Do we know when our clients get worse? an investigation of therapists' ability to detect negative client change

Deliberate Practice Supervision in Action: The Sentio Supervision Model

Deliberate Practice (DP) is gaining consensus by researchers as a potentially promising method to increase therapist's effectiveness. While many clinicians and trainers now support DP's potential benefits, there is still a lack of guidelines, research, and training on implementing DP in clinical supervision. Recently, Vaz and Rousmaniere have proposed the Sentio Supervision Model as a method to integrate three major supervision-enhancing contributions: the use of routine outcome monitoring, the use of therapy recordings, and the use of DP skills training. We present a case study focusing on one client's treatment progress and their therapist's engagement in weekly supervision following the Sentio Supervision Model. The client had been identified by the outcome measure as being at risk of deterioration, and after DP supervision showed recovery and became on track for a good treatment outcome. Annotated transcripts provide a closer look into the clinical and supervisory process and how the latter influenced the former. We highlight the potential benefits and challenges inherent to this novel Supervision Model.

Personalized and collaborative use of digital measurement-based care tools enhances engagement among young adults: a mixed-methods study

BACKGROUND

Measurement-based care (MBC) enables personalised and proactive mental healthcare through regular symptom monitoring and review, allowing clinicians to make timely adjustments to clients' interventions for improved outcomes. Yet, its uptake in youth mental health services remains minimal. This study aims to explore perceived barriers and facilitators for sustained use of MBC and potential of digital technologies to enhance its engagement in young adults.

METHODS

A mixed-methods study, comprising focus groups and surveys, was conducted with young adults who had previously accessed mental health services. Template analysis was used to analyze qualitative data, and descriptive analyses were performed with quantitative data.

RESULTS

Eighteen young adults (mean age = 21.7 years; SD = 3.4) participated in this study. Survey results showed that young adults agreed with the value of MBC in their care (15/18) and reported low rates of discomfort with progress evaluation (11/18). Focus groups revealed collaborative data review with clinicians as a key facilitator in MBC uptake, driving repeated engagement with data input and review. Participants expressed that generalized interpretation of data that does not consider individual context, and the use of standard measures that were perceived to be irrelevant to their personal treatment goals discouraged their future engagement with MBC. Digital features that improve accessibility and data interpretation were expected to enhance consistent engagement with MBC.

CONCLUSIONS

The findings indicate that the motivation and sustained engagement in MBC stem from young adults' comprehension of how collected data fosters shared decision-making and personalize treatment. Therefore, regular, collaborative data reviews would be crucial in cultivating a sense of autonomy and purpose within MBC for young adults. This study highlights the importance of data review in enhancing the uptake of MBC, a factor that is often overlooked. By demonstrating this, the study provides a deeper understanding of motivators in MBC and valuable insights for mental health services to explore strategies that could support clinicians to integrate data review as part of routine care. To this end, one effective approach could be developing technologies that facilitate client-clinician communication and empower young adults to advocate for personalized care.

Evaluating the UE-ATR Checklist: Nuanced Attribution in Unsuccessful Therapeutic Outcomes

Unwanted events in psychotherapy can hinder treatment, yet clinicians overlook them and tend to attribute treatment stagnation mainly to patient-related factors. The unwanted events-adverse treatment reaction (UE-ATR) checklist was developed to encourage a more balanced reflection on treatment difficulties, but its effectiveness remains unclear. This study investigated whether the UE-ATR checklist enables clinicians to allocate treatment difficulties in a more nuanced way across various contributing factors. Clinicians and psychology students (N = 104) were randomly assigned to either use the UE-ATR (n = 59) or not (n = 45) while reviewing a case vignette of a patient who experienced unwanted events during therapy and treatment stagnation. They allocated responsibility for suboptimal treatment outcome across five factors: the patient, the therapist, the treatment method, the patient's pathology or other circumstances. Attribution was analysed using the Herfindahl-Hirschman index (HHI), where higher scores indicate a monocausal and lower scores reflect a multicausal view. No significant differences were found between the conditions. Although most users found the checklist clinically useful, this positive perception did not lead to a more balanced perspective on the causes of unwanted events. Although the UE-ATR checklist can support clinical reflection, additional training is necessary to maximize its effectiveness.

Bridging the feedback implementation gap: A comparison of empirical and rational decision rules in naturalistic psychotherapy

Objective: Previous research indicates positive effects of feedback based on rational or empirical decision rules in psychotherapy. The implementation of these usually session-to-session-based feedback systems into clinical practice, however, remains challenging. This study aims to evaluate decision rules based on routine outcome monitoring with reduced assessment frequency. Method: Data routinely collected every 5-20 sessions of N = 3758 patients treated with CBT in an outpatient clinic (Msessions = 42.8, SD = 15.4) were used to develop feedback decision rules based on the expected treatment response and nearest neighbors approach, the reliable change index, and method of percental improvement. The detection of patients at risk of treatment failure served as primary endpoint. Results: Significantly lower reliable improvement, higher reliable deterioration rates, and smaller effect sizes were found for patients identified at risk of treatment failure by all rules. The nearest neighbors-based approach showed the highest sensitivity regarding the detection of reliably deteriorated cases. Conclusion: Consistent with previous research, the empirical models outperformed the rational rules. Still, the first-time used percental improvement-based rule also showed satisfactory results. Overall, the results point to the potential of basic feedback systems that might be easier to implement in practice than session-to-session based systems.

First do no harm: Client and staff experiences of negative effects from dialectical behaviour therapy

OBJECTIVES

Research has shown that dialectical behaviour therapy (DBT) is effective in reducing self-harm and suicidal ideation, but there is also some evidence of negative effects with differences in the reports from clients and staff. However, no research has focused on both groups' understandings of negative effects. This study aimed to explore client and staff experiences of the negative effects from DBT, investigate how their understandings compare, and how staff address any negative effects that arise.

METHODS

Eight client participants and seven staff participants, who had experienced or witnessed negative experiences from DBT, engaged in semi-structured interviews, the transcripts of which were analysed using reflexive thematic analysis.

RESULTS

Four themes relating to client experiences were generated: 'I'm the problem', 'DBT can do no wrong', 'No understanding of trauma' and 'An unhealthy "blueprint for relationships"'. Five themes relating to staff experiences were generated: 'It's not me, it's the client', 'DBT or nothing', 'We don't do 'why' in DBT', 'We did make some changes' and 'Organisational "restrictions"'.

CONCLUSIONS

Both staff and clients understood negative effects from DBT to include pathologisation and re-traumatisation. However, whilst clients related negative effects to the therapeutic relationship, staff highlighted the impact of organisational restrictions. The findings support a number of changes to practice, particularly the need to recognise potential negative effects and provide meaningful informed consent procedures.

Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

Renewed Feedback-Informed Group Treatment for Patients with Anxiety and Depressive Disorders

Feedback-Informed Group Treatment (FIGT) shows promise for improving outcomes, but results are mixed. The aim was investigating the feasibility, acceptability and effects of renewed FIGT on clinical outcomes and therapy processes. In a quasi-experimental pilot study, 65 patients with anxiety or depressive disorders and 15 therapists of interpersonal psychotherapy or cognitive behavioural therapy groups using renewed FIGT were included. Renewed FIGT contained three additions compared to the previous tool: (1) personalized goals along with the Outcome Questionnaire-45 (OQ-45), (2) therapists' training, coaching and intervision, and (3) instructions to actively use feedback in the group. Data on feasibility, acceptability, outcomes and process factors were analysed and compared with those of historical cohorts using only OQ-45 feedback or no feedback, using descriptive, multilevel and covariance statistical analyses. Feasibility was mostly improved, with patients experiencing more feedback discussions and better usability compared to only OQ-45 feedback. At least two thirds of the patients and therapists give preference to using feedback in the future. At the end of the study, therapists were less convinced that the OQ-45 and goals were able to detect change. Renewed FIGT did not improve effectiveness on clinical outcomes. Compared to no feedback, patients experienced more cohesion, engagement and less avoidance, but improved less on depressive symptoms. Even when renewed FIGT is more feasible and usable than only OQ-45 feedback and associated with more cohesiveness and engagement, it may not automatically lead to improved effectiveness on clinical outcomes in short-term group therapy. Implications and future directions are described.

Motives of Therapists for Using Routine Outcome Monitoring (ROM) and How it is Used by Them in Clinical Practice: Two Qualitative Studies

Despite its demonstrated value, many mental health institutions struggle to implement progress feedback effectively. There is also insufficient information about how therapists utilize progress feedback. To gain more insight, two qualitative studies were conducted. The first study compared the attitudes and motives of therapists who used and those who did not use progress feedback. The second study examined how psychologists incorporated progress feedback into their practice. In total, 23 therapists were interviewed, and the data were analyzed using thematic analysis. The first study found that almost all the therapists had a positive attitude about progress feedback. Those who did not use it indicated reasons such as a heavy workload and patient-related factors, and they also lacked sufficient information about the potential benefits of progress feedback. The second study revealed four major ways in which the therapists utilized feedback, namely: supporting actions to discuss progress feedback, discussing progress feedback with patients, modifications in the ongoing treatment, and peer consultation. However, discussions during peer consultations about using progress feedback for patients who were not benefitting from treatment and how the treatment might be adjusted accordingly were often lacking. In conclusion, it is crucial that training and education be provided to therapists on how to use progress feedback effectively. Having regular discussions about progress feedback during peer consultations could also facilitate its integration into clinical practice.

Negative effects in randomized controlled trials of psychotherapies and psychological interventions: A systematic review

Background: Psychotherapy is a key evidence-based method for the treatment of mental disorders. However, little research has been published on the negative effects of psychotherapies. Aims: We examined this issue through a systematic literature review of previous systematic reviews on randomized controlled trials (RCTs). Methods: We focused on previous reviews and meta-analyses on 1) RCTs examining the effectiveness of psychotherapies and 2) previous reviews and meta-analyses specifically focusing on the negative effects of psychotherapy. We included publications published in PubMed and the Cochrane Databases from the year 2000 or later. Results: Of the 1,430 relevant publications, only a small proportion (30%) mentioned negative outcomes, mostly withdrawal. Only 57 of the extracted original studies monitored potential negative effects, and only three small-scale studies indicated negative effects. Conclusions: The systematic monitoring of negative effects in psychotherapy has not been given the same attention as has been given to the benefits of therapy.

Understanding non-response in psychotherapy: A meta-synthesis

INTRODUCTION

There is considerable research focusing on the negative outcomes of psychotherapy, however, there remains an overlooked population: those who appear to show no response after treatment. This qualitative evidence synthesis aimed to review the available literature exploring client and therapist experiences of psychotherapy nonresponse.

METHOD

Seven databases were searched for studies using qualitative approaches to explore nonresponse. Twenty-four studies met inclusion criteria and were analysed using Thematic Synthesis.

RESULTS

Six overarching client perspective themes and 18 subthemes were identified: Hopes and fears; A difficult task; A Disconnected relationship; Staying involved; Therapy was not worth the investment and, On a trajectory for improvement. Four overarching therapist perspective themes and 10 subthemes were identified: High expectations; Experiencing a disconnect; Feeling threatened and Holding onto hope.

DISCUSSION

A model of psychotherapy nonresponse is proposed. The experience of nonresponse appears to involve both clients and therapists finding therapy difficult, experiencing problems connecting and not being open in the therapeutic relationship. Importantly, nonresponse appears not to be an absence of effects, but a range of experiences that are potentially harmful, particularly to clients. However, there were varied experiences of nonresponse, which indicates the importance of qualitative outcome measurement.

Do Therapists Know When Their Clients Deteriorate? An Investigation of Therapists' Ability to Estimate and Predict Client Change During and After Psychotherapy

In routine outcome monitoring, psychotherapists receive feedback from their clients about their self-reported progress during therapy. This practice is based on research indicating that therapists overestimate their effectiveness and cannot detect and predict negative client change. However, this assumption is based on only a few studies. This study aimed to investigate whether trainee therapists could estimate client deterioration after each session and after therapy and whether they, from session to session, could predict client post-therapy outcomes. Fifty-three postgraduate trainee therapists at a university clinic treated 105 clients, with an average of 13.1 sessions. A questionnaire was developed to measure the therapists' estimation of client change at each session and their session-by-session prediction of client post-therapy outcomes. The 10-item version of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was used to measure clients' self-reported change at each session. The data included 96 (91.5%) therapist estimations of client post-therapy outcomes, 1015 (87.8%) estimations of client change from the second to the penultimate session, and 1140 predictions of post-therapy outcomes. The study found that at post-therapy, the therapists were only able to identify one out of eight clients who showed deterioration on the CORE-10. Additionally, during therapy, they could accurately estimate only six out of 83 sessions in which clients had experienced deterioration on the CORE-10, and they failed to predict any of the eight clients who ended therapy with deterioration. In conclusion, therapists cannot rely on their clinical judgement alone to assess client progress and outcomes and will depend on routine outcome monitoring to detect client deterioration.

Beyond Detection: Towards Actionable Sensing Research in Clinical Mental Healthcare

Researchers in ubiquitous computing have long promised that passive sensing will revolutionize mental health measurement by detecting individuals in a population experiencing a mental health disorder or specific symptoms. Recent work suggests that detection tools do not generalize well when trained and tested in more heterogeneous samples. In this work, we contribute a narrative review and findings from two studies with 41 mental health clinicians to understand these generalization challenges. Our findings motivate research on actionable sensing, as an alternative to detection research, studying how passive sensing can augment traditional mental health measures to support actions in clinical care. Specifically, we identify how passive sensing can support clinical actions by revealing patients' presenting problems for treatment and identifying targets for behavior change and symptom reduction, but passive data requires additional contextual information to be appropriately interpreted and used in care. We conclude by suggesting research at the intersection of actionable sensing and mental healthcare, to align technical research in ubiquitous computing with clinical actions and needs.

Early Change as a Predictor of Treatment Outcome in Patients with a Personality Disorder

A significant proportion of patients with a personality disorder do not benefit from treatment. Monitoring treatment progress can help adjust ineffective treatments. This study examined whether early changes in symptoms and personality dysfunction during the first phase of therapy could predict treatment outcomes. Data from 841 patients who received specialized treatment for personality disorders were analyzed. The study focused on whether changes in the Outcome Questionnaire-45.2 (OQ-45.2) symptom distress scale (SD), the General Assessment of Personality Disorder (GAPD), and Severity Indices of Personality Problems (SIPP) in the early phase of therapy predicted post-treatment personality dysfunction, as measured by the SIPP and GAPD. Early changes within a specific SIPP domain were the strongest predictors of post-treatment outcomes in that same domain. Early changes in symptoms significantly predicted outcomes in Self-Control, Relational Functioning, and Identity Integration, while the GAPD predicted outcomes in Self-Control and Social Attunement on the SIPP. For the GAPD, early changes on the GAPD itself, followed by early changes on the OQ-45 SD and the SIPP domain Social Attunement, were significant predictors. Thus, when it comes to personality dysfunction, early changes in a specific domain or measure are the best predictors of outcomes in that same domain. While the OQ-45 predicted some aspects of personality dysfunction, it should not replace disorder-specific measures. Additionally, the SIPP domains and the GAPD should not be used interchangeably to predict each other. In sum, considering these factors, monitoring early change can be useful in assessing progress in the treatment of patients with personality disorders.

Clinicians' perspectives on retraumatisation during trauma-focused interventions for post-traumatic stress disorder: A survey of UK mental health professionals

Concerns regarding retraumatisation have been identified as a barrier to delivering trauma-focused therapy for post-traumatic stress disorder (PTSD). We explored clinicians' understanding of what constitutes potential signs of retraumatisation (PSoR), reported incidences of witnessing retraumatisation, use of (and confidence in) therapies for PTSD, fear of retraumatisation during therapy for PTSD, and whether having witnessed retraumatisation was associated with these variables. We surveyed 348 clinicians. There was variation in what clinicians viewed as PSoR. Retraumatisation was reported by clinicians in 3.4 % of patients undergoing trauma-focused therapy for PTSD. A variety of trauma-focused and non-trauma-focused therapies were routinely used, yet 14.4 % reported not using trauma-focused therapy. There was a significant negative correlation between participants' highest reported confidence in trauma-focused therapy and endorsement of PSoR (r = -.25) and fear of retraumatisation (r = -.28). Mean fear of retraumatisation was 30.3 (SD=23.4; a score we derived from asking participants out of 100 how much they worry about trauma-focused therapy being harmful in its own right/leading to a worsening of PTSD symptoms). Participants who had witnessed retraumatisation reported significantly greater endorsement of PSoR (d=.69 [95 % CI .37, 1.02]) and fear of retraumatisation (d=.94 [95 % CI .61, 1.26]). Confidence in using therapies for PTSD was varied and related to how clinicians understood retraumatisation. Retraumatisation is uncommon, but there is variability in clinicians' interpretation of what retraumatisation is, and its utility warrants research.

Comparison of the Efficacy Between Standard Measurement-Base Care (MBC) and Enhanced MBC for Major Depressive Disorder: A Pilot Study

Purpose

To validate the efficacy of enhanced measurement-based care against standard measurement-based care in patients with major depressive disorder.

Patients and Methods

In this pilot study of an ongoing multicenter cluster randomized controlled trails, 160 patients diagnosed with major depressive disorder were enrolled from 2 mental health centers, with a plan to include 12 centers in total. One hundred patients engaged in a six-month evaluation using a technology-enhanced measurement-based care tool, including assessments of clinical symptoms, side effects, and functionality at baseline, two months, four months and six months. Simultaneously, the remaining 60 patients underwent standard paper-based measurement-based care, utilizing the same set of scales over the same six-month period, with assessments at the same time points.

Results

Patients utilizing the enhanced measurement-based care tool demonstrated a significantly higher reduction rate in PHQ-9 scores compared to those using standard paper-based measurement-based care during the two-month follow-up. Additionally, a notable positive correlation was observed between the frequency of enhanced measurement-based care tool usage and the quality of life during the two-month follow-up.

Conclusion

Enhanced measurement-based care has the effect of reducing depressive symptoms. Our study emphasized that using enhanced measurement-based care via smartphones is a feasible tool for patients with major depressive disorder. Our future study, including results from additional research centers, may further validate the effectiveness of enhanced measurement-based care.

Adverse Events of Psychological Interventions: Definitions, Assessment, Current State of the Research and Implications for Research and Clinical Practice

BACKGROUND

The effectiveness of psychological interventions is undisputed. But while in other fields of health care the safety of interventions is studied alongside effectiveness, adverse events (AEs) have only recently been assessed in clinical studies of psychological interventions. This critical review summarizes the definition, assessment and current research status of AEs of psychological interventions.

SUMMARY

AEs are defined as any untoward event or unfavorable change that occurs in the course of a psychological intervention. AEs that are caused by the intervention can be classified into side effects of correctly applied treatment, malpractice (i.e., incorrectly applied treatment) and unethical conduct (e.g., sexual abuse). Ideally, they are assessed by independent raters or alternatively by self-report questionnaires that should also cover serious adverse events (SAEs, e.g., suicide attempts or self-injurious behaviors). About 1 to 2 in 3 patients report at least 1 AE and results of meta-analyses suggest that treatments might differ in frequency and/or severity of AE and in treatment acceptability (measured as dropout rates).

KEY MESSAGES

Measures of AEs and SAEs as well as more nuanced descriptions of dropout should be included in all clinical studies of psychological interventions. If this happens, we might learn that psychological interventions differ with respect to AEs, SAEs and acceptability. As many psychological interventions are about equally effective, they might one day be chosen based on differences in their safety profile rather than their differential effectiveness. Ideally, reducing AEs might also lead to more effective interventions.

Informing patients about possible negative effects of psychological treatment: A survey of Swedish clinical psychologists' attitudes and practices

OBJECTIVE

The present study explored Swedish clinical psychologists' attitudes and practices of informing patients about possible negative effects of psychological treatment.

METHOD

An anonymous online survey with closed and open-ended questions was distributed via Facebook and two mailing lists. In total, 320 clinical psychologists (age M = 38.6, SD = 10.3; 76% women; 77.3% Cognitive Behavior Therapy) completed the survey. Responses were analyzed using χ2, binominal regression analysis, and thematic analysis.

RESULTS

No significant associations were identified between demographic variables selected a priori and informing patients about possible negative effects, i.e., years in practice, therapeutic orientation, age, and male gender. The thematic analysis resulted in several positive (e.g., creating realistic expectations of treatment and increasing resilience) and negative attitudes (e.g., causing excessive worry) of sharing patients with information about possible negative effects. It also revealed various factors that prevent an open discussion on the topic, despite being seen as important.

CONCLUSION

The need to offer patients information about possible negative effects should be included in ethical guidelines, codes of conduct, and taught during clinical training. Lack of knowledge, fear, lack of time, and patient characteristics however seem to prevent therapists from discussing the issue during the informed consent procedure.

No pain, no gain revisited: the impact of positive and negative psychotherapy experiences on treatment outcome

Objective

Psychotherapy may have many benefits for patients with mental health problems, but patients may also have negative experiences related to the therapy. Not much is known about these negative psychotherapy experiences and their impact on treatment outcome. The aim of this study was to examine the association between positive and negative psychotherapy experiences and treatment outcome.

Methods

A total of 130 patients participated in the study. They received treatment as usual and were assessed for positive and negative psychotherapy experiences at mid-treatment and post-treatment using the Positive and Negative Experiences of Psychotherapy Questionnaire (PNEP). Treatment outcome was measured by the Outcome Questionnaire - 45 (OQ-45). Multiple linear regression was used to analyze the data.

Results

All patients reported positive psychotherapy experiences at mid-treatment. At least one negative experience was reported by 69% of participants. After correction for baseline severity (i.e., OQ-45 at baseline) and relevant demographic variables, positive psychotherapy experiences at mid-treatment emerged as a predictor for treatment outcome. In contrast, negative psychotherapy experiences did not predict treatment outcome. However, reporting more negative experiences was associated with reporting fewer positive experiences at mid- and end of treatment.

Conclusion

Both positive and negative psychotherapy experiences commonly occur. Although in this study negative psychotherapy experiences did not predict treatment outcome in terms of symptom reduction, the findings do suggest that negative experiences may influence the way in which patients evaluate their treatment. Although positive experiences outweigh negative experiences, patients should be informed that negative experiences may also occur.

Dynamic learning of individual-level suicidal ideation trajectories to enhance mental health care

There has recently been an increase in ongoing patient-report routine outcome monitoring for individuals within clinical care, which has corresponded to increased longitudinal information about an individual. However, many models that are aimed at clinical practice have difficulty fully incorporating this information. This is in part due to the difficulty in dealing with the irregularly time-spaced observations that are common in clinical data. Consequently, we built individual-level continuous-time trajectory models of suicidal ideation for a clinical population (N = 585) with data collected via a digital platform. We demonstrate how such models predict an individual's level and variability of future suicide ideation, with implications for the frequency that individuals may need to be observed. These individual-level predictions provide a more personalised understanding than other predictive methods and have implications for enhanced measurement-based care.

A Scale for Measuring Positive and Negative Experiences of Psychotherapy (PNEP): First Psychometric Findings of a New Instrument for Monitoring Clients' Experiences

BACKGROUND

Clients' adverse experiences during psychotherapy are rarely monitored in clinical practice or research trials. One obstacle here is the lack of a measure to gauge both positive and negative experiences during psychotherapy. We developed and evaluated a new instrument for measuring such experiences.

METHOD

The Positive and Negative Experiences of Psychotherapy (PNEP) questionnaire was developed based on pilot data, a literature review, and two existing scales for measuring primarily adverse experiences during psychotherapy. Mental healthcare clients (N = 200) anonymously completed and evaluated the PNEP. Subsequently, a sample of professionals (N = 34) who underwent psychotherapy in the context of their training filled in the PNEP twice, with a 2-week interval in between.

RESULTS

The positive and negative experiences subscales of the PNEP were found to possess excellent internal consistencies (αs ≥ 0.90). The PNEP test-retest reliability was 0.93 for the positive experiences subscale and 0.78 for the negative experiences subscale. For the positive subscale, four factors were extracted: symptom reduction and positive well-being, high quality of therapy and therapeutic relation, personal growth and acceptance and interpersonal functioning. For the negative subscale, exploratory factor analysis suggested a three-factor solution: escalation of symptoms and emotional distress, low quality of therapy and therapeutic relation and (self-)stigmatization and dependency. Participants related a median of 13 positive and six negative therapy experiences to their most recent treatment. The most frequently endorsed negative experiences were having more negative thoughts and memories, feeling emotionally overwhelmed and an increase in stress due to the therapy. A minority of participants (10.5%) reported no negative treatment experiences.

CONCLUSIONS

In the field of psychotherapy, the evaluation of risks and benefits is crucial for assessing safety and effectiveness. The PNEP could be a promising instrument for achieving this objective, although further research is needed to replicate and expand upon the current findings.

An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial

INTRODUCTION

Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings.

METHODS AND ANALYSIS

We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness.

ETHICS AND DISSEMINATION

Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Real-world clinical outcomes and treatment patterns in patients with MDD treated with vortioxetine: a retrospective study

BACKGROUND

This study included evaluation of the effectiveness of vortioxetine, a treatment for adults with major depressive disorder (MDD), using patient-reported outcome measures (PROMs) in a real-world setting.

METHODS

This retrospective chart review analyzed the care experiences of adult patients with a diagnosis of MDD from Parkview Physicians Group - Mind-Body Medicine, Midwestern United States. Patients with a prescription for vortioxetine, an initial baseline visit, and ≥ 2 follow-up visits within 16 weeks from September 2014 to December 2018 were included. The primary outcome measure was effectiveness of vortioxetine on depression severity as assessed by change in Patient Health Questionnaire-9 (PHQ-9) scores ~ 12 weeks after initiation of vortioxetine. Secondary outcomes included changes in depression-related symptoms (i.e., sexual dysfunction, sleep disturbance, cognitive function, work/social function), clinical characteristics, response, remission, and medication persistence. Clinical narrative notes were also analyzed to examine sleep disturbance, sexual dysfunction, appetite, absenteeism, and presenteeism. All outcomes were examined at index (start of vortioxetine) and at ~ 12 weeks, and mean differences were analyzed using pairwise t tests.

RESULTS

A total of 1242 patients with MDD met inclusion criteria, and 63.9% of these patients had ≥ 3 psychiatric diagnoses and 65.9% were taking ≥ 3 medications. PHQ-9 mean scores decreased significantly from baseline to week 12 (14.15 ± 5.8 to 9.62 ± 6.03, respectively; p < 0.001). At week 12, the response and remission rates in all patients were 31.0% and 23.1%, respectively, and 67% continued vortioxetine treatment. Overall, results also showed significant improvements by week 12 in anxiety (p < 0.001), sexual dysfunction (p < 0.01), sleep disturbance (p < 0.01), cognitive function (p < 0.001), work/social functioning (p = 0.021), and appetite (p < 0.001). A significant decrease in presenteeism was observed at week 12 (p < 0.001); however, no significant change was observed in absenteeism (p = 0.466).

CONCLUSIONS

Using PROMs, our study results suggest that adults with MDD prescribed vortioxetine showed improvement in depressive symptoms in the context of a real-world clinical practice setting. These patients had multiple comorbid psychiatric and physical diagnoses and multiple previous antidepressant treatments had failed.

Consultation as an Implementation Strategy to Increase Fidelity of Measurement-Based Care Delivery in Community Mental Health Settings: An Observational Study

Regularly administering outcome measures to clients to inform clinical decision making, referred to as measurement-based care (MBC), has the potential to improve mental health treatment due to its applicability across disorders and treatment settings. Given the utility of MBC, understanding predictors of high-fidelity MBC implementation is important. Training and consultation are widely used implementation strategies to increase the fidelity of evidence-based practice delivery but have rarely been studied with MBC. The current study will examine the relationship between time clinicians spent discussing a case in consultation ("dosage") and MBC fidelity. Thirty clinicians and 56 youth were in the MBC condition of a randomized controlled trial and completed baseline questionnaires. Consultation dosage was extracted from call notes. MBC fidelity was measured using the implementation index, which combines rates of administering and viewing questionnaires, using objective data from the online MBC system. Multi-level modeling was used. Greater consultation dosage significantly predicted a higher implementation index (ß = 0.27, SE = 0.06, p < .001). For every 30 min spent discussing a case in consultation, the case's MBC fidelity increased by 8.1%. Greater consultation dosage significantly predicted higher rates of administration (ß = 0.07, SE = 0.03, p = 0.033) and feedback report viewing (ß = 0.24, SE = 0.06, p < .001). More consultation at the case level predicts greater MBC fidelity using objective measures. The greatest impact was increasing the clinician feedback report viewing rate. The results of this study can help inform future efforts to increase the fidelity with which MBC is delivered and to make consultation as efficient and effective as possible.

EMPOWERED trial: protocol for a randomised control trial of digitally supported, highly personalised and measurement-based care to improve functional outcomes in young people with mood disorders

OBJECTIVES

Many adolescents and young adults with emerging mood disorders do not achieve substantial improvements in education, employment, or social function after receiving standard youth mental health care. We have developed a new model of care referred to as 'highly personalised and measurement-based care' (HP&MBC). HP&MBC involves repeated assessment of multidimensional domains of morbidity to enable continuous and personalised clinical decision-making. Although measurement-based care is common in medical disease management, it is not a standard practice in mental health. This clinical effectiveness trial tests whether HP&MBC, supported by continuous digital feedback, delivers better functional improvements than standard care and digital support.

METHOD AND ANALYSIS

This controlled implementation trial is a PROBE study (Prospective, Randomised, Open, Blinded End-point) that comprises a multisite 24-month, assessor-blinded, follow-up study of 1500 individuals aged 15-25 years who present for mental health treatment. Eligible participants will be individually randomised (1:1) to 12 months of HP&MBC or standardised clinical care. The primary outcome measure is social and occupational functioning 12 months after trial entry, assessed by the Social and Occupational Functioning Assessment Scale. Clinical and social outcomes for all participants will be monitored for a further 12 months after cessation of active care.

ETHICS AND DISSEMINATION

This clinical trial has been reviewed and approved by the Human Research Ethics Committee of the Sydney Local Health District (HREC Approval Number: X22-0042 & 2022/ETH00725, Protocol ID: BMC-YMH-003-2018, protocol version: V.3, 03/08/2022). Research findings will be disseminated through peer-reviewed journals, presentations at scientific conferences, and to user and advocacy groups. Participant data will be deidentified.

TRIAL REGISTRATION NUMBER

ACTRN12622000882729.

Improving measurement-based care implementation in adult ambulatory psychiatry: a virtual focus group interview with multidisciplinary healthcare professionals

BACKGROUND

Measurement-Based Care (MBC) is an evidence-based practice shown to enhance patient care. Despite being efficacious, MBC is not commonly used in practice. While barriers and facilitators of MBC implementation have been described in the literature, the type of clinicians and populations studied vary widely, even within the same practice setting. The current study aims to improve MBC implementation in adult ambulatory psychiatry by conducting focus group interviews while utilizing a novel virtual brainwriting premortem method.

METHODS

Semi-structured focus group interviews were conducted with clinicians (n = 18) and staff (n = 7) to identify their current attitudes, facilitators, and barriers of MBC implementation in their healthcare setting. Virtual video-conferencing software was used to conduct focus groups, and based on transcribed verbatin, emergent barriers/facilitators and four themes were identified. Mixed methods approach was utilized for this study. Specifically, qualitative data was aggregated and re-coded separately by three doctoral-level coders. Quantitative analyses were conducted from a follow-up questionnaire surveying clinician attitudes and satisfaction with MBC.

RESULTS

The clinician and staff focus groups resulted in 291 and 91 unique codes, respectively. While clinicians identified a similar number of barriers (40.9%) and facilitators (44.3%), staff identified more barriers (67%) than facilitators (24.7%) for MBC. Four themes emerged from the analysis; (1) a description of current status/neutral opinion on MBC; (2) positive themes that include benefits of MBC, facilitators, enablers, or reasons on why they conduct MBC in their practice, (3) negative themes that include barriers or issues that hinder them from incorporating MBC into their practice, and (4) requests and suggestions for future MBC implementation. Both participant groups raised more negative themes highlighting critical challenges to MBC implementation than positive themes. The follow-up questionnaire regarding MBC attitudes showed the areas that clinicians emphasized the most and the least in their clinical practice.

CONCLUSION

The virtual brainwriting premortem focus groups provided critical information on the shortcomings and strengths of MBC in adult ambulatory psychiatry. Our findings underscore implementation challenges in healthcare settings and provide insight for both research and clinical practice in mental health fields. The barriers and facilitators identified in this study can inform future training to increase sustainability and better integrate MBC with positive downstream outcomes in patient care.

Development and validation of the facilitative interpersonal skills scale for clients

OBJECTIVE

Psychotherapy studies have revealed that therapist characteristics are responsible for 5% to 9% of outcome variance. The therapist-facilitative interpersonal skills (FIS) have been shown to predict both alliance and outcomes, indicating that higher FIS therapists are more effective than lower FIS therapists. The current study focused on the development and validation of the FIS-client version (FIS-C) instrument, aimed at collecting the clients' perspectives on relevant therapist characteristics.

METHOD

The clinical outcomes in routine evaluation-outcome measures, the session rating scale, and the FIS questionnaire-client version were filled out by psychotherapy clients. Exploratory, confirmatory factor, and test-retest analysis were conducted.

RESULTS

Results indicate robust psychometric characteristics, in terms of validity (factorial, convergent, discriminant, and nomological), reliability, and sensitivity.

CONCLUSION

The validation of the FIS-C represents an important contribution to clinical research and practice, namely to the field of client feedback and therapist expertise.

The preliminary development and psychometric properties of the Psychotherapy Side Effects Scale

BACKGROUND

Side effects in psychotherapy are common and have a negative impact on patients or clients. However, effective evaluation tools are still lacking and have not been fully studied. The present study aims to develop a scale with good reliability and validity to measure the side effects of psychotherapy.

METHODS

The 25 items in the Psychotherapy Side Effects Scale (PSES) were condensed and distributed to 420 subjects online to test its psychometric properties.

RESULTS

The internal consistency of the PSES was satisfactory to excellent (Cronbach's ɑ coefficient was .95, and the Guttman split-half coefficient was 0.88). A statistically significant negative correlation between the satisfaction score and the total score of the PSES was shown (r = -0.51, p < .001). The PSES could effectively discriminate between two groups with and without side effects (F = 250.95, p < .001) and was able to predict the occurrence of side effects in psychotherapy with an area under curve of 0.932 and a 95% confidence interval of 0.900-0.964 (p < .001). A cutoff was set at 36 points in total PSES score, from which the maximum Youden's index (= 0.72) could be obtained. The positive rate of the PSES was 24% (101/420).

CONCLUSION

The PSES showed good internal consistency, content validity, concurrent validity, discriminant validity and predictive validity in evaluating and identifying side effects in psychotherapy. More advanced reliability testing methods and structural validity testing for PESE need to be practiced in the future to better serve clinical practice.

Which therapist perceptions best predict client outcomes? A naturalistic examination

Examining associations between therapists' perceptions of therapy sessions and client-reported outcomes in naturalistic settings (real-life therapy settings) can provide valuable guidance for the assessment, treatment, and monitoring of clients. This study included data of 1334 sessions from 127 clients (86 individual and 41 couple cases) and 15 therapists, collected at a therapy training center. Clients reported their personal functioning and individual symptoms before each session. Therapists rated clients' participation, receptivity, session progress, goal progress, and therapeutic alliance at the end of each therapy session. Multilevel Structural Equation Modeling analyses revealed that therapist-rated client participation and goal progress predicted better personal functioning, beyond clients' previous personal functioning scores. In contrast, none of therapist-rated session variables predicted clients' individual symptoms, beyond previous symptom scores. Power analyses suggested sufficient statistical power to detect small effect sizes. Findings of the current study have clinical implications for treatment planning and progress monitoring.

The development of a reliable change index and cutoff score for the SCORE-15

The Systemic Clinical Outcome and Routine Evaluation version 15 (SCORE-15) is a measure used to assess family-level change in family therapy. The SCORE-15 has been demonstrated to be a reliable and valid measure, with high clinical utility; however, the SCORE-15 lacks the ability to determine whether the change in family functioning during the course of therapy is clinically significant. This study aimed to establish a reliable change index (RCI) and clinical cutoff score so that researchers and clinicians can determine clinically significant change in family therapy. US samples of 71 clinical participants and 244 community participants completed the SCORE-15. Results indicated a cutoff score of 40.37 and an RCI of 9.52. Consequently, family members who improve their SCORE-15 score during the course of therapy by at least 9 points and who cross the threshold of 40 during the course of therapy are considered to have experienced clinically significant change.

Organization-level variation in therapists' attitudes toward and use of measurement-based care

PURPOSE

Despite significant interest in improving behavioral health therapists' implementation of measurement-based care (MBC)-and widespread acknowledgment of the potential importance of organization-level determinants-little is known about the extent to which therapists' use of, and attitudes toward, MBC vary across and within provider organizations or the multilevel factors that predict this variation.

METHODS

Data were collected from 177 therapists delivering psychotherapy to youth in 21 specialty outpatient clinics in the USA. Primary outcomes were use of MBC for progress monitoring and treatment modification, measured by the nationally-normed Current Assessment of Practice Evaluation-Revised. Secondary outcomes were therapist attitudes towards MBC. Linear multilevel regression models tested the association of theory-informed clinic and therapist characteristics with these outcomes.

RESULTS

Use of MBC varied significantly across clinics, with means on progress monitoring ranging from values at the 25th to 93rd percentiles and means on treatment modification ranging from the 18th to 71st percentiles. At the clinic level, the most robust predictor of both outcomes was clinic climate for evidence-based practice implementation; at the therapist level, the most robust predictors were: attitudes regarding practicality, exposure to MBC in graduate training, and prior experience with MBC. Attitudes were most consistently related to clinic climate for evidence-based practice implementation, exposure to MBC in graduate training, and prior experience with MBC.

CONCLUSIONS

There is important variation in therapists' attitudes toward and use of MBC across clinics. Implementation strategies that target clinic climate for evidence-based practice implementation, graduate training, and practicality may enhance MBC implementation in behavioral health.

Systematic review: Wearable remote monitoring to detect nonalcohol/nonnicotine-related substance use disorder symptoms

BACKGROUND AND OBJECTIVES

Substance use disorders (SUDs) are chronic relapsing diseases characterized by significant morbidity and mortality. Phenomenologically, patients with SUDs present with a repeating cycle of intoxication, withdrawal, and craving, significantly impacting their diagnosis and treatment. There is a need for better identification and monitoring of these disease states. Remote monitoring chronic illness with wearable devices offers a passive, unobtrusive, constant physiological data assessment. We evaluate the current evidence base for remote monitoring of nonalcohol, nonnicotine SUDs.

METHODS

We performed a systematic, comprehensive literature review and screened 1942 papers.

RESULTS

We found 15 studies that focused mainly on the intoxication stage of SUD. These studies used wearable sensors measuring several physiological parameters (ECG, HR, O2 , Accelerometer, EDA, temperature) and implemented study-specific algorithms to evaluate the data.

DISCUSSION AND CONCLUSIONS

Studies were extracted, organized, and analyzed based on the three SUD disease states. The sample sizes were relatively small, focused primarily on the intoxication stage, had low monitoring compliance, and required significant computational power preventing "real-time" results. Cardiovascular data was the most consistently valuable data in the predictive algorithms. This review demonstrates that there is currently insufficient evidence to support remote monitoring of SUDs through wearable devices.

SCIENTIFIC SIGNIFICANCE

This is the first systematic review to show the available data on wearable remote monitoring of SUD symptoms in each stage of the disease cycle. This clinically relevant approach demonstrates what we know and do not know about the remote monitoring of SUDs within disease states.

The feasibility, acceptability and effectiveness of a feedback-informed group treatment (FIGT) tool for patients with anxiety or depressive disorders

Monitoring treatment progress by the use of standardized measures in individual therapy, also called feedback-informed treatment (FIT), has a small but significant effect on improving outcomes. Results of FIT in group therapy settings are mixed, possibly due to contextual factors. The goals of this study were to investigate the feasibility, acceptability and effectiveness of a feedback-informed group treatment (FIGT) tool, based on the principles of the Contextual Feedback Theory and earlier FIGT research. Patients with anxiety or depressive disorders following interpersonal or cognitive behavioural group psychotherapy (IPT-G or CBT-G) were randomized to either feedback (n=104) or Treatment As Usual (TAU; n=93). In the feedback condition, patients filled out the Outcome-Questionnaire 45 (OQ-45) weekly in a FIGT tool and therapists were instructed to discuss the results in each session. Dropout, attendance and outcomes were measured. Additionally, in the feedback condition, OQ-45 response, feedback discussions and acceptability by patients and therapists were assessed. Results showed no differences on dropout, but lower attendance rates in the feedback condition. Although therapists reported high rates of feedback use and helpfulness, patients experienced that results were discussed with them only half of the time and they were also less optimistic about its usefulness. The findings indicate that the FIGT instrument was partially feasible, more acceptable to therapists than patients, and was not effective as intended. Future research is needed to discover how feedback can be beneficial for both therapists and patients in group therapy.

Client perspectives on psychotherapy failure

This study qualitatively examined client's definition and experiences of failed psychotherapy.

Thirteen clients were interviewed by phone regarding their experience of failed psychotherapy. Data were analyzed using consensual qualitative research (CQR).

Participants defined failed psychotherapy as negatively affecting clients, involving problems in the psychotherapy relationship, and not meeting clients' goals. When describing specific experiences of failed psychotherapy, participants gradually recognized the failure themselves, but the recognition was sometimes facilitated by others. Pre-termination, the failed psychotherapy yielded negative effects (worsened symptoms/functioning, deteriorating relationship, not addressing clients' concerns). Participants perceived therapists' contributions as involving action (insensitive/inappropriate responses to participants' concerns about psychotherapy) and inaction (not managing psychotherapy effectively). They perceived their own contributions as their difficulty voicing their concerns or asserting themselves. Post-termination effects were negative cognitively/affectively (heightened distress), behaviorally (disinterest in seeking mental health services), and interpersonally (relationship difficulties in later psychotherapy); the failed psychotherapy also helped participants pursue their needs in psychotherapy.

Failed psychotherapy consisted of problems in the relationship and the treatment not meeting client's goals. Such psychotherapy worsened clients' functioning, further damaged an already tenuous psychotherapy relationship, and both therapists and clients contributed to the failure. After termination, failed psychotherapy yielded cognitive/affective, behavioral, and interpersonal effects.

Therapy from my point of view: A case illustration of routine outcome monitoring and feedback in psychotherapeutic interventions

Lately, the use of patient-reported outcome measures (PROM) to adapt and improve ongoing psychotherapeutic treatments has become more widespread. Their main purpose is to support data-informed, collaborative treatment decisions which include the patient's point of view on their progress. In case of nonresponse or deterioration, these systems are able to warn clinicians and guide the process "back on track" in treatment. In this case illustration, the Greifswald Psychotherapy Navigator System (GPNS) detected the deterioration of 19-year-old Sarah during the first eight sessions of cognitive-behavioral therapy for social anxiety and depression. Here, the GPNS helped the therapist gain insight as to how Sarah's social anxiety affected their treatment and adjust her strategy accordingly. Using the symptom curves and progress scales of the GPNS, the therapist was able to then address her patient's struggles in detail during their sessions and with her supervisor. After adapting her therapeutic approach, the patient's deterioration could be averted while simultaneously strengthening their communication in the process. Clinical implications and the benefits of using PROM systems for evidence-based personalization of psychotherapy are presented.

Improving the Quality of Children's Mental Health Care with Progress Measures: A Mixed-Methods Study of PCIT Therapist Attitudes

Progress measures are an evidence-based technique for improving the quality of mental health care, however, clinicians rarely incorporate them into treatment. Research into how measure type impacts clinician preference has been recommended to help improve measure implementation. Parent–Child Interaction Therapy (PCIT) is an assessment-driven treatment that serves as an ideal intervention through which to investigate measure preferences given its routine use of two types of assessments, a behavioral observation (the Dyadic Parent–Child Interaction Coding System) and a parent-report measure (the Eyberg Child Behavior Inventory). This study investigated PCIT therapist attitudes towards progress measures used within PCIT and children’s mental health treatment generally. A mixed-method (QUAN + QUAL) study design examined PCIT therapist attitudes towards two types of progress measures and measures used in two contexts (PCIT and general practice). Multi-level modeling of a survey distributed to 324 PCIT therapists identified predictors of therapist attitudes towards measures, while qualitative interviews with 23 therapists expanded and clarified the rationale for differing perceptions. PCIT therapists reported more positive attitudes towards a behavioral observation measure, the DPICS, than a parent-report measure, the ECBI, and towards measures used in PCIT than in general practice. Clinician race/ethnicity was significantly related to measure-specific attitudes. Qualitative interviews highlighted how perceptions of measure reliability, type of data offered, ease of use, utility in guiding sessions and motivating clients, and embeddedness in treatment protocol impact therapist preferences. Efforts to implement progress monitoring should consider preferences for particular types of measures, as well as how therapists are trained to embed measures in treatment.

A routine outcome measure for youth mental health: Clinically interpreting MyLifeTracker

AIM

MyLifeTracker is a session-by-session mental health outcome measure for young people aged 12 to 25 years. The aim of this study was to determine clinically significant change indexes for this measure that would identify developmentally appropriate thresholds. The study also aimed to determine expected change trajectories to enable clinicians to compare a client's progress against average rates of change.

METHODS

Participants comprised young people aged 12 to 25 years from both a clinical and a community sample from Australia. The clinical sample was 63 840 young people that attended a headspace centre. The non-clinical group was an Australian representative community sample of 4034 young people.

RESULTS

Clinically significant change indexes were developed for MyLifeTracker specific for age and gender groups by comparing clinical and non-clinical samples. Males and young people aged 12 to 14 years needed to reach higher scores to achieve clinically significant change compared to females and other age groups, respectively. MyLifeTracker expected change trajectories followed a cubic pattern for those with lower baseline scores of 0 to 50, whereas those with baseline scores of 51 and above had varying patterns. For those with lower baseline scores, expected change trajectories showed that stronger change was evident early in treatment, which then tapered off before accelerating again later in treatment.

CONCLUSIONS

The development of MyLifeTracker benchmarks allows the measure to be used for Feedback Informed Treatment by supporting treatment planning and decision-making. This information can help clinicians to identify clients who are not on track or deteriorating and identify when clients are improving.

Defining and measuring meditation-related adverse effects in mindfulness-based programs

BACKGROUND

Research on the adverse effects of mindfulness-based programs (MBPs) has been sparse and hindered by methodological imprecision.

METHODS

The 44-item Meditation Experiences Interview (MedEx-I) was used by an independent assessor to measure meditation-related side effects (MRSE) following three variants of an 8-week program of mindfulness-based cognitive therapy (n = 96). Each item was queried for occurrence, causal link to mindfulness meditation practice, duration, valence, and impact on functioning.

RESULTS

Eighty-three percent of the MBP sample reported at least one MRSE. Meditation-related adverse effects (MRAEs) with negative valences or negative impacts on functioning occurred in 58% and 37% of the sample, respectively. Lasting bad effects occurred in 6-14% of the sample and were associated with signs of dysregulated arousal (hyperarousal and dissociation).

CONCLUSION

Meditation practice in MBPs is associated with transient distress and negative impacts at similar rates to other psychological treatments.

MFA and ASA-MF: A Psychometric Analysis of Attitudes Towards Measurement-Based Care

Measurement based care (MBC) improves client outcomes by providing clinicians with routine mental health outcome data that can be used to inform treatment planning but is rarely used in practice. The Monitoring and Feedback Attitudes Scale (MFA) and Attitudes Towards Standardized Assessment Scales-Monitoring and Feedback (ASA-MF) (Jensen-Doss et al., 2016) may identify attitudinal barriers to MBC, which could help trainings and implementation strategies. This study examines the psychometric properties of the MFA and ASA-MF, including the factor structure, longitudinal invariance, and indicators of validity, in a sample of community mental health clinicians (N = 164). The measures demonstrate adequate fit to their factor structures across time and predict MBC use as captured in a client's electronic health record. Given that clinician attitudes are associated with MBC use, using instruments with psychometric support to assess attitudes fills a research to practice gap.

Induction of false beliefs and false memories in laboratory studies-A systematic review

Psychological interventions often use guided discovery and other techniques for diagnostic exploration and intervention planning. This way, memories may arise in the person, which may be true or false. False memories of earlier events can be harmful and result in real suffering, similar to actual traumatic memories. Based on cognitive psychological and psycho-traumatological findings, there is pronounced dissent in the academic disciplines regarding the conceptualization, relevance and research of false memories. This review contributes to the basic question of how often false beliefs and false memories may be induced within the frame of different interactional techniques. A systematic review has been conducted of 59 articles from (quasi-)experimental studies and two qualitative sources from 30 data bases. Three main methods of memory induction provide the basis for reporting: imagination inflation, false feedback, and memory implantation. Due to the conceptual and methodological diversity of the studies, the results appear to be heterogeneous. Free and guided imagery, as well as suggestive statements, could induce false beliefs or false memories in, on average, 20%-50% of the participants who underwent experimental manipulation concerning false past events. A false belief induction may occur after dream interpretation or hypnosis in more than 50% of participants. Personalized suggestion is more effective in inducing memory than the general plausibility of the suggested events. Further research questions are which therapeutic actions seem appropriate in cases of harmful false memories. This depends not only on whether there are veridical elements in the false memory but also on the quality and meaning of the memory for the person's life and ability to cope with burdens.

Patient and physician perspectives of a smartphone application for depression: a qualitative study

BACKGROUND

Despite an increasing number of smartphone apps, such therapeutic tools have not yet consistently demonstrated their efficacy and many suffer from low retention rates. To ensure the development of efficient apps associated with high adherence, we aimed to identify, through a user-centred design approach, patient and physician expectations of a hypothetical app dedicated to depression.

METHODS

We conducted semi-structured interviews with physicians (psychiatrists and general practitioners) and patients who had experienced a major depressive episode during the last 12 months using the focus group method. The interviews were audio recorded, transcribed and analysed using qualitative content analysis to define codes, categories and emergent themes.

RESULTS

A total of 26 physicians and 24 patients were included in the study. The focus groups showed balanced sex and age distributions. Most participants owned a smartphone (83.3% of patients, 96.1% of physicians) and were app users (79.2% of patients and 96.1% of physicians). The qualitative content analysis revealed 3 main themes: content, operating characteristics and barriers to the use of the app. Expected content included the data collected by the app, aiming to provide information about the patient, data provided by the app, gathering psychoeducation elements, therapeutic tools and functionalities to help with the management of daily life and features expected for this tool. The "operating characteristics" theme gathered aims considered for the app, its potential target users, considered modalities of use and considerations around its accessibility and security of use. Finally, barriers to the use of the app included concerns about potential app users, its accessibility, safety, side-effects, utility and functioning. All themes and categories were the same for patients and physicians.

CONCLUSIONS

Physician and patient expectations of a hypothetical smartphone app dedicated to depression are high and confirmed the important role it could play in depression care. The key points expected by the users for such a tool are an easy and intuitive use and a personalised content. They are also waiting for an app that gives information about depression, offers a self-monitoring functionality and helps them in case of emergency.

Influencing Factors and Machine Learning-Based Prediction of Side Effects in Psychotherapy

Background: Side effects in psychotherapy are a common phenomenon, but due to insufficient understanding of the relevant predictors of side effects in psychotherapy, many psychotherapists or clinicians fail to identify and manage these side effects. The purpose of this study was to predict whether clients or patients would experience side effects in psychotherapy by machine learning and to analyze the related influencing factors. Methods: A self-compiled "Psychotherapy Side Effects Questionnaire (PSEQ)" was delivered online by a WeChat official account. Three hundred and seventy participants were included in the cross-sectional analysis. Psychotherapy outcomes were classified as participants with side effects and without side effects. A number of features were selected to distinguish participants with different psychotherapy outcomes. Six machine learning-based algorithms were then chosen and trained by our dataset to build outcome prediction classifiers. Results: Our study showed that: (1) the most common side effects were negative emotions in psychotherapy, such as anxiety, tension, sadness, and anger, etc. (24.6%, 91/370); (2) the mental state of the psychotherapist, as perceived by the participant during psychotherapy, was the most relevant feature to predict whether clients would experience side effects in psychotherapy; (3) a Random Forest-based machine learning classifier offered the best prediction performance of the psychotherapy outcomes, with an F1-score of 0.797 and an AUC value of 0.804. These numbers indicate a high prediction performance, which allowed our approach to be used in practice. Conclusions: Our Random Forest-based machine learning classifier could accurately predict the possible outcome of a client in psychotherapy. Our study sheds light on the influencing factors of the side effects of psychotherapy and could help psychotherapists better predict the outcomes of psychotherapy.

A qualitative evaluation of Veterans Health Administration's implementation of measurement-based care in behavioral health

Measurement-based care (MBC) in behavioral health involves the repeated collection of patient-reported data that is used to track progress, inform care, and engage patients in shared decision making about their treatment. Research suggests that MBC increases the quality and effectiveness of mental health care. However, there can be challenges to implementing MBC, such as time burden, lack of resources to support MBC, and clinician attitudes. The Veterans Health Administration (VHA) is currently undertaking a multiphase MBC roll-out, the first phase of which included 59 sites across the country. The present study examined implementation of this initiative in an effort to learn more about the process of implementation, including best practices, challenges, and innovations. Semistructured interviews were conducted with 20 MBC site champions and 60 staff members from 25 VHA medical centers across the country. Qualitative data analysis was conducted to identify key themes related to MBC implementation. Results were described for 3 components of MBC implementation: preparing for implementation, administering measures, and using and sharing data. Training and staff buy-in were key to the preparation phase. Staff members reported a variety of methods and frequencies for the collection of MBC data, with many staff members identifying a need to streamline the collection process. Staff members reported using data to track progress and adjust treatment with patients. Efforts to use data on a programmatic level were identified as a next step. Innovative solutions across clinics and sites are described in an effort to inform future MBC implementation, both within and outside of VHA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Core Interpersonal Patterns in Complex Trauma and the Process of Change in Psychodynamic Therapy: A Case Comparison Study

We performed a case comparison study to investigate the nature of interpersonal patterns in childhood trauma and the process of change therein. We analyzed three matching cases of childhood trauma that followed a psychodynamic treatment via a mixed-methods design. We found that (1) the core tendency to avoid negative reactions from others through passive behaviors emerged in all three cases, both in childhood and adulthood, (2) core interpersonal patterns transpired in the interaction between patient and therapist and thereby affected the therapeutic relationship, and (3) change ensued when a repetition of core interpersonal patterns was avoided and a new relational experience occurred. The accumulated findings across cases further resulted in several clinical implications and recommendations, such as the importance of the assessment of patients' (covert) conditions, responsiveness, supervision and facilitating patients' agency, and provided several avenues for further research.

Erwartungen und Kenntnisse von Ausbildungskandidaten in Verhaltenstherapie zu Psychotherapienebenwirkungen

<b><i>Hintergrund:</i></b> Die Aufklärung, Erkennung, Vorbeugung und Bearbeitung von Psychotherapienebenwirkungen stellt hohe Anforderungen an Therapeuten. Grundsätzlich gilt zudem, dass es psychologische Barrieren gibt, negative therapeutische Entwicklungen wahrzunehmen und dem eigenen therapeutischen Handeln zuzuordnen. Dazu trägt bei, dass dieses Thema bislang in der Ausbildung eher wenig Beachtung findet und kaum systematisch abgehandelt wird. Um den eventuellen Handlungsbedarf abschätzen zu können, sind Daten von Interesse zu den einschlägigen Einstellungen und Kenntnissen von Therapeuten in Ausbildung. <b><i>Methode:</i></b> In einem halbstrukturierten Interview wurden 100 Psychotherapeuten in Ausbildung mit dem Schwerpunkt Verhaltenstherapie zu Nebenwirkungen ihrer Arbeit befragt. Die Therapeuten machten Angaben zur Qualität, Häufigkeit und den möglichen Ursachen von Psychotherapienebenwirkungen. <b><i>Ergebnisse:</i></b> Therapeuten in Ausbildung rechnen in etwa jedem 2. Fall mit dem Auftreten von Nebenwirkungen. Sie erwarten vor allem Symptomverschlechte­rung und negative Entwicklungen im sozialen Netz. Es zeigt sich eine Tendenz, das eigene Verfahren und die eigenen Behandlungen für weniger riskant zu halten als die der Kollegen. Ursachen von Nebenwirkungen sehen die Therapeuten vor allem in der therapeutischen Beziehung sowie The­rapeutenvariablen und weniger in Patientencharakteristika. <b><i>Schlussfolgerung:</i></b> Psychotherapeuten in Ausbildung sind sich dem Problem der Nebenwirkungen durchaus bewusst, was ein guter Ansatzpunkt für die Vermittlung entspre­chender Ausbildungsinhalte ist. An den Aus- und Weiterbildungsinstituten sollten Seminare zum Problem der Psychotherapienebenwirkungen zum Standard gehören.

Improving PHQ9 Utilization Rates in a Primary Care-Mental Health Integration Setting

INTRODUCTION: Measurement-based care (MBC) uses standardized measurement to systematically monitor treatment response over time. Although MBC is underutilized in mental health settings, primary care-mental health integration (PC-MHI) settings are expected to provide MBC. This article describes a quality improvement (QI) process to increase Patient Health Questionnaire-9 (PHQ9) utilization within a PC-MHI setting. AIMS: Pre-intervention, rates of baseline and follow-up PHQ9 administration for veterans with a depressive disorder were 76% and 35%, respectively. This article describes a QI process to increase PHQ9 utilization rates within a PC-MHI setting, with the goal to improve provider PHQ9 utilization rates at baseline and within 4-week follow-up to 90%. METHOD: An educational intervention and weekly motivational enhancement sessions were implemented in 2017. Chart review data compared PHQ9 utilization rates from fall 2016 and 2017. RESULTS: Following intervention, provider PHQ9 utilization rates increased to 98% and 88% at baseline and follow-up. CONCLUSIONS: These findings demonstrate that a brief education-based intervention can increase clinician use of MBC within a PC-MHI setting. Meaningful use of MBC to inform treatment was not evaluated in this QI project and is an area for future investigation.

Approaches to denote treatment outcome: Clinical significance and clinical global impression compared

OBJECTIVES

The authors of a previous study proposed a statistically based approach to denote treatment outcome, translating pretest and posttest scores into clinically relevant categories, such as recovery and reliable improvement. We assessed the convergent validity of the Jacobson-Truax (JT) approach, using T-score based cutoff values, with ratings by an independent evaluator.

METHODS

Pretest and retest scores on the Brief Symptom Inventory (BSI) and clinical global impression improvement (CGI-I) ratings were collected repeatedly through routine outcome monitoring from 5,900 outpatients with common mental disorders. Data were collected in everyday practice in a large mental health care provider.

RESULTS

Continuous pretest-to-retest BSI change scores had a stronger association with CGI-I than the categorical variable based on JT. However, JT categorization and improvement according to CGI converged substantially with association indices (Somers' D) ranging from D = .50 to .56. Discordance was predominantly due to a more positive outcome according to JT than on CGI-I ratings.

CONCLUSION

Converting continuous outcome variables into clinically meaningful categories comes at the price of somewhat diminished concurrent validity with CGI-I. Nevertheless, support was found for the proposed threshold values for reliable change and recovery, and the outcome denoted in these terms corresponded with CGI improvement for most patients.

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.