Center Effects: Counseling Center Variables as Predictors of Psychotherapy Outcomes

Treatment context may have a unique impact on psychotherapy outcomes, above and beyond client, therapist, and therapy process variables. University counseling centers represent one such treatment context facing increasing treatment demands. This study examined the role of counseling centers and center variables in explaining differences in psychotherapy outcomes. The Center for Collegiate Mental Health, a large practice–research network, contained data from 116 counseling centers, 2,362 therapists, and 58,423 clients. Multilevel modeling tested if some counseling centers systematically achieved better outcomes than others (a “center effect”). Outcome was operationalized as clients’ magnitude and rate of change in distress across treatment. Results showed a relatively small “center effect” for both outcomes. Analyses sought to explain that center effect through administrative policies and characteristics. As a group, these variables partially explained the center effect. None explained a large portion of total outcome variance. Potential future implications for policy and advocacy efforts are discussed.

How much therapy is enough? The dose-response effect and its moderators in a psychology training clinic

OBJECTIVE

The current study aims to sharpen the understanding of the psychotherapy dose-response effect and its moderators in a psychology training clinic.

METHOD

Data were extracted from 58 client records. Weekly Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, as well as Outcomes Questionnaire-45.2, administered every fifth session, assessed whether clients achieved reliable change (RC) and clinically significant and reliable change (CSR) during treatment. Survival analyses were conducted to determine the sessions required for 50% of the sample to achieve these outcomes. Multilevel Cox frailty regressions were used to investigate client-and-therapy-based moderators.

RESULTS

The median time for 50% of the sample to achieve RC was 8-10 sessions and 11 sessions to achieve initial CSR. Past treatment history was a significant moderator of time to achieve RC.

CONCLUSIONS

From a population perspective, psychotherapy is most beneficial to patients early in treatment. Sharper understanding of the number of sessions required to achieve meaningful change can inform practice in training settings.

The dose-response curve in cognitive-behavioral therapy for anxiety disorders

Previous studies examining the dose-response curve in psychotherapy have suggested that 11-19 sessions may be necessary for at least 50% of individuals to show clinically significant improvement. However, this curve has not been examined specifically for cognitive-behavioral therapy (CBT) for anxiety disorders, for which a more rapid recovery curve may be expected. Survival analysis was used to assess the dose-response curve for 201 patients with anxiety disorders who received weekly CBT at an anxiety specialty clinic. The primary outcome measure was the Outcome Questionnaire-45.2, which patients completed prior to each treatment session. Sixty-four percent of the sample achieved reliable change, and this response occurred in approximately five sessions on average. Fifty percent of the sample achieved clinically significant improvement, which occurred in approximately eight sessions on average. The findings suggest that earlier response may be expected in CBT for anxiety disorders, and are discussed in terms of potential ways to further improve response rates for this treatment.

Dose-response patterns in low and high intensity cognitive behavioral therapy for common mental health problems

BACKGROUND

Cognitive-behavioral therapy (CBT) is effective for the treatment of common mental health problems, but the number of sessions required to maximize improvement in routine care remains unclear.

AIM

This study aimed to examine the dose-response effect in low (LiCBT) and high (HiCBT) intensity CBT delivered in stepped care services.

METHODS

A multi-service data set included N = 102 206 patients across N = 16 services. The study included patients with case-level depression and/or anxiety symptoms who accessed LiCBT and/or HiCBT. Patients with posttreatment reliable and clinically significant improvement in standardized outcome measures (PHQ-9, GAD-7) were classified as treatment responders. Survival analyses assessed the number of sessions necessary to detect 50%, 75%, and 95% of treatment responders. The 50% and 95% percentiles were used to define the lower and upper boundaries of an adequate dose of therapy that could be used to inform the timing of treatment progress reviews. Analyses were then stratified by diagnosis, and cox regression was used to identify predictors of time-to-remission.

RESULTS

Most responders (95%) attained RCSI within 7 sessions of LiCBT and 14 sessions of HiCBT. Patients with social anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder required HiCBT and lengthier treatments (6-16 sessions) to maximize improvement.

CONCLUSIONS

Distinctive dose-response patterns are evident for LiCBT and HiCBT, which can be used to support treatment planning and routine outcome monitoring.

Counseling services for Asian, Latino/a, and White American students: Initial severity, session attendance, and outcome

OBJECTIVE

The current study examined racial/ethnic differences in initial severity, session attendance, and counseling outcomes in a large and diverse sample of Asian American, Latino/a, and White student clients who utilized university counseling services between 2008 and 2012.

METHOD

We used archival data of 5,472 clients (62% female; M age = 23.1, SD = 4.3) who self-identified their race/ethnicity as being Asian American (38.9%), Latino/a (14.9%), or White (46.2%). Treatment engagement was measured by the number of counseling sessions attended; initial severity and treatment outcome were measured using the Outcome Questionnaire-45.

RESULTS

Asian American clients, particularly Chinese, Filipino/a, Korean, and Vietnamese Americans, had greater initial severity compared with White clients. Asian Indian, Korean, and Vietnamese American clients used significantly fewer sessions of counseling than White clients after controlling for initial severity. All racial/ethnic minority groups continued to have clinically significant distress in certain areas (e.g., social role functioning) at counseling termination.

CONCLUSIONS

These findings highlight the need to devote greater attention to the counseling experiences of racial/ethnic minority clients, especially certain Asian American groups. Further research directions are provided. (PsycINFO Database Record

Systematic review of practice-based research on psychological therapies in routine clinic settings

PURPOSE

To review the published material on practice-based research and to compare results with benchmarks derived from efficacy studies.

METHODS

Electronic and manual searches were carried out up to and including 2008. Studies were screened for content relevance and selected according to specified inclusion criteria. Data were extracted from all studies that met criteria and were quality assessed using an adapted version of a checklist designed for the appraisal of both randomized and non-randomized studies of health care interventions. Studies were synthesized according to (1) the type of problem being treated and (2) study design using descriptive and meta-analytic methods where appropriate.

RESULTS

Psychological treatment conducted in routine clinic settings is effective for a range of client problems, particularly common mental health problems (uncontrolled effect size = 1.29; 95% CI = 1.26-1.33, N = 10,842). When benchmarked against data from efficacy studies, practice-based studies yielded effect sizes that fell short of the selected benchmark. In contrast, the practice-based studies achieved the benchmark for percentage of clients meeting a stringent criterion for recovery.

CONCLUSIONS

Clients receiving treatment as normally delivered within routine practice report significant relief of symptoms. However, the result of comparisons with efficacy benchmarks is dependent on the outcome index used. Notwithstanding this, substantive factors are also likely to contribute. Therefore, in addition to attending to methodological issues, further work is required to understand the relative contribution of these factors.