Therapist effects and moderators of effectiveness and efficiency in psychological wellbeing practitioners: A multilevel modelling analysis

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.

Does clinical training improve mentalization skills in future therapists? A comparison of first and last year students of clinical psychology and of engineering

Objective

Mentalization has been suggested as a therapist skill that might be important for therapeutic success. The aim of this study was to explore whether the mentalization capacity of students of clinical psychology differs from other students, and whether last-year students differ from first-year students.

Method

A total of 297 students participated in this study, recruited from first and last years of psychology and engineering study programs. All participants filled out the MentS, a self-report measure of mentalization capacity.

Results

No significant differences were found in self-reported mentalization capacity between first and last year students of clinical psychology. The results did however show that first year students of psychology had significantly higher self-reported mentalization skills compared to students of engineering, and higher MentS-scores were associated with gender (female) and higher age.

Conclusion

The finding that students of clinical psychology rate themselves as having a higher capacity to mentalize compared to students of engineering might suggest that individuals with a higher capacity to mentalize are more likely to engage in clinical psychology and become therapists. However, the lack of significant difference in self-reported mentalization capacity in last year students of clinical psychology compared to first year students might indicate that the Norwegian education in clinical psychology does not succeed in enhancing mentalization in future therapists. Clinical psychology study programs might benefit from targeted mentalization training.

Effect of Matching Therapists to Patients vs Assignment as Usual on Adult Psychotherapy Outcomes: A Randomized Clinical Trial

IMPORTANCE

Psychotherapists possess strengths and weaknesses in treating different mental health problems, yet performance information is rarely harnessed in mental health care (MHC). To our knowledge, no prior studies have tested the causal efficacy of prospectively matching patients to therapists with empirically derived strengths in treating patients' specific concerns.

OBJECTIVE

To test the effect of measurement-based matching vs case assignment as usual (CAU) on psychotherapy outcomes.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, adult outpatients were recruited between November 2017 and April 2019. Assessments occurred at baseline and repeatedly during treatment at 6 community MHC clinics in Cleveland, Ohio. To be eligible, patients had to make their own MHC decisions. Of 1329 individuals screened, 288 were randomized. Excluding those who withdrew or provided no assessments beyond baseline, 218 patients treated by 48 therapists were included in the primary modified intent-to-treat analyses.

INTERVENTIONS

Therapist performance was assessed pretrial across 15 or more historical cases based on patients' pre-post reporting across 12 problem domains of the routinely administered Treatment Outcome Package (TOP). Therapists were classified in each domain as effective (on average, patients' symptoms reliably improved), neutral (on average, patients' symptoms neither reliably improved nor deteriorated), or ineffective (on average, patients' symptoms reliably deteriorated). Trial patients were randomly assigned to good-fitting therapists (matched group) or were assigned to therapists pragmatically (CAU group). There were multiple match levels, ranging from therapists being effective on the 3 most elevated domains reported by patients and not ineffective on any others (highest) to not effective on the most elevated domains reported by patients but also not ineffective on any domain (lowest). Therapists treated patients in the matched and CAU groups, and treatment was unmanipulated.

MAIN OUTCOMES AND MEASURES

General symptomatic and functional impairment across all TOP domains (average z scores relative to the general population mean; higher scores indicate greater impairment), global distress (Symptom Checklist-10; higher scores indicate greater distress), and domain-specific impairment on each individual's most elevated TOP-assessed problem.

RESULTS

Of 218 patients, 147 (67.4%) were female, and 193 (88.5%) were White. The mean (SD) age was 33.9 (11.2) years. Multilevel modeling indicated a match effect on reductions in weekly general symptomatic and functional impairment (γ110 = -0.03; 95% CI, -0.05 to -0.01; d = 0.75), global distress (γ110 = -0.16; 95% CI, -0.30 to -0.02; d = 0.50), and domain-specific impairment (γ110 = -0.01; 95% CI -0.01 to -0.006; d = 0.60), with no adverse events.

CONCLUSIONS AND RELEVANCE

Matching patients with therapists based on therapists' performance strengths can improve MHC outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02990000.

Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?

BACKGROUND

The Improving Access to Psychological Therapies (IAPT) programme has been impactful in increasing access to psychological therapies at primary care level. However, it remains unclear whether IAPT's widely disseminated achievements include the reduction in service users' transition to secondary care services and whether IAPT services are providing interventions that match the level of complexity of presenting problems of those who are referred.

AIMS

This review sets out to clarify the clinical characteristics of IAPT cohorts, whether the interventions provided target these characteristics, and whether outcomes are related to the use of the stepped-care model advocated in the operationalization of IAPT services.

METHOD

A systematic literature search was undertaken on PsycINFO, MEDLINE, and Embase using the terms: IAPT, anxiety, and depression.

RESULTS

Of 472 paper identified, 24 articles were deemed pertinent. It appears that IAPT cohorts are complex and current service delivery frameworks may not meet their needs. IAPT developments and research for long-term physical health conditions and serious mental illness have been recently advocated, though whether these are sufficient and viable when set in IAPT's prescriptive backdrop remains unclear.

CONCLUSIONS

Improving Access to Psychological Therapies provision and research at present does not adequately consider the complexity of its clientele in the context of treatment outcomes and service delivery. Recommendations are provided for future research and practice to tackle these deficiencies.

PRACTITIONER POINTS

Improving Access to Psychological Therapies (IAPT) has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged. Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model's original objectives is required, as a precursor to its expansion into other clinical areas. The review indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands. Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

Challenges in the design, planning and implementation of trials evaluating group interventions

Background

Group interventions are interventions delivered to groups of people rather than to individuals and are used in healthcare for mental health recovery, behaviour change, peer support, self-management and/or health education. Evaluating group interventions in randomised controlled trials (RCTs) presents trialists with a set of practical problems, which are not present in RCTs of one-to-one interventions and which may not be immediately obvious.

Methods

Case-based approach summarising Sheffield trials unit’s experience in the design and implementation of five group interventions. We reviewed participant recruitment and attrition, facilitator training and attrition, attendance at the group sessions, group size and fidelity aspects across five RCTs.

Results

Median recruitment across the five trials was 3.2 (range 1.7–21.0) participants per site per month. Group intervention trials involve a delay in starting the intervention for some participants, until sufficient numbers are available to start a group. There was no evidence that the timing of consent, relative to randomisation, affected post-randomisation attrition which was a matter of concern for all trial teams. Group facilitator attrition was common in studies where facilitators were employed by the health system rather than the by the grant holder and led to the early closure of one trial; research sites responded by training ‘back-up’ and new facilitators. Trials specified that participants had to attend a median of 62.5% (range 16.7%–80%) of sessions, in order to receive a ‘therapeutic dose’; a median of 76.7% (range 42.9%–97.8%) received a therapeutic dose. Across the five trials, 75.3% of all sessions went ahead without the pre-specified ideal group size. A variety of methods were used to assess the fidelity of group interventions at a group and individual level across the five trials.

Conclusion

This is the first paper to provide an empirical basis for planning group intervention trials. Investigators should expect delays/difficulties in recruiting groups of the optimal size, plan for both facilitator and participant attrition, and consider how group attendance and group size affects treatment fidelity.

Trial registration

ISRCTN17993825 registered on 11/10/2016, ISRCTN28645428 registered on 11/04/2012, ISRCTN61215213 registered on 11/05/2011, ISRCTN67209155 registered on 22/03/2012, ISRCTN19447796 registered on 20/03/2014.

The Impact of Patients' and Therapists' Views of the Therapeutic Alliance on Treatment Outcome in Psychotherapy

This article reports about the role of psychotherapists in creating a good enough therapeutic alliance as the basic task for other therapeutic factors come into play. Data from a naturalistic study involving 237 patients treated by 68 psychotherapists using 10 different psychotherapy approaches were analyzed in a process-outcome research design. The results show that therapists had to adapt their alliance perspectives to patients' level of alliance ratings as treatments progressed. Treatment concepts did not play a role in outcome. The view of a similar quality of the therapeutic alliance seems to be an indispensable precondition for favorable treatment outcomes. Successful treatments were conducted more often by therapists who showed significant convergence of alliance ratings over time, whereas discrepant alliance ratings correlated significantly with unsuccessful treatments.

Modelling changes in anxiety and depression during low-intensity cognitive behavioural therapy: An application of growth mixture models

OBJECTIVES

Research largely supports the clinical effectiveness of low-intensity cognitive behavioural therapy (LICBT) for mild-to-moderate anxiety and depression, delivered by psychological well-being practitioners (PWPs). Knowledge regarding the predictors of treatment response, however, is relatively limited. The primary aim of this study was to model the heterogeneity in longitudinal changes in anxiety and depression throughout LICBT provided by PWPs in Northern Ireland (NI), and to explore associations between pre-treatment variables and differences in treatment response.

METHODS

Growth mixture modelling (GMM) techniques were employed to examine changes in psychological status in clients (N = 253) over the first six sessions of treatment, to identify divergent early response trajectories. A series of pre-treatment variables were used to predict class membership using chi-square tests and binary logistic regression models.

RESULTS

There was one class representing improvement and one representing no improvement for both anxiety and depression. Class membership was predictive of treatment outcome. Pre-treatment variables associated with less improvement included unemployment, risk of suicide, neglect of self or others, using medication, receiving previous or concurrent treatments, a longer duration of difficulties, and comorbidities.

CONCLUSIONS

Findings indicate most of the sample populated an 'improvers' class for both depression and anxiety. Pre-treatment variables identified as predictive of poor treatment response may need to be considered by practitioners in potential triage referral decision policies, supporting cost-effective and efficient services. Further research around predictors of clinical outcome is recommended.

PRACTITIONER POINTS

Most of the sample belonged to an 'improvers' class. Several pre-treatment variables predicted poor treatment response (unemployment, suicide risk, neglect, medication, previous or concurrent treatments, longer duration of difficulties, and comorbidities). Few studies have utilized GMM to determine predictors of outcome following LICBT Regarding pre-treatment variables, the possibility of self-report bias cannot be excluded. The time period was relatively short, although represented the optimum number of sessions recommended for LICBT. The lack of a control group and random allocation were the main limitations.

A meta-analysis of the effect of therapist experience on outcomes for clients with internalizing disorders

Objective: This meta-analysis synthesized the literature regarding the effect of therapist experience on internalizing client outcomes to evaluate the utility of lay providers in delivering treatment and to inform therapist training. Method: The analysis included 22 studies, contributing 208 effect sizes. Study and client characteristics were coded to examine moderators. We conducted subgroup meta-analyses examining the relationship of therapist experience across a diverse set of internalizing client outcomes. Results: Results demonstrated a small, but significant relationship between therapist experience and internalizing client outcomes. There was no relationship between therapist experience and outcomes in clients with primary anxiety disorders. In samples of clients with primary depressive disorders and in samples of clients with mixed internalizing disorders, there was a significant relationship between experience and outcomes. The relationship between therapist experience and outcomes was stronger when clients were randomized to therapists, treatment was not manualized, and for measures of client satisfaction and "other" outcomes (e.g., dropout). Conclusions: It appears that therapist experience may matter for internalizing clients under certain circumstances, but this relationship is modest. Continuing methodological concerns in the literature are noted, as well as recommendations to address these concerns.

Exploring relapse through a network analysis of residual depression and anxiety symptoms after cognitive behavioural therapy: A proof-of-concept study

Objective: Many patients relapse within one year of completing effective cognitive behavioural therapy (CBT) for depression and anxiety. Residual symptoms at treatment completion have been demonstrated to predict relapse, and so this study used network analyses to improve specificity regarding which residual anxiety and depression symptoms predict relapse. Method: A cohort study identified relapse cases following low- and high-intensity CBT in a stepped care psychological therapy service. The sample included N = 867 "recovered" treatment completers that attended a six-month follow-up review. At follow-up, N = 93 patients had relapsed and N = 774 remained in-remission. Networks of final treatment session depression (PHQ-9) and anxiety (GAD-7) symptoms were estimated for both sub-groups. Results: Qualitatively similar symptom networks were found. Difficulty concentrating was a highly central symptom in the relapse network, whilst of only average centrality in the remission network. In contrast, trouble relaxing was highly central in the remission network, whilst of only average centrality in the relapse network. Discussion: Identification of central residual symptoms holds promise in improving the specificity of prognostic models and the design of evidence-based relapse prevention strategies. The small sample of relapse cases limits this study's ability to draw firm conclusions.

An evaluation of large group cognitive behaviour therapy with mindfulness (CBTm) classes

BACKGROUND

Ensuring equitable and timely access to Cognitive Behaviour Therapy (CBT) is challenging within Canada's service delivery model. The current study aims to determine acceptability and effectiveness of 4-session, large, Cognitive Behaviour Therapy with Mindfulness (CBTm) classes.

METHODS

A retrospective chart review of adult outpatients (n = 523) who attended CBTm classes from 2015 to 2016. Classes were administered in a tertiary mental health clinic in Winnipeg, Canada and averaged 24 clients per session. Primary outcomes were (a) acceptability of the classes and retention rates and (b) changes in anxiety and depressive symptoms using Generalized Anxiety Disorder 7-item (GAD-7) and Patient Health Questionnaire 9-item (PHQ-9) scales.

RESULTS

Clients found classes useful and > 90% expressed a desire to attend future sessions. The dropout rate was 37.5%. A mixed-effects linear regression demonstrated classes improved anxiety symptoms (GAD-7 score change per class = - 0.52 [95%CI, - 0.74 to - 0.30], P < 0.001) and depressive symptoms (PHQ-9 score change per class = - 0.65 [95%CI, - 0.89 to - 0.40], P < 0.001). Secondary analysis found reduction in scores between baseline and follow-up to be 2.40 and 1.98 for the GAD-7 and PHQ-9, respectively. Effect sizes were small for all analyses.

CONCLUSIONS

This study offers preliminary evidence suggesting CBTm classes are an acceptable strategy to facilitate access and to engage and maintain clients' interest in pursuing CBT. Clients attending CBTm classes experienced improvements in anxiety and depressive symptoms. Symptom improvement was not clinically significant. Study limitations, such as a lack of control group, should be addressed in future research.

In the Absence of Effects: An Individual Patient Data Meta-Analysis of Non-response and Its Predictors in Internet-Based Cognitive Behavior Therapy

Background: Negative effects of psychological treatments have recently received increased attention in both research and clinical practice. Most investigations have focused on determining the occurrence and characteristics of deterioration and other adverse and unwanted events, such as interpersonal issues, indicating that patients quite frequently experience such incidents in treatment. However, non-response is also negative if it might have prolonged an ongoing condition and caused unnecessary suffering. Yet few attempts have been made to directly explore non-response in psychological treatment or its plausible causes. Internet-based cognitive behavior therapy (ICBT) has been found effective for a number of diagnoses but has not yet been systematically explored with regard to those patients who do not respond. Methods: The current study collected and aggregated data from 2,866 patients in 29 clinical randomized trials of ICBT for three categories of diagnoses: anxiety disorders, depression, and other (erectile dysfunction, relationship problems, and gambling disorder). Raw scores from each patient variable were used in an individual patient data meta-analysis to determine the rate of non-response on the primary outcome measure for each clinical trial, while its potential predictors were examined using binomial logistic regression. The reliable change index (RCI) was used to classify patients as non-responders. Results: Of the 2,118 patients receiving treatment, and when applying a RCI of z ≥ 1.96, 567 (26.8%) were classified as non-responders. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline, Odds Ratio (OR) = 2.04, having a primary anxiety disorder (OR = 5.75), and being of male gender (OR = 1.80), might have higher odds of not responding to treatment. Conclusion: Non-response seems to occur among approximately a quarter of all patients in ICBT, with predictors related to greater symptoms, anxiety disorders, and gender indicating increasing the odds of not responding. However, the results need to be replicated before establishing their clinical relevance, and the use of the RCI as a way of determining non-response needs to be validated by other means, such as by interviewing patients classified as non-responders.

Why therapists should walk the talk: The theoretical and empirical case for personal practice in therapist training and professional development

The key proposition of this invited essay is that personal practice (PP), coupled with self-reflection, is central to the development of the most effective therapists. To date, the discussion about personal practice in therapist training and professional development has largely revolved around the value of personal therapy, subscribed to by some schools of psychotherapy but not by others. However, since the turn of the century a new landscape of personal practices for therapists has emerged. In particular, two forms of personal practice, meditation programs and self-practice/self-reflection (SP/SR) programs, have developed a growing evidence base. Here it is proposed that there is now a strong theoretical and empirical case to accord personal practice an explicit role in therapist training and professional development. The case rests on recent research suggesting that: (1) personal and interpersonal qualities of therapists play a key role in client outcomes; and (2) personal practice is the most effective way to achieve changes in therapists' personal and interpersonal qualities. It is suggested that the research agenda needs to move beyond asking whether or not personal practice is effective towards a more sophisticated set of questions: what personal practice, facilitated by whom, is most effective with which practitioners, in what contexts, at what point in time? To make further progress, trainers and researchers need to be supported to include personal practices in therapist training and to undertake research to evaluate their impacts.

Memory Strategy Training in Older Adults with Subjective Memory Complaints: A Randomized Controlled Trial

OBJECTIVES

Subjective memory complaints (SMC) in older adults are associated with a decline in everyday functioning and an increased risk for future cognitive decline. This study examines the effect of a memory strategy training compared to a control memory training on memory functioning in daily life.

METHODS

This was a randomized controlled trial with baseline, post-treatment, and 6-month follow-up assessments conducted in 60 older adults (50-87 years) with SMC. Participants were randomly assigned to either seven sessions of memory strategy training or seven sessions of control memory training. Both interventions were given in small groups and included psycho-education. Primary outcome measure was memory functioning in daily life. Objective measures of memory performance and self-reported measures of strategy use were included as secondary outcome measures.

RESULTS

Participants in each intervention group reported an improvement in personal memory goals (p<.0005), up to 6 months after training. An interaction effect showed that participants following memory strategy training reported a larger improvement in personal memory goals (p=.002). Both intervention groups improved on two memory tests (p<.001 and p<.01). In the memory strategy training group, an increase in strategy use in daily life was the strongest predictor (p<.05) of improvement in subjective memory functioning.

CONCLUSIONS

Older adults with subjective memory complaints benefit from memory strategy training, especially in their memory functioning in daily life. (JINS, 2018, 24, 1110-1120).

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.

Efficacy of narrative reformulation during cognitive analytic therapy for depression: Randomized dismantling trial

BACKGROUND

Narrative reformulation (NR) is a component of cognitive analytic therapy (CAT) that is assumed to increase client engagement and improve clinical outcomes. This study set out to test these claims.

METHODS

A single-blind randomized and controlled dismantling trial investigated treatment outcomes for moderate to severely depressed patients receiving CAT in Primary Care. Ninety-five participants were randomized to either full-CAT (n = 52) or CAT minus narrative reformulation (CAT-NR, n = 43). Treatment duration in both arms was 8-sessions and was matched apart from the omission of the NR in the CAT-NR arm. The primary outcome measure was the Patient Health Questionnaire (PHQ-9), with secondary outcome measures of anxiety, functioning, helpfulness and the therapeutic alliance. Outcomes were assessed at screening, every treatment session and at 8-weeks follow-up.

RESULTS

Growth curve modelling found that NR did not enhance the efficacy of CAT for depression. There were no significant differences between groups in terms of attendance, adverse events, anxiety, functioning, helpfulness or therapeutic alliance. There were large within-group effect sizes (d₊ > 1.5), as CAT with or without NR produced significant reductions in depression (p < .01).

LIMITATIONS

The primary outcome were assessed via self-report and the follow-up period was brief.

CONCLUSIONS

These results suggest that NR may be redundant when treating depression with CAT. Whilst a brief 8-session version of the CAT model appears suitable for treating depression in Primary Care, further research regarding the need for NR is indicated.

A New Community-Based Model for Training in Evidence-Based Psychotherapy Practice

It is critical that evidence-based practices (EBP's) be provided to patients. Efforts to train clinicians in the community in EBP's, however, has been hindered by a lack of resources and rigid and resource intensive models of training. We describe efforts to overcome these barriers in a large scale community-based training program for Interpersonal Psychotherapy implemented with over 1400 clinicians in Los Angeles working within the Los Angeles County Department of Mental Health public system of care. The program, described in detail, is a potential template for training for community-based clinicians in evidence-based psychotherapy practices.

Associations between therapists' occupational burnout and their patients' depression and anxiety treatment outcomes

BACKGROUND

Occupational burnout is common in mental health professionals, but its impact on patient outcomes is as yet uncertain. This study aimed to investigate associations between therapist-level burnout and patient-level treatment outcomes after psychological therapy.

METHODS

We used multilevel modeling using depression (PHQ-9) and anxiety (GAD-7) outcomes data from 2,223 patients nested within 49 therapists. Therapists completed a survey including the Oldenburg Burnout Inventory (OLBI) and a job satisfaction scale (JDSS).

RESULTS

After controlling for case-mix, around 5% of variability in treatment outcomes was explained by therapist effects (TE). Higher therapist OLBI-disengagement and lower JDSS scores were significantly associated with poorer treatment outcomes, explaining between 31 and 39% of the TE estimate. Higher OLBI scores were also correlated with lower job satisfaction ratings.

CONCLUSIONS

Therapist burnout has a negative impact on treatment outcomes and could be the target of future preventive and remedial action.

A systematic review of therapist effects: A critical narrative update and refinement to review

OBJECTIVE

To review the therapist effects literature since Baldwin and Imel's (2013) review.

METHOD

Systematic literature review of three databases (PsycINFO, PubMed and Web of Science) replicating Baldwin and Imel (2013) search terms. Weighted averages of therapist effects (TEs) were calculated, and a critical narrative review of included studies conducted.

RESULTS

Twenty studies met inclusion criteria (3 RCTs; 17 practice-based) with 19 studies using multilevel modeling. TEs were found in 19 studies. The TE range for all studies was 0.2% to 29% (weighted average = 5%). For RCTs, 1%-29% (weighted average = 8.2%). For practice-based studies, 0.2-21% (weighted average = 5%). The university counseling subsample yielded a lower TE (2.4%) than in other groupings (i.e., primary care, mixed clinical settings, and specialist/focused settings). Therapist sample sizes remained lower than recommended, and few studies appeared to be designed specifically as TE studies, with too few examples of maximising the research potential of large routine patient datasets.

CONCLUSIONS

Therapist effects are a robust phenomenon although considerable heterogeneity exists across studies. Patient severity appeared related to TE size. TEs from RCTs were highly variable. Using an overall therapist effects statistic may lack precision, and TEs might be better reported separately for specific clinical settings.

Negative effects in psychotherapy: commentary and recommendations for future research and clinical practice

BACKGROUND

Psychotherapy can alleviate mental distress and improve quality of life, but little is known about its potential negative effects and how to determine their frequency.

AIMS

To present a commentary on the current understanding and future research directions of negative effects in psychotherapy.

METHOD

An anonymous survey was distributed to a select group of researchers, using an analytical framework known as strengths, weaknesses, opportunities and threats.

RESULTS

The researchers perceive an increased awareness of negative effects in psychotherapy in recent years, but also discuss some of the unresolved issues in relation to their definition, assessment and reporting. Qualitative methods and naturalistic designs are regarded as important to pursue, although a number of obstacles to using such methods are identified.

CONCLUSION

Negative effects of psychotherapy are multifaceted, warranting careful considerations in order for them to be monitored and reported in research settings and routine care.

DECLARATION OF INTEREST

None.

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership.

Associations between socioeconomic status and psychological therapy outcomes: A systematic review and meta-analysis

BACKGROUND

Socioeconomic deprivation is associated with higher prevalence of mental health problems; however, the influence of socioeconomic status (SES) on psychological therapy outcomes is as yet unclear.

AIM

To review published evidence on the association between indicators of SES (income, education, employment, neighborhood deprivation, social position) and the outcomes of psychological interventions for depression and anxiety.

METHODS

Systematic review and meta-analysis of outcomes research studies published in the last 10 years.

RESULTS

Seventeen studies including 165,574 patients measured at least one indicator of SES and its relationship with psychological therapy outcomes. Twelve of these studies found significant relationships between SES measures and mental health outcomes. Six studies focusing on employment status offered sufficient quantitative information to conduct meta-analysis. The overall effect of employment was not significant (-0.66, confidence of interval (CI) -1.33, 0.02). A sensitivity analysis (k = 5) showed a small effect (-0.22, CI -0.36, -0.09) of employment on treatment outcomes.

CONCLUSIONS

There is some evidence to indicate that socioeconomic deprivation is associated with poorer treatment outcomes, although limitations of the available data warrant treating this as a preliminary conclusion.

Guided self-help in a brave new world

Cognitive-behavioural therapy self-help offers an accessible and efficient way to treat common mental disorders. The evidence-based self-help movement has an important foothold in the healthcare arena. This article surveys the emergence of self-help at a particular social and historical junction, and summarises key lessons from experimental and practice-based studies. Declaration of interest None.

Personality Styles of German-Speaking Psychotherapists Differ from a Norm, and Male Psychotherapists Differ from Their Female Colleagues

Variables pertaining to the person of the psychotherapist have been neglected in psychotherapy research for some time. Concerning personality in particular, however, research has mostly focused on its relation with the psychotherapist's choice of method, or differences between the various major therapy approaches. That is, psychotherapists were compared to each other without specifying how exactly psychotherapists are in comparison to "ordinary people." We wanted to know: Are there specific personality styles that distinguish psychotherapists from the norm? A sample of 1,027 psychotherapists from Germany, Austria, and Switzerland filled out the short version of the Personality Style and Disorder Inventory (PSDI-S) via online survey. The PSDI-S is a self-report questionnaire that assesses 14 personality styles, partly related to the non-pathological equivalents of classifiable personality disorders. The psychotherapists were compared to a normative sample of 3,392 people of different professions. The results could be divided into three groups: (1) Large differences in four personality styles that might contribute to relationship skills and may enable psychotherapists to put their own personal opinion aside, show empathy and appreciation, open themselves to the emotional experience of the patient, and provide a trusting relationship. (2) Moderate differences in seven personality styles that are equally indicative of the professional social skills of the psychotherapists, i.e., they were neither submissive nor passive, not excessively helpful, but also not too self-assertive. (3) Hardly any or no differences regarding a charming (histrionic) style, optimism, and conscientiousness. Gender-specific results revealed that male psychotherapists differed from their female colleagues, but they did so differently than men and women in the normative sample do. The main limitations were that we relied on self-report and did not statistically control for gender, age, and education, when comparing to the norm. As a conclusion, German-speaking psychotherapists show personality styles that we interpret as functional for psychotherapeutic practice but this needs corroboration from studies that use different methods and measures.

The Role of the Therapist in Therapeutic Change: How Knowledge From Mental Health Can Inform Pediatric Rehabilitation

The therapist is a neglected and poorly understood variable in pediatric rehabilitation. Much more attention has been paid to the role of intervention on client change than the role of therapist-related variables. This article synthesizes what is known in the adult and child mental health literature about the role of the therapist, and integrates this with work in pediatric rehabilitation. The article reviews the mental health literature on the therapist as a random variable associated with client outcomes (role of the therapist alone) and the role of three other therapist-related constructs: the therapist-client relationship (therapist and client), treatment implementation (therapist and intervention), and therapy process (therapist, client, and intervention considered holistically). Implications for clinical practice in pediatric rehabilitation include recognition of change as a multi-determined phenomenon involving common therapist-related factors, the therapist's role in creating facilitative conditions for change (through supportive relationships, positive expectancies, and mastery and learning experiences), and the importance of training in collaborative partnership skills. A contextual approach to therapeutic change is advocated, in which psychosocial factors and mechanisms are acknowledged, the therapist is seen as crucial, and the intervention process is seen as the context or vehicle through which changes occur.

How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study

BACKGROUND

Depression and anxiety disorders are relapse-prone conditions, even after successful treatment with pharmacotherapy or psychotherapy. Cognitive behavioural therapy (CBT) is known to prevent relapse, but there is little evidence of the durability of remission after low intensity forms of CBT (LiCBT).

METHOD

This study aimed to examine relapse rates 12 months after completing routinely-delivered LiCBT. A cohort of 439 LiCBT completers with remission of symptoms provided monthly depression (PHQ-9) and anxiety (GAD-7) measures during 12 months after treatment. Survival analysis was conducted to model time-to-relapse while controlling for patient characteristics.

RESULTS

Overall, 53% of cases relapsed within 1 year. Of these relapse events, the majority (79%) occurred within the first 6 months post-treatment. Cases reporting residual depression symptoms (PHQ-9 = 5 to 9) at the end of treatment had significantly higher risk of relapse (hazard ratio = 1.90, p < 0.001).

CONCLUSIONS

The high rate of relapse after LiCBT highlights the need for relapse prevention, particularly for those with residual depression symptoms.

Development and Evaluation of Cognitive Analytic Guided Self-Help (CAT-SH) for Use in IAPT Services

BACKGROUND

There is a lack of treatment plurality at step 2 of Improving Access to Psychological Therapies (IAPT) services. This project therefore sought to develop and pilot a cognitive analytic informed guided self-help treatment for mild-to-moderate anxiety for delivery by Psychological Wellbeing Practitioners (PWPs).

METHOD

Medical Research Council treatment development guidelines were used. Phase I included development of the six-session treatment manual using practice guidelines, small-scale modelling (n = 3) and indicated manual iterations. Phase II consisted of a mixed methods case series design (n = 11) to index feasibility, uptake and clinical outcomes.

RESULTS

Cognitive analytic guided self-help (CAT-SH) met established quality parameters for guided self-help. A high treatment completion rate was observed, with 10/11 patients who attended the first treatment session subsequently completing full treatment. Six out of ten patients completing full treatment met reliable recovery criteria at follow-up. Effect sizes and recovery rates equate with extant PWP outcome benchmarks. Practitioner feedback indicated that delivery of CAT-SH was feasible.

CONCLUSION

CAT-SH shows promise as a low-intensity treatment for anxiety, and so further, larger and more controlled evaluations are indicated.

Effectiveness of Group Behavioural Activation for Depression: A Pilot Study

Background: The evidence base for behavioural activation (BA) is mainly grounded in the individual delivery method, with much less known about the impact of group delivery. Aims: To conduct a pilot study of behavioural activation in groups (BAG) for depression delivered in a routine service setting, in order to explore acceptability, effectiveness and predictors of outcome. Methods: The manualized group treatment format was delivered in a Primary Care mental health setting, at step three of an Improving Access to Psychological Therapies (IAPT) service. BAG was facilitated by cognitive behavioural psychotherapists, and outcome measures (depression, anxiety and functional impairment) were taken at each session. Seventy-three participants were referred and treated within nine groups. Results: BAG was an acceptable treatment generating a low drop-out rate (7%). Significant pre–post differences were found across all measures. There was a moderate to large depression effect size (d+ = 0.74), and 20% met the criteria for a reliable recovery in depression. Greater severity of initial depression and attendance of at least four BAG sessions predicted better outcomes. Conclusions: BAG appears to be an effective depression treatment option that shows some clinical promise. Further larger and more controlled studies are nevertheless required.

Impact of long-term medical conditions on the outcomes of psychological therapy for depression and anxiety

BACKGROUND

Long-term conditions often coexist with depression and anxiety.

AIMS

To assess the effectiveness of stepped-care psychological therapies for patients with long-term conditions.

METHOD

Data from 28 498 patients were analysed using regression to model depression (Patient Health Questionnaire (PHQ-9)) and anxiety (Generalised Anxiety Disorder scale (GAD-7)) outcomes. Post-treatment symptoms and effect sizes (d) were estimated for individuals with and without long-term conditions, controlling for covariates. The likelihood of access and response to intensive psychological interventions was also examined.

RESULTS

Higher post-treatment symptoms were predicted for patients with musculoskeletal problems (d = 0.22-0.27), chronic obstructive pulmonary disease (d = 0.26-0.33), diabetes (d = 0.05-0.13) and psychotic disorders (d = 0.50-0.58). Most long-term conditions were associated with greater odds of accessing high-intensity therapies, yet individuals who accessed these continued to have higher average post-treatment symptoms.

CONCLUSIONS

Some long-term conditions are associated with greater intensity of care and poorer outcomes after therapy.

On poverty, politics and psychology: the socioeconomic gradient of mental healthcare utilisation and outcomes

Since 2008, the Improving Access to Psychological Therapies (IAPT) programme has disseminated evidence-based interventions for depression and anxiety problems. In order to maintain quality standards, government policy in England sets the expectation that 50% of treated patients should meet recovery criteria according to validated patient-reported outcome measures. Using national IAPT data, we found evidence suggesting that the prevalence of mental health problems is greater in poorer areas and that these areas had lower average recovery rates. After adjusting benchmarks for local index of multiple deprivation, we found significant differences between unadjusted (72.5%) and adjusted (43.1%) proportions of underperforming clinical commissioning group areas.

“Stress Control” as a Large Group Psychoeducational Intervention at Step 2 of IAPT Services: Acceptability of the Approach and Moderators of Effectiveness

Background:“Stress Control” (SC) has been adopted as a core intervention in step 2 of Improving Access to Psychological Therapies (IAPT) services, but contemporary evidence of effectiveness has lagged behind service uptake.Aims:To investigate the acceptability and effectiveness of SC and to explore moderators of outcome.Method:Analysis of acceptability (via attendance rates) and effectiveness (via IAPT minimum dataset).Results:SC was well tolerated with 73.3% of all patients and 75.4% of “clinical cases” attending three or more sessions. Of the 546 “clinical cases” attending SC and not in receipt of other interventions, 37% moved to recovery. Attendance improved outcome; for those patients attending all SC sessions the recovery rate rose to 59.2%.Conclusion:SC appears a well-tolerated and effective intervention that enables large numbers to gain access to treatment in an organizationally efficient manner. Attendance is important in facilitating SC outcomes and research evaluating attendance interventions are needed.