the Norwegian study "Mechanisms of change in psychotherapy" (the MOP study). The post-therapy interviews addressed the participants' experiences from therapy. The data were analyzed with thematic content analysis and hermeneutic interpretation. The analysis identified four helpful dimensions: "Therapist activities" comprised supporting and acknowledging, advising and offering tips for everyday life, questioning and pressuring. "Patient activities" included opening up, caring for oneself and showing agency. "Facilitators" for improvement were learning from therapy, learning to receive therapy and agreed goals. "Achievements" comprised new perspectives and understandings, increased self-awareness and mastery and changed thinking and feeling. Improvements from psychodynamic therapy seemed reliant on the degree to which the therapy could activate and be relevant to the patients' everyday life. Tailoring therapy for patients with depression should link the focus on symptoms and ways of thinking and feeling with their life circumstances.

Therapist personality traits as predictors of psychological treatment outcomes

Aim: To investigate if therapists' personality influences their patients' treatment outcomes. Methods: N = 4,052 patients were treated by 69 therapists, including 36 Psychological Wellbeing Practitioners (PWPs) and 33 Cognitive Behavioural Therapists (CBTs). Therapists completed the NEO-PI-R personality inventory, they reported years of clinical experience, and expert assessors rated their clinical competence and reflective abilities. Their patients completed pre and post-treatment measures of depression (PHQ-9) and anxiety (GAD-7). Associations between therapist personality traits and patient treatment outcomes were examined using multilevel modelling, controlling for therapist demographics, clinical experience, technical competence and reflective ability. Results: Relative to other sources of variability, therapists accounted for 1% to 3% of overall variability in treatment outcomes. However, the magnitude of systematic heterogeneity in performance between therapists was around 6%, such that the best-performing therapists outperformed average therapists by a margin of moderate to large effects (g = .57-1.10). Clinical experience, technical competence and reflective ability were unrelated to treatment outcomes. Patients treated by PWPs with above-average agreeableness scores and CBTs with above-average openness to experience scores had poorer treatment outcomes. Conclusions: Therapist effects may be partly explained by the influence of their personality on their work with anxious and depressed patients.

Therapist beliefs about exposure therapy implementation

Exposure therapy is consistently indicated as the first-line treatment for anxiety-related disorders. Unfortunately, therapists often deliver exposure therapy in an overly cautious, less effective manner, characterized by using their own ‘therapist safety behaviours’. Cognitive behavioural models postulate that beliefs about therapist safety behaviours are related to their use; however, little is known about the beliefs therapists hold regarding therapist safety behaviour use. The present study aimed to identify the beliefs exposure therapists have regarding the necessity of therapist safety behaviours and to examine the relationship between this construct and therapist safety behaviour use. Australian psychologists (n = 98) completed an online survey that included existing measures of therapist safety behaviour use, therapist negative beliefs about exposure therapy, likelihood to exclude anxious clients from exposure therapy, and use of intensifying exposure techniques. Participants also completed the Exposure Implementation Beliefs Scale (EIBS), a measure created for the present study which assesses beliefs regarding the necessity of therapist safety behaviours. Beliefs about the necessity of therapist safety behaviours – particularly in protecting the client – significantly predicted therapist safety behaviour use. Findings suggest that exposure therapy training media should aim to decrease therapist safety behaviour use by addressing beliefs about the necessity of therapist safety behaviours, especially in protecting the client.

Key learning aims

(1)

Therapy discontinuation in a primary care psychological service: why patients drop out

The present study aimed to explore patients’ experience with an Improving Access to Psychological Therapies (IAPT) service, and to investigate the reasons for discontinuing their treatment. A qualitative approach was adopted using thematic analysis of semi-structured interviews carried out with 818 patients attending for treatment in Talking Change from November 2015 to January 2019, retrospectively. The five main themes that emerged from the study were: ‘Felt better’, ‘Issues with group settings’, ‘Therapeutic alliance breakdown’, ‘Miscommunication’ and ‘Impracticalities’. The qualitative study uncovered a wide range of reasons for people who had dropped out from their treatment. The findings mainly emphasised general dissatisfaction and inconvenient appointments. However, improvement in symptoms of depression and anxiety was also identified as a key factor among patients who discontinued their treatment. This recovery is known as ‘progress withdrawal’ in which patients withdraw from treatment early due to good therapeutic progress. We present clinical and procedural implications arising from these themes.

Key learning aims

(1)

Service- and practitioner-level variation in non-consensual dropout from child mental health services

Non-attendance of mental health service appointments is an international problem. In the UK, for example, the estimated cost of non-attendance in child mental health services is over £45 million (US dollar 60.94 million) per annum. The objective of this study was to examine whether there were service- and practitioner-level variation in non-consensual dropout in child mental health services. This was an analysis of routinely collected data. Service-level variation (as services covered different geographic areas) and practitioner-level variation were examined in N = 3622 children (mean age 12.70 years; SD 3.62, 57% female, 50% white or white British) seen by 896 practitioners across 39 services. Overall, 35% of the variation in non-consensual dropout was explained at the service level and 15% at the practitioner level. Children were almost four times more likely to drop out depending on which service they attended (median odds ratio = 3.92) and were two-and-a-half times more likely to drop out depending on which practitioner they saw (median odds ratio = 2.53). These levels of variation were not explained by levels of deprivation in areas covered by services or by children's demographic and case characteristics. The findings of the present research may suggest that, beyond service-level variation, there is also practitioner-level variation in non-consensual dropout in child mental health services.

Predicting Dropout from Inpatient Substance Use Disorder Treatment: A Prospective Validation Study of the OQ-Analyst

Background and Aims:

There is an urgent need for tools allowing therapists to identify patients at risk of dropout. The OQ-Analyst, an increasingly popular computer-based system, is used to track patient progress and predict dropout. However, we have been unable to find empirical documentation regarding the ability of OQ-Analyst to predict dropout. The aim of the present study was to perform the first direct test of the ability of the OQ-Analyst to predict dropout.

Design:

Patients were consecutively enlisted in a naturalistic, prospective, longitudinal clinical trial. As interventions based on feedback from the OQ-Analyst could alter the outcome and potentially render the prediction wrong, feedback was withheld from patients and therapists.

Setting:

The study was carried out during 2011–2013 in an inpatient substance use disorder clinic in Oslo, Norway.

Participants:

Patients aged 18 to 28 years who met criteria for a principal diagnosis of mental or behavioural disorder due to psychoactive substance use (ICD 10; F10.2–F19.2).

Measurements:

Red signal (predictions of high risk) from the Norwegian version of the OQ-Analyst were compared with dropouts identified using patient medical records as the standard for predictive accuracy.

Findings:

A total of 40 patients completed 647 OQ assessments resulting in 46 red signals. There were 27 observed dropouts, only one of which followed after a red signal. Patients indicated by the OQ-Analyst as being at high risk of dropping out were no more likely to do so than those indicated as being at low risk. Random intercept logistic regression predicting dropout from a red signal was statistically nonsignificant. Bayes factor supports no association.

Conclusions:

The study does not support the predictive ability of the OQ-Analyst for the present patient population. In the absence of empirical evidence of predictive ability, it may be better not to assume such ability.

The Relationship of MMPI-2-RF Scales to Treatment Engagement and Alliance

Clients' personality characteristics can be important correlates of treatment engagement and alliance. The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) is one of the most comprehensive and widely used personality measures in clinical settings and includes measures of symptom validity. A few prior studies using the MMPI-2 and MMPI-2-RF suggest that externalizing characteristics and the validity scales might be associated with treatment engagement, but no studies to date have examined MMPI correlates of treatment alliance. This study examined the relationship of MMPI-2-RF scales to treatment engagement and alliance in 134 individuals seeking outpatient treatment at a psychology department training clinic. It was predicted that validity scales and externalizing scales would be related to treatment engagement (premature termination, no-show rate) and to alliance. Contrary to expectations, MMPI-2-RF validity scales were not related to premature termination but high scores on F-r were related to higher no-show rates and high scores on Symptom Validity (FBS-r) were related to lower alliance. As predicted, higher scores on scales assessing externalizing psychopathology were related to premature termination and higher no-show rate. Exploratory analyses also suggested higher scores on somatic and interpersonal scales were related to lower alliance. Accuracy statistics using clinical cutoffs on MMPI scales are provided.

Modest, yet progressive: Effective therapists tend to rate therapeutic change less positively than their patients

Objective: Empirical findings on self-serving biases amongst psychotherapists are inconsistent. We tested in a large naturalistic data set, if therapists are prone to illusory superiority when estimating their patients' outcome and whether this effect is buffered by therapists' effectiveness. Method: A post-hoc analysis with N = 69 therapists, who treated N = 1080 patients, was conducted. Therapists' and patients' mean ratings for therapeutic improvement in the Clinical Global Impression Scale (CGI) were compared. Using a multilevel modelling approach, we further investigated the relation between the patient-therapist divergence in the CGI and actual therapeutic change in the Global Severity Index (GSI) of the Brief Symptom Inventory and in the Satisfaction With Life Scale (SWLS). Results: Ratings in the CGI did not show significant differences between patients' and therapists' assessment of therapeutic change. Lower estimations by therapists, compared to patients' self-report, were associated with greater therapeutic change in GSI and SWLS. Conclusions: Therapists, on a whole, did not seem to be prone to illusory superiority when assessing therapeutic outcome. Contrary, the more modest the therapists' estimation of therapeutic outcome was, the greater the actual therapeutic change.

Using network analysis for the prediction of treatment dropout in patients with mood and anxiety disorders: A methodological proof-of-concept study

There are large health, societal, and economic costs associated with attrition from psychological services. The recently emerged, innovative statistical tool of complex network analysis was used in the present proof-of-concept study to improve the prediction of attrition. Fifty-eight patients undergoing psychological treatment for mood or anxiety disorders were assessed using Ecological Momentary Assessments four times a day for two weeks before treatment (3,248 measurements). Multilevel vector autoregressive models were employed to compute dynamic symptom networks. Intake variables and network parameters (centrality measures) were used as predictors for dropout using machine-learning algorithms. Networks for patients differed significantly between completers and dropouts. Among intake variables, initial impairment and sex predicted dropout explaining 6% of the variance. The network analysis identified four additional predictors: Expected force of being excited, outstrength of experiencing social support, betweenness of feeling nervous, and instrength of being active. The final model with the two intake and four network variables explained 32% of variance in dropout and identified 47 out of 58 patients correctly. The findings indicate that patients’ dynamic network structures may improve the prediction of dropout. When implemented in routine care, such prediction models could identify patients at risk for attrition and inform personalized treatment recommendations.

A comparison between the clinical significance and growth mixture modelling early change methods at predicting negative outcomes

Objective: Routine outcome monitoring benefits treatment by identifying potential no change and deterioration. The present study compared two methods of identifying early change and their ability to predict negative outcomes on self-report symptom and wellbeing measures. Method: 1467 voluntary day patients participated in a 10-day group Cognitive Behaviour Therapy (CBT) program and completed the symptom and wellbeing measures daily. Early change, as defined by (a) the clinical significance method and (b) longitudinal modelling, was compared on each measure. Results: Early change, as defined by the simpler clinical significance method, was superior at predicting negative outcomes than longitudinal modelling. The longitudinal modelling method failed to detect a group of deteriorated patients, and agreement between the early change methods and the final unchanged outcome was higher for the clinical significance method. Conclusions: Therapists could use the clinical significance early change method during treatment to alert them of patients at risk for negative outcomes, which in turn could allow therapists to prevent those negative outcomes from occurring.

Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review

BACKGROUND

Despite growing attention to the general therapist effects in a wide range of clinical settings, little is known about the individual, cross-situational, and therapy-nonspecific variables that impact on the differential effectiveness of clinicians. The current study is a systematic review of the evidence relating to the influence of therapist's subjective characteristics on outcomes of psychodynamic psychotherapies.

METHOD

A multistage and systematic search of articles published between 1987 and 2017 identified 30 relevant studies, which were organized into 6 areas according to the specific therapist's variable considered.

RESULTS

Therapists' interpersonal functioning and skills showed the strongest evidence of a direct effect on treatment outcomes. Furthermore, there were preliminary evidence that therapists' attachment styles, their interpersonal history with caregivers, and their self-concept might affect outcomes through interaction effects with other constructs, such as technical interventions, patient's pathology, and therapeutic alliance. The high variability between studies on therapists' overall reflective or introspective abilities and personality characteristics suggested the need for more systematic research in these areas, whereas therapists' values and attitudes showed small effects on therapeutic outcome.

CONCLUSIONS

The present review clarifies how a deep examination of the contribution of therapists' subjective characteristics can help elucidate the complex association between relational and technical factors related to the outcome of psychodynamic treatments.

Evaluating the effectiveness and cost-effectiveness of British Sign Language Improving Access to Psychological Therapies: an exploratory study

Background

Improving Access to Psychological Therapies (IAPT) is a National Institute for Health and Care Excellence-approved approach to intervention for depression and/or anxiety. This exploratory study sets the groundwork for comparing psychological therapies for Deaf sign language users experiencing anxiety and/or depression, delivered in British Sign Language (BSL) by a Deaf therapist with usual access through an interpreter within the IAPT national programme.

Objectives

(1) To explore the following questions: (a) is BSL-IAPT more effective than standard IAPT for Deaf people with anxiety and/or depression? and (b) is any additional benefit from BSL-IAPT worth any additional cost to provide it? (2) To establish relevant BSL versions of assessment tools and methods to answer research questions (a) and (b). (3) To gauge the feasibility of a larger-scale definitive study and to inform its future design.

Design

A mixed-methods exploratory study combing an economic model to synthesise data from multiple sources; a qualitative study of understanding and acceptability of randomisation and trial terminology; statistical determination of clinical cut-off points of standardised assessments in BSL; secondary data analysis of anonymised IAPT client records; realist inquiry incorporating interviews with service providers and survey results.

Settings

IAPT service providers (NHS and private); the Deaf community.

Participants

Deaf people who use BSL and who are clients of IAPT services (n = 502); healthy Deaf volunteers (n = 104); IAPT service providers (NHS and private) (n = 118).

Interventions

IAPT at steps 2 and 3.

Main outcome measures

Reliable recovery and reliable improvement defined by IAPT; Deaf community views on the acceptability of randomisation; BSL terminology for trial-related language; clinical cut-off measurements for the BSL versions of the Patient Health Questionnaire-9 items (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7); a valid BSL version of the EuroQol-5 Dimensions five-level version (EQ-5D-5L); costs, quality-adjusted life-years and incremental cost-effectiveness ratios.

Data sources

IAPT service provider anonymised records of the characteristics and clinical outcomes of Deaf BSL users of BSL-IAPT and of standard IAPT; published literature.

Results

Randomisation may be acceptable to Deaf people who use IAPT if linguistic and cultural requirements are addressed. Specifications for effective information in BSL for recruitment have been established. A valid EQ-5D-5L in BSL has been produced. The clinical cut-off point for the GAD-7 BSL is 6 and for the PHQ-9 BSL is 8. No significant difference in rates of reliable recovery and reliable improvement between Deaf users of standard IAPT or BSL-IAPT has been found. Whether or not BSL-IAPT is more cost-effective than standard IAPT is uncertain.

Limitations

The small number of participating standard IAPT services who have seen Deaf clients means that there is statistical uncertainty in the comparable clinical outcome result. Clinical cut-off scores have not been verified through gold standard clinical interview methodology. Limited data availability means that whether or not BSL-IAPT is more cost-effective than standard IAPT is uncertain.

Conclusions

There is a lack of evidence to definitively compare reliable recovery and reliable improvement between Deaf users of standard IAPT and BSL-IAPT. Instrumentation and prerequisites for a larger-scale study have been established.

Future work

A prospective observational study for definitive results is justified.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.