No Change? A Grounded Theory Analysis of Depressed Patients' Perspectives on Non-improvement in Psychotherapy

How do we know whether treatment has failed? Paradoxical outcomes in counseling with young people

Background

In both routine practice contexts and research studies, evidence from standardized self-report symptom measures, administered pre- and post-treatment, is predominantly used to determine whether psychotherapy has been successful. Understanding the nature of unsuccessful psychotherapy requires an ability to evaluate the credibility of outcome data generated by such techniques. An important body of research has identified discrepancies between outcomes assessed through symptom measures and those obtained from other sources. However, not enough is known about the extent to which such paradoxical outcomes exist.

Objective

This study analyzes the relationship between outcomes, as assessed by a standardized self-report measure, and as assessed by ratings of young people's descriptions of change at post-counseling interviews.

Methods

Participants were 50 young people (13-16 years old) who had taken part in a trial of up to 10 weeks of school-based humanistic counseling. Our primary standardized measure was the Young Person's CORE (YP-CORE). To assess young people's experiences of counseling change, three independent raters scrutinized transcripts of post-counseling interviews, and scored levels of helpfulness on a 1 (Not at all helpful) to 10 (Extremely helpful) scale. Inter-rater reliabilities were 0.94 (Cronbach's Alpha) and 0.96 (McDonald's Omega). Sensitivity analyses were conducted to explore relationships between helpfulness ratings and other outcome measures, i.e., satisfaction with counseling (ESQ) and the Goal-Based-Outcome Tool (GBO), and process measures, i.e., the Working Alliance Inventory (WAI-S) and the Barret Lennard Relationship Inventory (BLRI).

Results

Multilevel analysis indicated that helpfulness ratings were not significantly associated with changes in YP-CORE scores. Analyzed categorically, 38% of those showing reliable improvement on the standardized measure were below the median for self-described helpfulness, and 47% of those not showing reliable change were at or above the median for self-described helpfulness. Sensitivity analyses demonstrated closer correlations between helpfulness ratings and other outcome measures (ESQ and GBO), and between helpfulness ratings and process measures (WAI-S and BLRI).

Discussion

Our results raise questions about reliance on symptom change outcome measures for defining treatment success and failure, given their disparity with clients' own descriptions of the helpfulness of therapy. Implications for practice and research are discussed.

User Experiences of CBT for Anxiety and Depression: A Qualitative Systematic Review and Meta-synthesis

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety and depression. It is important to determine the positive and negative aspects of CBT from the perspective of service users. However, there has been a lack of qualitative exploration into service user experiences of the therapy. This review aimed to address this gap by examining participants' experiences of CBT for anxiety and depression. Databases were searched and data were synthesised thematically. CBT was well-received by participants, though barriers to engagement were identified. CBT was often perceived as too difficult or demanding, as well as interventions being short and therefore superficial. Clinician qualities of being trustworthy, non-judgemental, and understanding appear to be significant contributors to client engagement and recovery. Findings support the delivery of in-depth clinician led CBT for anxiety and depression, as well as highlighting the need to review CBT delivery to better support service users.

Negative experiences in psychotherapy from clients' perspective: A qualitative meta-analysis

OBJECTIVE

A considerable number of clients report adverse or unwanted effects of psychological treatments. This study aimed to synthesize the findings of qualitative studies focused on what clients perceive as negative experiences in psychotherapy.

METHOD

A database search was conducted to find primary studies, and a qualitative meta-analysis was used to aggregate the findings on the kinds of negative experiences psychotherapy clients reported.

RESULTS

A total of 936 statements were extracted from 51 primary studies and categorized into 21 meta-categories, some of which were further divided into subcategories. These meta-categories covered clients' experiences, which fell into four broad clusters: therapists' misbehaviour, hindering aspects of the relationship, poor treatment fit, and negative impacts of treatment.

CONCLUSION

Clients' negative experiences of psychotherapy are a vast and heterogeneous area, the breadth of which is not captured by any single study. By synthesizing the findings of many primary studies, this meta-analysis represents the most comprehensive summary of these experiences to date.

Understanding "patient deterioration" in psychotherapy from depressed patients' perspectives: A mixed methods multiple case study

OBJECTIVE

This study scrutinizes the meaning of deterioration in psychotherapy beyond the widely used statistical definition of reliable symptom increase pre-to-post treatment.

METHOD

An explanatory sequential mixed-methods multiple case study was conducted, combining quantitative pre-post outcome evaluation of self-reported depression symptoms and qualitative analysis of patients' interviews. In a Randomized Controlled Study on the treatment of Major Depression, three patients showing reliable increase in symptom severity on the BDI-II pre-to-post therapy were selected. An interpretative phenomenological analysis (IPA) was performed on individual interviews conducted pre-, peri- and post-treatment.

RESULTS

Cross-case outcome experiences were: (1) uncontrollable complaints; (2) remaining questions and uninternalized insights and (3) persisting interpersonal difficulties. Within-case idiosyncratic differences revealed that the statistical classification of "deterioration" not necessarily corresponds to a "deteriorated experience," nor univocally indicates unwanted therapy effects. Our findings point at the influences of the patient's (lack of) agency in the process, a discrepancy between patients' expectations and the therapy offer, the therapeutic relationship, interpersonal difficulties, and contextual influences.

CONCLUSION

The meaning of symptomatic deterioration should be interpreted within a patient's idiosyncratic context. The multi-faceted nature of deterioration requires further research to rely on multiple perspectives and mixed methods.

Framework of humanistic care for patients in the ICU: A preliminary study

BACKGROUND

Humanistic care involves caring, concern, paying attention to people's individuality, meeting their needs and respecting their rights, which is the core concept and central task of nursing. Effective care can enhance patients' ability to deal with stress and promote patient recovery. Implementing humanistic care in the intensive care unit (ICU) is particularly important for health care providers.

AIM

This study aims to develop a framework of the humanistic care in the ICU.

STUDY DESIGN

The qualitative research followed Strauss' procedural grounded theory approach. Purposive sampling and theoretical sampling were used to select 12 nurses in the Department of Critical Medicine, 16 patients, and eight family members for semi-structured interviews from October 2020 to April 2021. Results were summarized and analysed through three-level coding based on grounded principles.

RESULTS

Sixteen subcategories and six main categories were extracted after three-level coding, and the final ICU humanistic care framework was formed with home, activity, visit, environment, nursing and safety ("HAVENS") as the core.

CONCLUSIONS

This study provides an explanatory theory of humanistic care in the ICU that can guide nurses' practice in ICU clinical work.

RELEVANCE TO CLINICAL PRACTICE

This theory provides guidance for nurses to implement humanistic care in critical care practice to improve the ICU stay experience of critically ill patients.

The lived experience of depression: a bottom-up review co-written by experts by experience and academics

We provide here the first bottom-up review of the lived experience of depression, co-written by experts by experience and academics. First-person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of depression, family members and carers, representing a global network of organizations. The material was enriched by phenomenologically informed perspectives and shared with all collaborators in a cloud-based system. The subjective world of depression was characterized by an altered experience of emotions and body (feeling overwhelmed by negative emotions, unable to experience positive emotions, stuck in a heavy aching body drained of energy, detached from the mind, the body and the world); an altered experience of the self (losing sense of purpose and existential hope, mismatch between the past and the depressed self, feeling painfully incarcerated, losing control over one's thoughts, losing the capacity to act on the world; feeling numb, empty, non-existent, dead, and dreaming of death as a possible escape route); and an altered experience of time (experiencing an alteration of vital biorhythms, an overwhelming past, a stagnation of the present, and the impossibility of the future). The experience of depression in the social and cultural context was characterized by altered interpersonal experiences (struggling with communication, feeling loneliness and estrangement, perceiving stigma and stereotypes), and varied across different cultures, ethnic or racial minorities, and genders. The subjective perception of recovery varied (feeling contrasting attitudes towards recovery, recognizing recovery as a journey, recognizing one's vulnerability and the need for professional help), as did the experience of receiving pharmacotherapy, psychotherapy, and social as well as physical health interventions. These findings can inform clinical practice, research and education. This journey in the lived experience of depression can also help us to understand the nature of our own emotions and feelings, what is to believe in something, what is to hope, and what is to be a living human being.

Understanding treatment non-responders: A qualitative study of depressed adolescents' experiences of 'unsuccessful' psychotherapy

OBJECTIVES

This paper aimed to explore the experiences of depressed adolescents who completed but did not 'respond' to standard psychotherapy, based on a lack of improvement in pre-post symptoms scores.

DESIGN

This was a qualitative study employing interpretative phenomenological analysis (IPA).

METHOD

Seventy-seven adolescents with moderate to severe depression were interviewed as part of a qualitative arm of a randomised controlled trial. Five adolescents' post-treatment interviews were purposively sampled, based on lack of improvement on pre-post symptom scores, and adolescents still scoring above the clinical threshold for depression. The interviews were analysed using IPA.

RESULTS

Adolescents made sense of their depression as part of their identity and held negative expectations of therapy. Some aspects of therapy brought up intolerable feelings that contributed to disengagement in the therapeutic process and culminated in disappointing and hopeless endings. On the other hand, where a stronger therapeutic relationship was developed, some participants experienced certain improvements.

CONCLUSIONS

Findings highlight how actively exploring the adolescent's therapy expectations, developing a strong early therapeutic relationship and being mindful of the potential impact of endings are important in therapeutic work with adolescents with depression, especially where they may have a strong sense of hopelessness and self-criticism. Moreover, the finding that adolescents experienced improvements in other domains despite a lack of symptom reduction highlights the need to review how treatment outcomes are currently defined. Integrating individual perspectives of therapy with quantitative outcome measures can provide a more nuanced insight of treatment effects.

Rigorous idiography: Exploring subjective and idiographic data with rigorous methods-The method of derangements

Psychological research often seeks general rules applying across individuals, an aim that is in tension with examining that which is unique to any individual. There are general statistical regularities across individuals' subjective self-report which enable much psychology and psychotherapy research to combine data from self-report questionnaire responses with statistical and psychometric methods to create a fundamental part of Cronbach and Meehl's foundational nomological networks of validity. However, these methods only apply when most participants answer the same questions on measures creating nomothetic data and this has led to a neglect of idiographic data. This paper reviews a method of analysis of idiographic data, of "rigorous idiography": the method of derangements. This is a remarkably simple statistical test of whether purely idiographic data convey reliable information. We show how the method appeared to become stuck in a bibliometric backwater but we expand on its potential for research and practise and hope it will be taken up and used correctly and more widely.

Digging down or scratching the surface: how patients use metaphors to describe their experiences of psychotherapy

BACKGROUND

In the present study, we wanted to explore which metaphors patients suffering from major depressive disorder (MDD) use to explain their experience of being in therapy and their improvement from depression.

METHODS

Patients with MDD (N = 22) received either psychodynamic therapy (PDT) or cognitive behavioral therapy (CBT). They were interviewed with semi-structured qualitative interviews after ending therapy. The transcripts were analyzed using a method based on metaphor-led discourse analysis.

RESULTS

Metaphors were organized into three different categories concerning the process of therapy, the therapeutic relationship and of improvement from depression. Most frequent were the metaphorical concepts of surface and depth, being open and closed, chemistry, tools, improvement as a journey from darkness to light and depression as a disease or opponent.

CONCLUSIONS

Patient metaphors concerning the therapeutic experience may provide clinicians and researchers valuable information about the process of therapy. Metaphors offer an opportunity for patients to communicate nuances about their therapeutic experience that are difficult to express in literal language. However, if not sufficiently explored and understood, metaphors may be misinterpreted and become a barrier for therapeutic change.

TRIAL REGISTRATION

Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Chinese App User's Needs Profile: From Questionnaire Measurement to Behavior Analysis

With the widespread use of mobile devices, the Apps people install and use could be closely linked to their needs. A precise profile of the needs of the user has become a vital foundation of the experience of the user. Previous studies mainly rely on self-reporting to understand the subjective attitudes of the App user toward a single App. This research combined questionnaire measurement and behavior analysis to profile the needs of the App user from a broader perspective. Based on the theoretical model of previous research studies, study 1 developed a novel needs questionnaire measurement of a Chinese App user, which showed good reliability and validity. In study 2, authorized App usage data were collected to construct the behavioral needs profile of a Chinese user. The results showed that the primary needs of the Chinese user remained a relatively high consistency between the questionnaire and the behavior data. The questionnaire-based and behavioral data-based needs profiles provide a reference for further personalized user experience design.

What too strict a method obscures about the validity of outcome measures

Objective: To assess the outcome of psychotherapeutic treatments, psychotherapy researchers often compare pre- and post-treatment scores on self-report outcome measures. In this paper, the common assumption is challenged that pre-to-post decreasing and increasing outcome scores are indicative of successful and failed therapies, respectively.Method: The outcome of 29 psychotherapeutic treatments was evaluated by means of quantitative analysis of pre- and post-treatment scores on commonly used outcome measures (such as the Symptom Checklist-90-R, the Inventory of Interpersonal Problems, and the General Health Questionnaire-12), as well as through consensual qualitative research.Results: Overall, a moderate to low convergence between qualitative and quantitative evaluations of outcome was observed. Detailed analyses of six cases are presented in which pre-to-post comparisons of outcome measures proved misleading.Conclusions: It is concluded that psychotherapy outcome research might benefit from assessment strategies that are sensitive to the singularities of individual treatments and to the complexity of the phenomenon of therapeutic outcome. Furthermore, classical psychometric evaluations of the validity of outcome measures might be supplemented with less-systematic evaluations that take any contingent source of information on outcome into account.

A comprehensive mapping of outcomes following psychotherapy for adolescent depression: The perspectives of young people, their parents and therapists

As mental health systems move towards person-centred care, outcome measurement in clinical research and practice should track changes that matter to young people and their families. This study mapped the types of change described by three key stakeholder groups following psychotherapy for depression, and compared the salience of these outcomes with the frequency of their measurement in recent quantitative treatment effectiveness studies for adolescent depression.Using qualitative content analysis, this study identified and categorized outcomes across 102 semi-structured interviews that were conducted with depressed adolescents, their parents, and therapists, as part of a randomized superiority trial. Adolescents had been allocated to Cognitive-Behavioral Therapy, Short-Term Psychoanalytic Psychotherapy, or a Brief Psychosocial Intervention.The study mapped seven high-level outcome domains and 29 outcome categories. On average, participants discussed change in four domains and six outcome categories. The most frequently discussed outcome was an improvement in mood and affect (i.e., core depressive symptoms), but close to half of the participants also described changes in family functioning, coping and resilience, academic functioning, or social functioning. Coping had specific importance for adolescents, while parents and therapists showed particular interest in academic functioning. There was some variation in the outcomes discussed beyond these core themes, across stakeholder groups and treatment arms.Of the outcomes that were frequently discussed in stakeholder narratives, only symptomatic change has been commonly reported in recent treatment studies for adolescent depression. A shift towards considering multiple outcome domains and perspectives is needed to reflect stakeholder priorities and enable more nuanced insights into change processes.

B Corps: A Socioeconomic Approach for the COVID-19 Post-crisis

The current global health and economic crisis caused by COVID-19 has opened the possibility to adopt the B Corp model and focus more on the person. Based on grounded theory, we have examined 147 organizations from 14 countries listed at the B Corp Directory for Latin America. Latin American B Corps have traits linked to family-related issues that are distinct from other B Corps located in different continents. Our main findings are that B Corps develop a more inclusive and sustainable economy to benefit society, go beyond the notion of CSR, and move away from traditional companies, as B Corps combine social development and economic growth.

Types of Utilization and Types of Treatment Response in a Collaborative Care Approach for Depressive Disorders in Old Age in Primary Care

Background: Treatment of depressive disorders in old age is hindered by several barriers. Most common are time pressure in primary care and latency for specialized therapeutic care. To improve treatment, the collaborative care approach GermanIMPACT was evaluated in a cluster-randomized controlled trial. Care managers offered a complex stepped-care intervention of monitoring, psychoeducation, and behavioral activation techniques. Twenty-six percent of the intervention group responds with a remission of depressive symptoms compared with 11% who received treatment as usual (TAU). The low-threshold intervention was more successful than TAU. Nevertheless, three-quarters did not respond with a remission. The aim of this study is to identify and describe the different types of utilization and of treatment response to understand what constitutes an effective intervention. Methods: Of 64 patients from the intervention group, we carried out problem-centered interviews with 26 patients from the intervention group. We analyzed the interviews using a qualitative type-building content analysis. For type construction, we performed a contrasting case comparison, regarding inductive and deductive categories of the intervention utilization and the symptom development. Results: The 26 participants' ages ranged from 62 to 87 years (mean = 72 years). Three participants were male. We identified five types of utilization, which differ primarily in the realization of pleasant activations, depending on own activity at the beginning and during the therapy: "activatable relief seekers," "active relief seekers," "active relaxation seekers," "passive problem-solving seekers," and "passive relief seekers." In the second typology, we analyzed four deductively determined types of treatment response responders, slight improvers, constant moderates, and non-responders. Patient-specific characteristics are a recent history of depression, an affinity for activities, supportive contacts, and limited comorbidity. In contrast, non-responders report contrary characteristics. Conclusion: Our two typologies emphasize that an effective intervention requires a match between intervention components and patient characteristics. We saw no intersections between utilization and treatment response. GermanIMPACT is an effective low-threshold intervention for moderately burdened patients, who are still capable of self-activation. An expansion of the intervention, especially for depression with a long history and comorbidities impairing mobility, could increase the effectiveness and improve the care situation of older people suffering from depression.