The outcome of psychotherapy: yesterday, today, and tomorrow

Transgenerational trauma and collective resilience: A qualitative analysis of the experiences of settler-colonial violence among three generations of Palestinian refugees

BACKGROUND

Palestinian people have endured collective dispossession and social suffering for 74 years from the so-called Al-Nakba (Palestinian catastrophe).

AIMS

The present exploratory work sought to analyze experiences of settler-colonial violence over three generations of Palestinian refugees.

METHODS

Forty-five participants (Mage = 44.45; range 13-85) were recruited via snowball sampling and interviewed to explore their understanding of transgenerational and collective trauma. Interviews were analyzed through thematic content analysis, resulting in four emerging themes distributed among the three generations.

RESULTS

The four themes encompassed (1) The impact of Al-Nakba, (2) Hardships, challenges, and quality of life, (3) Coping strategies, and (4) Dreams and hopes for the future. The results have been discussed using local idioms of distress and resilience.

CONCLUSIONS

The Palestinian experience of transgenerational trauma and resilience depicts a portrait of extreme trauma and endurance that cannot be reduced to the mere nosographic collection of Western-informed psychiatric symptoms. Instead, a human rights approach to Palestinian social suffering is most recommended.

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.

Do clients train therapists to become eclectic and use the common factors? A qualitative study listening to experienced psychotherapists

BACKGROUND

Psychotherapists must choose from an overwhelming number of theoretical models and empirically supported treatments to guide their work. Meta-analytic studies show there is comparable efficacy among the choices, making the decision about which approach to use difficult. Research indicates there are pantheoretical elements found in all effective models, called the common factors, which can offer psychotherapists a focusing point to maximize their effectiveness regardless of their chosen approach. Most psychotherapists begin practicing from a traditional theoretical orientation, but then their approach evolves over time toward an unintentional eclecticism, derived primarily from their practice experience with clients.

METHODS

This exploratory qualitative study conducted in-depth interviews with six experienced clinical social workers about their evolution as psychotherapists and what they believe creates change in psychotherapy. The interviews were conducted using standardized prompts and then coded and analyzed utilizing thematic analysis based on a six-phase framework.

RESULTS

The analysis suggests the psychotherapists had evolved to conducting therapy via an implicit and unique approach based on an unintentional heavy use of common factors. Five prominent themes emerged as central components of change in psychotherapy: the therapeutic relationship as a primary change agent, the importance of the therapist genuineness, the need to acknowledge and act upon a poor therapist-client match, the client bearing the primary responsibility for change, and the therapists' development of unintended eclecticism in response to client interactions.

CONCLUSIONS

In practice, most psychotherapists start practicing from a traditional theoretical orientation only to find their approach evolves over time toward an informal eclecticism featuring common factors. This common factors-based eclecticism emerges primarily from practice experience with clients. These findings suggest an avenue for further inquiry-if psychotherapists are going to gradually evolve in an unplanned eclectic direction guided by their client interactions, are they also concurrently and inherently drawn to the common factors? If the answer proves to be yes, what are the implications for early training? Should the gradual emphasis toward common factors be supplanted with a more intentional and efficient focus on them in the training of students and early career clinicians?

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual

Suicide rates have been steadily increasing in both the U.S. general population and military, with significant psychological and economic consequences. The purpose of the current study was to examine the economic costs and cost-benefit of the suicide-focused Collaborative Assessment and Management of Suicidality (CAMS) intervention versus enhanced treatment as usual (ETAU) in an active duty military sample using data from a recent randomized controlled trial of CAMS versus ETAU. The full intent-to-treat sample included 148 participants (mean age 26.8 years ± 5.9 SD years, 80% male, 53% White). Using a micro-costing approach, the cost of each condition was calculated at the individual level from a healthcare system perspective. Benefits were estimated at the individual level as cost savings in past-year healthcare expenditures based on direct care reimbursement rates. Cost-benefit was examined in the form of cost-benefit ratios and net benefit. Total costs, benefits, cost-benefit ratios, and net benefit were calculated and analyzed using general linear mixed modeling on multiply imputed datasets. Results indicated that treatment costs did not differ significantly between conditions; however, CAMS was found to produce significantly greater benefit in the form of decreased healthcare expenditures at 6-month follow-up. CAMS also demonstrated significantly greater cost-benefit ratios (i.e., benefit per dollar spent on treatment) and net-benefit (i.e., total benefit less the cost of treatment) at 12-month follow-up. The current study suggests that beyond its clinical effectiveness, CAMS may also convey potential economic advantages over usual care for the treatment of suicidal active duty service members. Our findings demonstrate cost savings in the form of reduced healthcare expenditures, which theoretically represent resources that can be reallocated toward other healthcare system needs, and thus lend support toward the overall value of CAMS.

Do young people prefer older psychotherapists?

In times of demographic change, psychotherapists tend to stay longer in their jobs. Against the background of two contradictory age stereotypes (wise/generous versus senile/outdated old person), this analogue study investigates young adults' preference for old over young psychotherapists, depending on presenting problem. In a within-subjects design, therapy-motivated young female participants (N = 79) received two kinds of hypothetical presenting problems, 'universal problems' (addressing fundamental questions of life virulent across the adult life span) and 'young problems' (life events that are developmentally close to and specific for young adulthood in today's world). For each presenting problem, participants were presented with two naturalistic photographs of an old (55 + years) and a young (< 35 years) female psychotherapist; in a two-alternative forced choice decision task, participants were then asked to decide whom of the two psychotherapists they would prefer. Participants had neither an overall preference for old nor for young psychotherapists. As expected, we found a preference for old psychotherapists in case of 'universal problems' (friend's death, natural disaster, quarreling with one's past). In turn, a preference for young psychotherapists was observed in case of 'young problems' (cyberbullying, paternalizing parents, lovesickness). Effect size was medium-to-large. Organizations that provide services to younger people may want to inquire about a patient's preference about age of a therapist prior to treatment. As catering to patient's preferences for therapy has been shown to lead to better engagement and therapy outcomes, health care providers should try to meet the patient's needs.

Personal style of the therapist and personality dimensions in a sample of Argentinian therapists

The Personal Style of the Therapist (PST) is an important aspect to assess in the therapeutic process. Previous research has explored therapist’s profiles and their differences according to a variety of theoretical orientations, as well as the association between these profiles and personality traits. This study aims to put together these lines of research through a cluster analysis. The specific goals were to describe the profiles of therapists with respect to the functions of the PST and personality traits; and to analyze whether the professionals’ profiles and their theoretical orientations were related. The sample was comprised of 546 Argentinian therapists. The Personal Style of the Therapist Questionnaire (PST-Q) and the Big Five Inventory (BFI) were used as measuring instruments. Using the methodology of hierarchical analysis based on a cluster analysis integrating the five factors of the PST, a four-cluster solution was confirmed to be the most satisfactory. Subsequently, a cluster analysis of k-means based on the five factors of each test (PST-Q and BFI) was performed. Finally, the relationship between the clusters and theoretical orientation and years of clinical practice was assessed, rendering positive outcomes. The results are discussed based on previous research studies and the significance of studying the therapist’s personal variables and their connection with psychotherapy efficacy.

Cross-Cultural Research on Psychotherapy: The Need for a Change

Psychotherapy models, some of which now have a history over a century, have been practiced worldwide. However, considering that the most prevalently applied psychotherapy models are the products of Western culture, questioning the extent of these models’ effectiveness and efficiency for people belonging to diverse cultural backgrounds is legitimate. No doubt, ethno-cultural groups living in Western multicultural societies will interact with Western culture more deeply compared with people living in non-Western countries; therefore, to also think that their needs will differ is reasonable. In this case, the quantity and quality of the required adaptations may also change. Although a promising number of studies exist on intercultural adaptations necessitated by the needs of multicultural societies, the literature on the effectiveness of these models in the non-Western world and the local psychotherapy models is quite limited. One important question is whether psychotherapy models can be adapted to address non-Western cultures without transforming their fundamental assumptions, and if so, can this be conducted efficiently? With these questions in mind, the aim is to review the current state of scientific studies on psychotherapy practices in various cultures. In addition, considering the large spectrum of cultural migration taking place in modern days and the difficulty of receiving mental health services in underdeveloped countries, the importance of adapted and local psychotherapy research has been emphasized and some suggestions for consideration in future research have been made.

Studying the Efficacy of Psychodrama With the Hermeneutic Single Case Efficacy Design: Results From a Longitudinal Study

Throughout the last decades, scientific and therapeutic communities have made common efforts to collect reliable information concerning the efficacy of psychotherapies. One of these initiatives has, recently, involved the psychodrama community and its desire to achieve progress in the validation of this therapy. Based on Robert Elliott's Hermeneutic Single Case Efficacy Design, we followed five participants (three women, two men, aged 27-48 years) of a psychodrama group over the course of their therapeutic process, which ranged from 24 months to 5 years. For the single case study, we selected the participant who had the longest data collecting record, including one follow-up. Participants generally reported improvement in their personal therapeutic goals, decrease in symptoms and life problems, and some showed a marked increase in spontaneity levels. In the single case, these results are confirmed, and following decision criteria it is possible to assert that the participant improved in all the variables assessed and that therapy is the main cause of these changes. Furthermore, the participant frequently rated psychodrama sessions as being helpful and stated they had a transformational impact on his life. This research contributes toward validating psychodrama as an efficient therapeutic method, hopefully stimulating practitioners to integrate therapy and research-which, for years, were considered independent and incompatible-and to facilitate their use in a complementary way.

Common Factors' Role in Accredited MFT Training Programs

Common factors proponents discuss the benefits and methods of including common factors in marriage and family therapy (MFT) training; yet there are no empirical investigations of how common factors are incorporated into MFT curricula. The purpose of this study was to obtain a baseline understanding of common factors' role in MFT training. Thirty-one directors of COAMFTE- and CACREP-accredited MFT training programs responded to a survey about the inclusion of common factors in their training program, as well as the benefits, challenges, and students' reactions to common factors training. Findings show that common factors are regularly included in MFT training programs and have garnered largely positive responses. Additional results are discussed regarding the implications of common factors in MFT training.

A case study of lessons learnt from implementing a routine outcome monitoring system for psychotherapy in a South African community clinic

Monitoring outcomes in psychotherapy is important for advancing research into empirically supported treatments, collecting data to inform practice-based evidence and for monitoring patient treatment responses during routine care. We implemented two routine outcome monitoring measures in a community psychology clinic in South Africa, namely, the Outcome Rating Scale and Kessler Psychological Distress Scale. In this article, we adopt a case study methodology to describe and critically reflect on the implementation process and evaluate the utility of the outcome data collected during the first year of implementation. Our findings suggest that the measures have some utility but that there were significant problems with implementation. We found that Outcome Rating Scale and Kessler Psychological Distress Scale scores correlated in the expected direction; however, Outcome Rating Scale intake scores for the present population were at odds with the measure’s norms. The findings highlight the care that needs to be taken to change routine clinical practice when outcome measures are implemented in local settings and the need for research to validate the use of these ROM measures in South African clinical settings.

The Depression Conundrum and the Advantages of Uncertainty

According to the WHO (2012), the prevalence of unipolar depressive disorders is rising, even in those places where mental health treatments are widely available. The WHO predicts that these disorders will be the leading contributor to the global burden of disease by 2030. This sobering projection fits poorly with how psychological treatments for depression are presented in the mainstream scientific literature: as highly effective therapies, based upon a sound understanding of the causes of distress. There is a clear discrepancy between the rising prevalence figures on the one hand, and the confident claims of this effectiveness research on the other. This discrepancy prompts a set of complex interlinked questions, which we have called ‘The Depression Conundrum.’ In search of a partial answer, the aim of our study was to critically analyze five meta-analytic studies investigating the effectiveness of psychological EBTs for depression, all of which had been published in high impact factor journals. Our examination established a number of methodological and statistical shortcomings in every study. Furthermore, we argue that the meta-analytic technique is founded upon problematic assumptions. The implications of our analysis are clear: decades of quantitative research might not allow us to conclude that psychological EBTs for depression are effective. The uncertainty and questions raised by our findings might act as a catalyst to broaden the way in which depression and associated therapies are researched. In addition, it might contribute toward a more vigorous and interdisciplinary debate about how to tackle this soon-to-be global public health priority number one.

The application of a feedback-informed approach in psychological service with youth: Systematic review and meta-analysis

Research with adults has consistently demonstrated that the use of regular client feedback in psychological services can improve outcomes. However, there appear to be fewer studies with youth. The purpose of the current review was to explore/assess (1) current developments in research on the use of feedback-informed approaches in mental health interventions or services for youth 10-19years of age; (2) the efficacy of client feedback in youth treatment settings; and (3) consider future directions for research. A total of 12 studies were included in this review, comprising a meta-analysis (n=9) and a qualitative review (n=3). Most studies assessed the benefits of a feedback framework in terms of symptom severity, functioning levels and/or goal attainments in therapy (i.e., ratings on the feedback-informed tools). The Hedges's g indexes of 0.20 (for independent-groups trials), 0.32 (single-group trials) and 0.28 (for all trials) suggest that the collection and application of continuous feedback from youth clients throughout the course of the interventions/services can boost and produce beneficial outcomes for the youth, while noting the feedback effect to be in the small range. Based on these initial findings, implications for future research and clinical practice are discussed, including considering fruitful research directions.

Wisdom in professional knowledge: Why it can be valuable to listen to the voices of senior psychotherapists

OBJECTIVE

To explore the nature of professional wisdom, through learning from the experiences of a group of highly experienced senior therapists.

METHOD

Twelve senior psychotherapists took part in qualitative in-depth interviews about their professional role and their views around a range of aspects of therapy theory and practice. Interview transcripts were subjected to thematic analysis.

RESULTS

The analysis yielded nine wisdom themes, clustered within three domains. Each domain represented efforts to resolve dilemmas arising from the experience of being a therapist, around the use of theory in psychotherapy practice, the type of therapeutic relationship that is most helpful for clients, and the experience of therapeutic failure.

CONCLUSIONS

Therapist wisdom can be viewed as a form of contextualized knowledge, which functions as a source of emergent insights that arise as responses to the limitations of prevailing ways of thinking. Research into the nature of therapist wisdom draws attention to sources of knowledge within philosophy and the humanities that have the potential to enhance therapy practice and contribute to our understanding of therapist expertise.

Emotional Freedom Techniques to Treat Posttraumatic Stress Disorder in Veterans: Review of the Evidence, Survey of Practitioners, and Proposed Clinical Guidelines

BACKGROUND

High prevalence rates of posttraumatic stress disorder (PTSD) in active military and veterans present a treatment challenge. Many PTSD studies have demonstrated the efficacy and safety of Emotional Freedom Techniques (EFT).

OBJECTIVES

To develop clinical best practice guidelines for the use of EFT to treat PTSD, on the basis of the published literature, practitioner experience, and typical case histories.

METHODS

We surveyed 448 EFT practitioners to gather information on their experiences with PTSD treatment. This included their demographic profiles, prior training, professional settings, use of assessments, and PTSD treatment practices. We used their responses, with the research evidence base, to formulate clinical guidelines applying the "stepped care" treatment model used by the United Kingdom's National Institute for Health and Clinical Excellence.

RESULTS

Most practitioners (63%) reported that even complex PTSD can be remediated in 10 or fewer EFT sessions. Some 65% of practitioners found that more than 60% of PTSD clients are fully rehabilitated, and 89% stated that less than 10% of clients make little or no progress. Practitioners combined EFT with a wide variety of other approaches, especially cognitive therapy. Practitioner responses, evidence from the literature, and the results of a meta-analysis were aggregated into a proposed clinical guideline.

CONCLUSION

We recommend a stepped care model, with 5 EFT therapy sessions for subclinical PTSD and 10 sessions for clinical PTSD, in addition to group therapy, online self-help resources, and social support. Clients who fail to respond should be referred for appropriate further care.

The Role of Theory-Specific Techniques and Therapeutic Alliance in Promoting Positive Outcomes: Integrative Psychotherapy for World Trade Center Responders

World Trade Center responders demonstrate high symptom burden, underscoring the importance of refining treatment approaches for this cohort. One method is examining the impact of therapy techniques on outcomes, and the interactions between technique and alliance on outcomes. This study a) examined the interaction of early treatment techniques on integrative psychotherapy outcomes and b) explored whether associations differed at varying levels of alliance. Twenty-nine adult responders diagnosed with partial or full posttraumatic stress disorder received outpatient psychotherapy and completed weekly measures of alliance, technique, and symptom distress. Analyses indicated significant interactions between 1) alliance and psychodynamic interventions on outcomes and 2) alliance and cognitive behavioral (CB) interventions on outcomes. Clients with high alliance had better outcomes when their therapist used fewer CB techniques. No meaningful differences were found between technique and outcomes for clients with lower alliance. These findings reiterate the critical roles technique and responsiveness to the alliance play in engendering successful outcomes.

Feedback-informed treatment in emergency psychiatry; a randomised controlled trial

BACKGROUND

Immediate patient feedback has been shown to improve outcomes for patients in mild distress but it is unclear whether psychiatric patients in severe distress benefit equally from feedback. This study investigates the efficacy of an immediate feedback instrument in the treatment of patients with acute and severe psychosocial or psychiatric problems referred in the middle of a crisis.

METHODS

A naturalistic mixed diagnosis sample of patients (N = 370) at a Psychiatric Emergency Centre was randomised to a Treatment-as-Usual (TAU) or a Feedback (FB) condition. In the FB condition, feedback on patient progress was provided on a session-by-session basis to both therapists and patients. Outcomes of the two treatment conditions were compared using repeated measures MANCOVA, Last Observation Carried Forward and multilevel analysis.

RESULTS

After 3 months, symptom improvement in FB (ES 0.60) did not significantly differ from TAU (ES 0.71) (p = 0.505). After 6 weeks, FB patients (ES 0.31) actually improved less than TAU patients (0.56) (p = 0.019).

CONCLUSIONS

Patients with psychiatric problems and severe distress seeking emergency psychiatric help did not benefit from direct feedback.

TRIAL REGISTRATION

Dutch Trial Register, NTR3168 , date of registration 1-9-2009.

Technology for evidence-based cognitive behavioural supervision: new applications and research to improve organizational support

There has recently been an increasing call for new research and development in cognitive behavioural supervision, particularly in the area of evidence-based clinical supervision. New developments in supervision technology offer the potential to answer this call by providing greater objective measurement and corrective feedback in supervision. In this article, two new technologies that hold particular promise in this area are described: software for routine outcome measurement and videoconference for internet-based live one-way-mirror supervision. Notable challenges involved in supervision technology are discussed, and an example of technology being integrated into a graduate clinical training programme is described.

Neuroimaging of psychotherapy for obsessive-compulsive disorder: A systematic review

The symptoms of obsessive-compulsive disorder (OCD) include intrusive thoughts, compulsive behavior, anxiety, and cognitive inflexibility, which are associated with dysfunction in dorsal and ventral corticostriato-thalamocortical (CSTC) circuits. Psychotherapy involving exposure and response prevention has been established as an effective treatment for the affective symptoms, but the impact on the underlying neural circuits is not clear. This systematic review used the Medline, Embase, and PsychINFO databases to investigate how successful therapy may affect neural substrates of OCD. Sixteen studies measuring neural changes after therapy were included in the review. The studies indicate that dysfunctions in neural function and structure are partly reversible and state-dependent for affective symptoms, which may also apply to cognitive symptoms. This is supported by post-treatment decreases of symptoms and activity in the ventral circuits during symptom provocation, as well as mainly increased activity in dorsal circuits during cognitive processing. These effects appear to be common to both psychotherapy and medication approaches. Although neural findings were not consistent across all studies, these findings indicate that people with OCD may experience functional, symptomatic, and neural recovery after successful treatment.

Effect size calculations for the clinician: methods and comparability

OBJECTIVE

The measurement of clinical change via single-group pre-post effect size has become increasingly common in psychotherapy settings that collect practice-based evidence and engage in feedback-informed treatment. Different methods of calculating effect size for the same sample of clients and the same measure can lead to wide-ranging results, reducing interpretability.

METHOD

Effect sizes from therapists-including those drawn from a large web-based database of practicing clinicians-were calculated using nine different methods.

RESULTS

The resulting effect sizes varied significantly depending on the method employed. Differences between measurement methods routinely exceeded 0.40 for individual therapists.

CONCLUSIONS

Three methods for calculating effect sizes are recommended for moderating these differences, including two equations that show promise as valid and practical methods for use by clinicians in professional practice.