The effects of training in time-limited dynamic psychotherapy: changes in therapeutic outcome

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.

Confessions of a New York rupture researcher: An insider's guide and critique

OBJECTIVE

The study of alliance rupture has become quite prevalent since 1990 and especially in the past 10 years where we have seen a noticeable surge in empirical publications on the subject. This honorary paper attempts to provide a critical review of this literature from the perspective of someone who has contributed to it in his collaborative work on a research program designed to investigate ruptures and to develop intervention and training models to resolve them.

METHOD

This paper is organized into three topics or sections: (1) alliance rupture, (2) rupture resolution, and (3) alliance training; and it addresses definitions, findings, questions, and lessons with regard to each topic.

RESULTS/CONCLUSIONS

It suggests some clinical conceptualizations (concerning agency and communion as well as mutual recognition), training implications (regarding emotion regulation and deliberate practice), and methodological considerations (promoting pluralism and contextualism), along with future directions.

Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial

BACKGROUND

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.

METHODS

To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.

DISCUSSION

It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.

TRIAL REGISTRATION

NCT02449421 . Registered 02/09/2015.

Does the supervisor's teaching style influence the supervisee's learning prescribed techniques?

OBJECTIVES

This study examined the directive and non-directive supervisors' instructional styles, supervisees' interactive communications within supervision sessions as well as the relative success of supervisees' learning to apply specific techniques within psychotherapy.

METHOD

The developers of Time-Limited Dynamic Psychotherapy (TLDP) provided the supervised training for 16 therapists as part of the "Vanderbilt II" psychotherapy project. Supervision sessions were rated for supervisors' adherence to TLDP content. Both supervisors and supervisee were rated for classroom interactive behaviors of "initiation" speech (e.g., introducing ideas) and "responsive" speech (e.g., amplifying the other speaker's topic). The third therapy session was targeted for discussion within supervision. Therapy sessions immediately before and after supervision were rated on TLDP adherence.

RESULTS

One of the supervisors (Supervisor A) was found to use an instructional style of relatively more initiation-based speech, whereas the other (Supervisor B) used more response-based speech. Technical adherence for supervisees of Supervisor A was significantly higher than those assigned to Supervisor B. Supervisees' initiation-based speech during supervision predicted less use of TLDP techniques in the therapy session after supervision. Supervisors' interactive style was not associated with therapy adherence.

CONCLUSIONS

Relatively more directive and structured supervision may influence the acquisition and use of manual-prescribed therapy techniques.

Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome

OBJECTIVES

Therapist effects, independent of the treatment provided, have emerged as a contributor to psychotherapy outcomes. However, past research largely has not identified which therapist factors might be contributing to these effects, though research on psychotherapy implicates relational characteristics. The present Randomized Clinical Trial tested the efficacy of therapists who were selected by their facilitative interpersonal skills (FIS) and training status.

METHOD

Sixty-five clients were selected from 2713 undergraduates using a screening and clinical interview procedure. Twenty-three therapists met with 2 clients for 7 sessions and 20 participants served in a no-treatment control group.

RESULTS

Outcome and alliance differences for Training Status were negligible. High FIS therapists had greater pre-post client outcome, and higher rates of change across sessions, than low FIS therapists. All clients treated by therapists improved more than the silent control, but effects were greater with high FIS than low FIS therapists. From the first session, high FIS therapists also had higher alliances than low FIS therapists as well as significant improvements on client-rated alliance.

CONCLUSIONS

Results were consistent with the hypothesis that therapists' common relational skills are independent contributors to therapeutic alliance and outcome.

Investigating the relationship between competence and patient outcome with CBT

Little is understood about the relationship between therapist competence and the outcome of patients treated for common mental health disorders. Understanding the relationship between competence and patient outcome is of fundamental importance to the dissemination and implementation of Cognitive Behavioural Therapy (CBT). The current study extends existing literature by exploring the relationship between CBT competence and patient outcome in routine clinical practice within the framework of the British Government's Improving Access to Psychological Therapies (IAPT) programme. Participants comprised 43 therapists treating 1247 patients over a training period of one year. Results found little support of a general association between CBT competence and patient outcome; however significantly more patients of the most competent therapists demonstrated a reliable improvement in their symptoms of anxiety than would be expected by chance alone, and fewer experienced no reliable change. Conversely, significantly more patients treated by the least competent therapists experienced a reliable deterioration in their symptoms than would be expected. The implications of these results for the dissemination and implementation of CBT are discussed.

Training in time-limited dynamic psychotherapy: A systematic comparison of pre- and post-training cases treated by one therapist

OBJECTIVE

This qualitative study systematically compared cases treated by the same therapist in order to understand the group comparison findings of a larger study on training of experienced therapists (the "Vanderbilt II" psychotherapy project).

METHOD

The therapist, Dr C., was selected based on the therapist's overall treatment successes. His two patients were selected based on their outcomes and the relative training cohort from which they were drawn: a case with successful outcome from the pre-training cohort and a case of negligible improvement from the post-training cohort.

RESULTS

Dr C. demonstrated a variety of interpersonal skills throughout his pre-training case, though there was also poor interpersonal process throughout. However, in the second case he had considerable difficulty in adapting his typical therapeutic approach to the requirements of the time-limited dynamic psychotherapy (TLDP) manual, even while appearing to work hard to find ways to use the manual.

CONCLUSIONS

Dr C.'s spontaneity, and his unique set of interpersonal skills may enhanced his initial rapport and alliance building with clients and yet may not have interfaced well with TLDP. His unique interpersonal skills also may have contributed to problems of interpersonal process. Future research may benefit from examining the interaction of between therapist interpersonal skills and the implementation of the treatment manual.

Investigating the impact of alliance-focused training on interpersonal process and therapists' capacity for experiential reflection

OBJECTIVE

In this article we present preliminary findings from a research program designed to investigate the value of alliance-focused training (AFT), a supervision approach designed to enhance therapists' ability to work constructively with negative therapeutic process.

METHOD

In the context of a multiple baseline design, all therapists began treating their patients using cognitive therapy and then joined AFT supervision groups at either session 8 or 16 of a 30 session protocol. Study I investigated the impact of AFT on patient and therapist interpersonal process as assessed through the Structural Analysis of Social Behavior (SASB). Study 2 investigated the impact of AFT on therapists' tendency to reflect on their relationships with their patients in an experientially grounded fashion, as assessed via the Experiencing Scale (EXP). Since one of the goals of AFT is to train therapists to use their own emerging feelings as important clues regarding what may be taking place in the therapeutic relationship, we hypothesized that they would show increased levels of EXP after undergoing AFT.

RESULTS AND CONCLUSION

The results of both studies 1 and 2 were for the most part consistent with hypotheses. Implications and future research directions are discussed.

The influence of supervision on manual adherence and therapeutic processes

OBJECTIVES

To identify the effectiveness of psychotherapy supervision on therapists' immediate (next session) and long-term (1 year) adherence to time-limited dynamic psychotherapy (TLDP).

METHOD

Sixteen therapists from the Vanderbilt II psychotherapy project were assigned new cases in pretraining, training, and booster/posttraining year-long cohorts. Technical adherence to the manual, as well as general therapeutic relational processes, were rated for clinical supervisory sessions in which the third therapy session was discussed. The therapy sessions immediately before and after the supervisory sessions were also rated for technical adherence and relational processes.

RESULTS

Postsupervision adherence increased from the presupervision session during the training cohort. In supervision, therapists' discussion of techniques and strategies from the manual in supervision was significantly related to technical adherence in the session prior to (but not after) supervision. However, supervisors' discussion of specific techniques predicted therapists' total technical adherence in the therapy session after (but not before) supervision. In terms of the type of techniques, supervisors' influenced postsupervision therapy adherence on TLDP's unique approach to formulation, the cyclical maladaptive pattern, but did not influence technical adherence on the therapeutic relationship.

CONCLUSIONS

In supervision, therapists tend to focus on how they adhered to techniques from the previous session, whereas supervisors' comments about specific techniques predicted how the therapist would adhere to techniques in the next therapy session. The findings provide support for the immediate effects of supervision in shaping therapist techniques as well as highlighting the challenges of altering common relational processes through technical training.

Short-term and long-term effects of training in emotionally focused couple therapy: professional and personal aspects

This study investigated the immediate and long-term personal and professional effects of a 4-day externship training in emotionally focused couple therapy (EFT). EFT externship training uses lecture, discussion, video vignettes, live demonstrations, and role-plays to convey an attachment-based approach to working with couples. The two samples included clinicians (N = 76) who completed surveys immediately before and after training, and a subset of these clinicians (N = 29) who completed measures an average of 8 months later. Results indicate that following training, participants increased in their EFT knowledge and competence, became more open to their feelings, were more self-compassionate, were less likely to use avoidant attachment behaviors, and improved their own personal relationships.

The experience of learning Emotionally Focused Couples Therapy

This study examined the process of learning Emotionally Focused Couples Therapy (EFT) as reported by 122 EFT therapists and therapists-in-training. Participants completed an online questionnaire assessing their experiences of learning EFT, with particular emphasis on EFT theory, alliance, interventions, perceived impact on clients, and impact on self. Findings suggest that therapists are drawn to the attachment-based model of EFT, appreciate the EFT framework and structure, that clients endorse the usefulness of the model and that learning the model has contributed to personal healing and improved relationships for the trainees. Results also show that the transition to EFT from another model can be taxing and requires time, support, and additional supervision/training to increase comfort level and competency with EFT. Nevertheless, results also highlight that learning EFT can be a rewarding and worthwhile endeavor.

Counseling Competence

Working from their proposed model of counseling competence, the authors address critical implications and applications of the model. First, they present a 10-parameter juxtaposition of the model of counseling competence and the microskills training model, including points of comparision and contrast. Second, they discuss implications of the model for practice, including guidelines for teaching and an application exercise. Third, they discuss implications of the model for research, including improvements over design flaws and the limited focus that has typified research on microskills training.

Beyond Microskills

Heeding the call to the profession, the authors present both a definition and model of counseling competence. Undergirding the model are 15 foundational principles. The authors conceptualize counseling competence as more complex and nuanced than do traditional microskills models and include cognitive, affective, and behavioral components. The model consists of 4 superordinate competencies—determining therapeutic outcomes, facilitating therapeutic outcomes, evaluating therapeutic outcomes, and sustaining therapeutic outcomes—and 12 subordinate competencies: self-appraisal/self-evaluating, structuring the therapy, building a therapeutic alliance, applying a conceptual map of therapeutic change, using therapeutic techniques, self-correcting, surmounting obstacles, leveraging opportunities, managing special situations, working with other systems of care, consulting other sources, and terminating therapy. Integral to the model is the integrated deep structure, which consists of 5 metacognitions: purposefulness, motivation, selection, sequencing, and timing.

Training in Counseling Psychology

This Major Contribution, consisting of four articles, critically evaluates the status of training in counseling psychology, especially at the entry level, and offers a model for moving the field forward. In this first article, we provide a rationale for the contribution, laying the foundation for the subsequent three articles. Specifically, we ask the questions, Do training programs in counseling psychology produce the desired results? and Is the prevailing paradigm of training effective in developing counselor competence? Then we report on the research showing a disappointing relationship among training, experience, and expertise. We conclude by inviting the profession to engage in honest self-reflection about the status and future direction of training in counseling psychology.

The role of therapist training in the implementation of psychosocial treatments: a review and critique with recommendations

Evidence-based treatments (EBT) are underutilized in community settings, where consumers are often seen for treatment. Underutilization of EBTs may be related to a lack of empirically informed and supported training strategies. The goals of this review are to understand the state of the literature for training therapists in psychotherapy skills and to offer recommendations to improve research in this area. Results of this review of 55 studies evaluating six training methods indicate that multi-component trainings have been studied most often and have most consistently demonstrated positive training outcomes relative to other training methods. Studies evaluating utility of reading, self-directed trainings, and workshops have documented that these methods do not routinely produce positive outcomes. Workshop follow-ups help to sustain outcomes. Little is known about the impact of train-the-trainer methods. Methodological flaws and factors that may influence training outcome and future directions are also reviewed.

Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective

Evidence-based practice (EBP), a preferred psychological treatment approach, requires training of community providers. The systems-contextual (SC) perspective, a model for dissemination and implementation efforts, underscores the importance of the therapist, client, and organizational variables that influence training and consequent therapist uptake and adoption of EBP. This review critiques the extant research on training in EBP from an SC perspective. Findings suggest that therapist knowledge improves and attitudinal change occurs following training. However, change in therapist behaviors (e.g., adherence, competence, and skill) and client outcomes only occurs when training interventions address each level of the SC model and include active learning. Limitations as well as areas for future research are discussed.

Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations

Post-traumatic stress disorder (PTSD) represents a frequent consequence of a variety of extreme psychological stressors. Lists of empirically supported treatments for PTSD usually include cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR), but nonresponse and dropout rates in these treatments often are high. We review the treatment dropout and nonresponse rates in 55 studies of empirically supported treatments for PTSD, review the literature for predictors of dropout and nonresponse, discuss methodological inconsistencies in the literature that make comparisons across studies difficult, and outline future directions for research. Dropout rates ranged widely and may have depended, at least in part, on the nature of the study population. It was not uncommon to find nonresponse rates as high as 50%. Standard methods of reporting dropout and nonresponse rates are needed for reporting outcomes. We suggest guidelines for collecting data to help identify characteristics and predictors of dropouts and nonresponders.

The video assessment of simulated encounters (VASE): Development and validation of a group-administered method for evaluating clinician skills in motivational interviewing

The authors developed and evaluated a group-administered method for measuring motivational interviewing (MI) skills. The video assessment of simulated encounters (VASE) consists of three videotaped vignettes of actors playing substance abusers. Each vignette is followed by eight questions asking examinees to generate written responses consistent with MI principles. Twenty-two clinicians completed the VASE questionnaire and two other measures of MI skill: a paper-and-pencil measure that elicited responses to written scenarios and an audiotaped interaction with a standardized patient (SP), subsequently scored for MI skill by independent tape raters. Psychometric analyses of this original VASE scale evaluated: (1) scoring reliability of the 24 VASE items; (2) internal reliability of the VASE full-scale score, seven subscale scores and the three vignettes; and (3) concurrent validity with aforementioned indices of MI skill. Analyses informed the removal of two subscales, redesign of a third and revisions to a fourth. The resulting 18-item VASE-R scale retains its three-vignette format, and assesses overall MI skill as well as the following five MI "microskills": reflective listening, responding to resistance, summarizing, eliciting change talk and developing discrepancy. The VASE-R requires further analysis to evaluate these revisions, but shows promise as a cost-effective alternative for use in MI skill assessment in a variety of training and research contexts.

Do patients and their therapists agree on the content of treatments?

Agreement between therapist and patient regarding their perception of therapist's interventions and qualities was studied. Based on previous instruments, a 36-item inventory (TIQI) was constructed to cover common therapist interventions/qualities as perceived by both therapist and patient. This inventory was given to patient and therapist at the termination of 300 outpatients' treatments. Interventions made by the therapist and their perceived usefulness in the treatment were rated by both participants. The mean agreement between patient and therapist for each of the 36 items was low to moderate (r = .23). However, explorative factor analysis on patient and therapist data revealed some meaningful common treatment factors. In addition, cross invariance (patient and therapist perspective) was found by use of confirmatory factor analysis. Agreement varied considerably depending on which aspects were dealt with and the method used to measure the agreement. Possible explanations for disagreement are discussed.