Duration of psychological therapy: relation to recovery and improvement rates in UK routine practice. [corrected]

Artificial intelligence vs. human coaches: examining the development of working alliance in a single session

The collaborative relationship, or working alliance, between a client and their coach is a well-recognized factor that contributes to the effectiveness of coaching. The rise of artificial intelligence (AI) challenges us to explore whether human-to-human relationships can extend to AI, potentially reshaping the future of coaching. Our presumption that the skills of professional human coaches surpass AI in forging effective relationships stands untested - but can we really claim this advantage? The purpose of this study was to examine client perceptions of being coached by a simulated AI coach, who was embodied as a conversational vocal live-motion avatar, compared to client perceptions of partnering with a human coach. The mixed methods randomized controlled trial explored if and how client ratings of working alliance and the coaching process aligned between the two coach types in an alternative treatments design. Both treatment groups identified a personal goal to pursue and had one 60-min session guided by the CLEAR (contract, listen, explore, action, review) coaching model. Quantitative data were captured through surveys and qualitative input was captured through open-ended survey questions and debrief interviews. To sidestep the rapid obsolescence of technology, the study was engineered using the Wizard of Oz approach to facilitate an advanced AI coaching experience, with participants unknowingly interacting with expert human coaches. The aim was to glean insights into client reactions to a future, fully autonomous AI with the capabilities of a human coach. The results showed that participants built similar moderately high levels of working alliance with both coach types, with no significant difference between treatments. Qualitative themes indicated the client's connection with their coach existed within the context of the study wherein the coach was a guide who used a variety of techniques to support the client to plan towards their goal. Overall, participants believed they were engaging with their assigned coach type, while the five professional coaches, acting as confederates, were blinded to their roles. Clients are willing to and appreciate building coaching partnerships with AI, which has both research and practical implications.

Evaluating the evidence base for university counseling services and their effectiveness using CORE measures: A systematic review and meta-analysis

BACKGROUND

The Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) is a pantheoretical measure of psychological functioning. Use of routine outcome measures (ROMs) assessing university counseling outcomes (i.e., clinical effectiveness) are essential to demonstrate evidence-based practice. But the evidence in higher education is limited as data usage and adoption of ROMs are not inherent within services, restricting knowledge of their effectiveness. This systematic review and meta-analysis document the evidence-base for in-house university counseling services (UCSs) and use of ROMs.

METHODS

The review protocol was pre-registered on PROSPERO doi:tinyurl.com/2vw5464d and reported following PRISMA guidelines. Scopus, PsycInfo, Opengrey, reference lists, and Sheffield Star Plus were searched March 22nd, 2021 and May 29th, 2024. Subgroup analyses explored the effectiveness of services using multiple therapies compared to a single therapy.

RESULTS

15 studies (N = 28,237) were included in the narrative synthesis and 13 studies (N = 14,795) included in a meta-analysis. CORE-OM data showed a large pre-post effect size (g = 1.19) demonstrating a reduction in students' psychological distress. The effect size for services using a range of therapies was significantly larger (g = 1.34) than those using a single therapy (g = 0.90).

LIMITATIONS

The small number of papers demonstrates the limited body of evidence evaluating the effectiveness of UCSs. Lack of follow-up rates, likely due to limited ROM adoption, also hindered the evaluation.

CONCLUSIONS

Quality of studies was good and UCSs are more effective than comparative CORE-OM benchmark data of no treatment derived from a large dataset of psychological therapy services.

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.

Goal-Directed Treatment of Patients With Anxiety and Mood Disorders in a Regular Curative Mental Health Care Setting

This study examined whether goal-directed treatment leads to improved treatment outcomes for patients with a primary mood or anxiety disorder and whether beneficial outcomes are achieved sooner compared to treatment as usual. In a quasi-experimental controlled study with a nested design, 17 therapists received training in goal-directed treatment and treated 105 patients with anxiety or mood disorders using principles of goal-directed treatment. Treatment results on a generic self-report instrument were compared with two control groups: a historical control group consisting of 16 of the 17 participating therapists, who provided treatment as usual to 97 patients before having received training in goal-directed treatment, and a parallel control group consisting of various therapists, who provided treatment as usual to 105 patients. Symptom reduction on a self-report measure was compared using multilevel analysis. A survival analysis was performed to assess whether a satisfactory end state had been reached sooner after goal-directed treatment. The results of this study show that goal-directed treatment only led to a significantly better overall treatment outcome compared to the parallel treatment as usual group. Furthermore, goal-directed treatment was significantly shorter than both treatment as usual groups. In conclusion, this research suggest that goal-directed treatment led to a similar or better treatment outcome in a shorter amount of time.

Is there a prospective association between psychological distress as measured by the CORE-OM and treatment attendance and treatment duration? A follow-up study at a Norwegian Community Mental Health Centre

BACKGROUND

Feasible and reliable methods for identifying factors associated with treatment duration and treatment attendance in mental health services are needed. This study examined to what degree the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the start of treatment is associated with treatment attendance and treatment duration.

METHODS

Outpatients (N = 124) at a community mental health centre in Norway completed the 34-item CORE-OM questionnaire addressing the domains of subjective well-being, problems and symptoms, functioning and risk at the start of treatment. The CORE-OM subscales and the 'all' items total scale were used as predictor variables in regression models, with treatment duration, number of consultations attended, treatment attendance (number of therapy sessions attended divided by number of sessions offered) and termination of treatment (planned versus unplanned) as outcome variables.

RESULTS

Higher CORE-OM subscale scores and the 'all' scale were associated with longer treatment duration. No association was found between CORE-OM scales and number of therapy sessions, treatment attendance (sessions attended/offered) or whether the patients unexpectedly ended treatment.

CONCLUSION

Higher patient-reported psychological distress as measured by the CORE-OM at the start of treatment was prospectively associated with treatment duration but not with treatment attendance or drop-out of treatment. The findings imply that patients with higher initial psychological distress need longer treatment but that treatment attendance may be related to factors other than the severity of distress.

Association between severity of symptoms and minimum mental health treatment duration in humanitarian contexts: a retrospective observational study

Background

Understanding and optimising mental health and psychosocial support (MHPSS) interventions in humanitarian crises is crucial, particularly for the most prevalent mental health conditions in conflict settings: anxiety, depression, and post-traumatic stress disorder. However, research on what is the most appropriate length of psychological intervention is lacking in this setting. We aimed to establish which factors are most closely related to improvement and to determine the required number of consultations needed to achieve this improvement.

Methods

We retrospectively analysed records from 9028 patients allocated to treatment for anxiety, depression, and post-traumatic symptoms from the MHPSS programme in Borno State, Nigeria, from January 2018 to December 2019. Patient characteristics, severity (Clinical Global Impression of Severity Scale, CGI-S scale), and clinical improvement were assessed by an attending counsellor (CGI-I scale) and by the patient (Mental Health Global State, MHGS scale). Improvement was defined as scores 1, 2, and 3 in the Clinical Global Impression of Improvement (CGI-I) scale, and as a decrease of at least 4 points in the MHGS scale. We investigated the associations between the category of symptoms, the severity of illness, and improvement of symptoms using multivariable logistic regression. We used Kaplan-Meier (KM) curves to assess the number of consultations (i.e., time of treatment) needed to achieve improvement of symptoms, by symptom category and symptom severity.

Findings

The patients included were referred to treatment for anxiety (n = 3462), depression (n = 3970), or post-traumatic symptoms (n = 1596). Median age was 31 years (range 16-103), and 84.3% were female. Patients categorised as severe were less likely to present improvement according to the CGI-I scale (OR 0.11, 95% CI 0.05-0.25), while none of the other categories of symptoms showed significant results. Overall, three or more consultations were associated with improvement in both scales (OR 3.55, 95% CI 1.47-8.57 for CGI-I; and OR 3.04, 95% CI 2.36-3.90 for MHGS). KM curves for the category of symptoms showed that around 90% of patients with anxiety, depression, or post-traumatic symptoms, as well as those with mild or moderate severity, presented improvement after three consultations, compared with six consultations for those with severe symptoms.

Interpretation

Classification by severity among patients with anxiety, depression, or post-traumatic symptoms could predict the probability of improvement, whereas classification by symptoms could not. Our study highlights the importance of classifying patient severity in MHPSS programmes to plan and implement the appropriate duration of care. A major limitation was the number of patients lost to follow up after the first consultation and excluded from the logistic regression and KM analysis.

Funding

The study was funded and staffed entirely by Médicos Sin Fronteras (Médecins Sans Frontières), Spain.

Cost-effectiveness of providing university students with a mindfulness-based intervention to reduce psychological distress: economic evaluation of a pragmatic randomised controlled trial

OBJECTIVE

Increasing numbers of young people attending university has raised concerns about the capacity of student mental health services to support them. We conducted a randomised controlled trial (RCT) to explore whether provision of an 8 week mindfulness course adapted for university students (Mindfulness Skills for Students-MSS), compared with university mental health support as usual (SAU), reduced psychological distress during the examination period. Here, we conduct an economic evaluation of MSS+SAU compared with SAU.

DESIGN AND SETTING

Economic evaluation conducted alongside a pragmatic, parallel, single-blinded RCT comparing provision of MSS+SAU to SAU.

PARTICIPANTS

616 university students randomised.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the university counselling service. Costs relate to staff time required to deliver counselling service offerings. QALYs were derived from the Clinical Outcomes in Routine Evaluation Dimension 6 Dimension (CORE-6D) preference based tool, which uses responses to six items of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM; primary clinical outcome measure). Primary follow-up duration was 5 and 7 months for the two recruitment cohorts.

RESULTS

It was estimated to cost £1584 (2022 prices) to deliver an MSS course to 30 students, £52.82 per student. Both costs (adjusted mean difference: £48, 95% CI £40-£56) and QALYs (adjusted mean difference: 0.014, 95% CI 0.008 to 0.021) were significantly higher in the MSS arm compared with SAU. The incremental cost-effectiveness ratio (ICER) was £3355, with a very high (99.99%) probability of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY.

CONCLUSIONS

MSS leads to significantly improved outcomes at a moderate additional cost. The ICER of £3355 per QALY suggests that MSS is cost-effective when compared with the UK's National Institute for Health and Care Excellence thresholds of £20 000 per QALY.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry, ACTRN12615001160527.

The effects of executive coaching on behaviors, attitudes, and personal characteristics: a meta-analysis of randomized control trial studies

Background

A growing number of studies emphasize executive coaching as an effective developmental tool that managers can use to increase their performance in organizational settings. However, the coaching research suggests a large variety of processes and outcomes, lacking clarity on the primary psychological dimensions most impacted.

Method

Reviewing 20 studies with a rigorous methodological design that used control trials and pre-post tests, we evaluated and compared the relative effects of coaching on different types and sub-types of outcomes by means of a classification of coaching outcomes based on previously used taxonomies.

Results

The results indicate that the impact of coaching on behavioral outcomes was higher compared to attitudes and person characteristics outcomes, suggesting that behavioral coaching outcomes, especially cognitive behavioral activities, are the most impacted by executive coaching. Moreover, we found significant positive effects for some specific outcomes, such as self-efficacy, psychological capital, and resilience, indicating that executive coaching is effective in producing change even on dimensions considered relatively stable over time. The results show no moderation effects of the number of sessions. The length of the coaching program was a significant moderator only for the attitudes outcomes.

Discussion

These findings provide evidence that executive coaching is a powerful instrument for organizations to support positive change and personal development.

Severity, symptomatology, and treatment duration for mental health disorders: a retrospective analysis from a conflict-affected region of northern Nigeria

Background

Mental Health and psychosocial support (MHPSS) programs are essential during humanitarian crises and in conflict settings, like Nigeria’s Borno State. However, research on how types of traumatic stress and symptom severity affect clinical improvement is lacking in these contexts, as is consensus over how long these patients must engage in mental health care to see results.

Methods

Records from 11,709 patients from the MHPSS program in Pulka and Gwoza local government areas in Borno State, Nigeria from 2018 and 2019 were retrospectively analyzed. Patient information, symptoms, stress type, severity (CGI-S scale), and clinical improvement (CGI-I and MHGS scales) were assessed by the patient and counselor. Associations between variables were investigated using logistic regression models.

Results

Clinical improvement increased with consultation frequency (OR: 2.5, p < 0.001 for CGI-I; OR: 2, p < 0.001 for MHGS), with patients who received three to six counseling sessions were most likely to improve, according to severity. Survivors of sexual violence, torture, and other conflict/violence-related stressors were nearly 20 times as likely to have posttraumatic stress disorder (PTSD) (OR: 19.7, p < 0.001), and depression (OR: 19.3, p < 0.001) symptomatology. Children exposed to conflict-related violence were also almost 40 times as likely to have PTSD (OR: 38.2, p = 0.002). Most patients presented an improvement in outcome at discharge, per both counselors (92%, CGI-I) and self-rating scores (73%, MHGS).

Conclusion

We demonstrate a threshold at which patients were most likely to improve (3 sessions for mild or moderate patients; 6 sessions for severe). In addition, we identify the specific types of stress and symptom severity that affected the number of sessions needed to achieve successful outcomes, and highlight that some stress types (especially torture or having a relative killed) were specifically linked to PTSD and depression. Therefore, we emphasize the importance of classifying patient stress type and severity to identify the appropriate duration of care needed.

Review: systematic review of effectiveness of art psychotherapy in children with mental health disorders

Art therapy and art psychotherapy are often offered in Child and Adolescent Mental Health services (CAMHS). We aimed to review the evidence regarding art therapy and art psychotherapy in children attending mental health services. We searched PubMed, Web of Science, and EBSCO (CINHAL®Complete) following PRISMA guidelines, using the search terms ("creative therapy" OR "art therapy") AND (child* OR adolescent OR teen*). We excluded review articles, articles which included adults, articles which were not written in English and articles without outcome measures. We identified 17 articles which are included in our review synthesis. We described these in two groups-ten articles regarding the treatment of children with a psychiatric diagnosis and seven regarding the treatment of children with psychiatric symptoms, but no formal diagnosis. The studies varied in terms of the type of art therapy/psychotherapy delivered, underlying conditions and outcome measures. Many were case studies/case series or small quasi-experimental studies; there were few randomised controlled trials and no replication studies. However, there was some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma or who have post-traumatic stress disorder (PTSD) symptoms. There is extensive literature regarding art therapy/psychotherapy in children but limited empirical papers regarding its use in children attending mental health services. There is some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma. Further research is required, and it may be beneficial if studies could be replicated in different locations.

A national evaluation of the Irish public health counselling in primary care service- examination of initial effectiveness data

BACKGROUND

The Counselling in Primary Care service (CIPC) is the first and only nationally available public counselling service in the Republic of Ireland. This study provides initial data for the effectiveness of short-term psychotherapy delivered in a primary care setting in Ireland for the first time.

METHOD

A practice-based observational research approach was employed to examine outcome data from 2806 clients receiving therapy from 130 therapists spread over 150 primary care locations throughout Ireland. Pre-post outcomes were assessed using the CORE-OM and reliable and clinically significant change proportions. Binary logistic regression examined the effect of pre therapy symptom severity on the log odds of recovering. Six and 12 month follow up data from a subsample of 276 clients were also analysed using growth curve analysis.

RESULTS

Of 14,156 referred clients, 5356 presented for assessment and 52.3% (N = 2806) consented to participate. Between assessment and post-therapy a large reduction in severity of symptoms was observed- Cohen's d = 0.98. Furthermore, 47% of clients achieved recovery,a further 15.5% reliably improved, 2.7% reliably deteriorated and34.7% showed no reliable improvement. Higher initial severity was associated with less chance of recovering at post-therapy. Significant gains were maintained between assessment and12 months after therapy- Cohen's d = 0.50.

CONCLUSIONS

Outcomes for clients in the CIPC service compared favourably with large scale counselling and psychotherapy services in jurisdictions in the U.K., the U.S.A., Norway and Sweden. This study expands the international primary care psychotherapy research base to include the entire Republic of Ireland jurisdiction.

Effects of Dog-Based Animal-Assisted Interventions in Prison Population: A Systematic Review

BACKGROUND

Animal-assisted interventions, in concrete dog-assisted intervention, have been introduced in prisons to reduce recidivism as well as to improve the well-being of prisoners. Therefore, the aim of the present systematic review is to provide an up-to-date analysis of the research on the effects of dog-based animal-assisted therapy in prison population.

METHODS

An electronic search of the literature was performed, and 20 articles were included. The PRISMA guideline methodology was employed.

RESULTS

Included studies involved a total of 1577 participants. The vast majority of protocols included activities related with dog training, dog caring, or activities, which included vocational or educational components. Duration of dog-based therapies ranged between 60 and 120 min, with the frequency being between 1 and 3 days/week. Statistically significant improvements in prisoners were observed in 13 studies.

CONCLUSIONS

Dog-based animal-assisted therapy may improve anxiety, stress, recidivism, and other social variables in male or female inmates.

Acceptance and Commitment Therapy for perinatal mood and anxiety disorders: A feasibility and proof of concept study

OBJECTIVES

The aim of the current study was to assess the feasibility, safety, and effectiveness of a newly developed Acceptance and Commitment Therapy (ACT) intervention developed specifically to address the unique context of pregnancy and parenthood. The intervention was delivered to women accessing a specialist Perinatal Community Mental Health Service (PCMHS).

DESIGN

An open-label pilot study was conducted of an 8-week, group-delivered ACT intervention targeting women with moderate-to-severe mood and/or anxiety disorders during pregnancy and/or postpartum.

METHODS

Outcomes included session attendance rates, dropout rates, crisis/inpatient service use, and standardized symptom scales. Participant's responses to open-ended questions contained in an end of therapy questionnaire were analysed using thematic analysis.

RESULTS

Seventy-four women were referred to the intervention with 65 (88%) completing treatment. The median number of sessions attended was 7. No women required input from crisis/inpatient services. All reported finding the intervention helpful. The implementation of ACT in daily life, therapist support, and group processes were cited as helpful aspects of the intervention. At post-treatment, there was a significant reduction in global distress (d = 0.99) and depressive symptoms (d = 1.05), and an increase in psychological flexibility (d = 0.93). On the secondary outcome of global distress, 38% of women were classified as recovered, 31% had reliably improved, 27% remained the same, and 4% had reliably deteriorated.

CONCLUSIONS

The delivery of ACT in a routine practice setting is feasible, safe, and effective. A randomized control trial (RCT) is needed to establish the efficacy and cost-effectiveness of this group-delivered ACT intervention.

PRACTITIONER POINTS

Group-delivered Acceptance and Commitment Therapy (ACT) is acceptable for women with moderate-to-severe perinatal mood and/or anxiety disorders and can be feasibly delivered in a routine practice setting. The trans-diagnostic nature of ACT enables the concurrent treatment of depressive and anxiety symptoms within the same intervention which is particularly helpful in the perinatal context given the comorbidity of mood and anxiety disorders. With training and supervision, mental health practitioners without extensive education in the delivery of psychological therapies can facilitate the ACT group programme. As this was a feasibility study, there was no control group, adherence to the manual was not assessed, and the absence of a follow-up period limits our knowledge of the longer-term benefits of the ACT group programme.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Therapist effects vary significantly across psychological treatment care sectors

Psychological intervention outcomes depend in part on the therapist who provides the intervention (a therapist effect). However, recent reviews suggest that therapist effects may vary as a function of the context in which care is provided and therefore should not be generalized beyond that context. This study statistically analysed therapist effect differences between care sectors delivering psychological interventions. The sample comprised routine clinical data from 26,814 patients (69% female; mean age 38) and 466 therapists in five care sectors: primary care, secondary care, university, voluntary, and workplace. Therapist effects were analysed using multilevel models and Markov chain Monte Carlo credible intervals. The therapist effect was significantly larger in primary care (8.4%) than in any other sector (1.1%-2.3%) except secondary care (4.1%), after controlling for explanatory baseline and process variables as well as accounting for differences between clinics. There were no other significant differences detected between care sectors. These findings support the hypothesis that differences in effectiveness between therapists vary depending on the context in which psychological treatment is provided. Differences in relative therapist impact can vary by a factor of 4-8 across treatment sectors. This should be considered in the application of research evidence, treatment planning, and the design and delivery of psychological care provision.

Clinical judgement, case complexity and symptom scores as predictors of outcome in depression: an exploratory analysis

BACKGROUND

Clinical guidelines for depression in adults recommend the use of outcome measures and stepped care models in routine care. Such measures are based on symptom severity, but response to treatment is likely to also be influenced by personal and contextual factors. This observational study of a routine clinical sample sought to examine the extent to which "symptom severity measures" and "complexity measures" assess different aspects of patient experience, and how they might relate to clinical outcomes, including disengagement from treatment.

METHODS

Subjects with symptoms of depression (with or without comorbid anxiety) were recruited from people referred to an established Primary Care Mental Health Team using a stepped care model. Each participant completed three baseline symptom measures (the Personal Health Questionnaire (PHQ), Generalised Anxiety Disorder questionnaire (GAD) and Clinical Outcomes in Routine Evaluation (CORE-10)), and two assessments of "case complexity" (the Minnesota-Edinburgh Complexity Assessment Measure (MECAM) and a local complexity assessment). Clinician perception of likely completion of treatment and patient recovery was also assessed. Outcome measures were drop out and clinical improvement on the PHQ.

RESULTS

298 subjects were recruited to the study, of whom 258 had a sufficient dataset available for analysis. Data showed that the three measures of symptom severity used in this study (PHQ, GAD and CORE-10) seemed to be measuring distinct characteristics from those associated with the measures of case complexity (MECAM, previous and current problem count). Higher symptom severity scores were correlated with improved outcomes at the end of treatment, but there was no association between outcome and complexity measures. Clinicians could predict participant drop-out from care with some accuracy, but had no ability to predict outcome from treatment.

CONCLUSIONS

These results highlight the extent to which drop-out complicates recovery from depression with or without anxiety in real-world settings, and the need to consider other factors beyond symptom severity in planning care. The findings are discussed in relation to a growing body of literature investigating prognostic indicators in the context of models of collaborative care for depression.

The Vasarhelyi Method of Child Art Psychotherapy in Child and Adolescent Mental Health Services: a stakeholder survey of clinical supervisors

OBJECTIVES

The Vasarhelyi Method of Child Art Psychotherapy (CAP) is a largely understudied psychotherapeutic modality. This study aims to describe the Vasarhelyi Method of CAP and to describe a stakeholder survey of the views and attitudes of CAP placement supervisors towards CAP among various Child and Adolescent Mental Health Services (CAMHS) teams nationwide.

METHODS

A phone- and letter-based survey of 17 CAP placement supervisors who oversee CAP masters students attached to CAMHS teams was performed. A questionnaire was designed enquiring about their experiences with CAP in their clinic and their thoughts on the validity of CAP in various conditions/patient demographics. Participants received written correspondence and were asked to return the survey by post; this was followed up by a telephone call to complete missing surveys.

RESULTS

In all, 12 (70.6%) complete surveys were returned. Of the 12 respondents, all considered the CAP student to be a valuable member of the team. In total, 10 respondents (83.33%) stated they would make regular use of the service if it were made available to them. With regard to the therapy itself, nine respondents (75%) believed it was better for internalising symptoms than externalising symptoms. Depression, anxiety, attachment difficulties, trauma, deliberate self-harm and possible psychosomatic illnesses are the conditions viewed as receiving the most benefit from CAP. No gender difference was reported.

CONCLUSION

CAP is considered an effective modality and valuable addition to a psychotherapeutic repertoire. Further, more extensive studies are needed in this field.

The dose-response effect in routinely delivered psychological therapies: A systematic review

The dose-response effect refers to the relationship between the dose (e.g., length, frequency) of treatment and the subsequent probability of improvement. This systematic review aimed to synthesize the literature on the dose-response effect in routine psychological therapies delivered to adult patients with mental health problems. Twenty-six studies were eligible for inclusion. Different methodological approaches have been used to examine the dose-response effect; including survival analysis, multilevel modelling and descriptive cluster analyses. Replicated and consistent support was found for a curvilinear (log-linear or cubic) relationship between treatment length and outcomes, with few exceptions such as eating disorders and severe psychiatric populations. Optimal doses of psychotherapy in routine settings range between 4 and 26 sessions (4-6 for low intensity guided self-help) and vary according to setting, clinical population and outcome measures. Weekly therapy appears to accelerate the rate of improvement compared to less frequent schedules. Most of the reviewed evidence is from university counselling centres and outpatient psychotherapy clinics for common mental health problems. There is scarce and inconclusive evidence in clinical samples with chronic and severe mental disorders.

An evaluation of predictors of dropout from an Emotional Coping Skills programme in a community mental health service

Drop-out from mental health services is a significant problem, leading to inefficient use of resources and poorer outcomes for clients. Adapted dialectical behaviour therapy (DBT), often termed Emotional Coping Skills (ECS) programmes, show some of the highest rates of drop-out from therapy recorded in the literature. The present study aimed to add to the evidence base, by evaluating predictors of drop-out from an ECS programme in a UK-based Community Mental Health Team (CMHT). An existing data set of 49 clients, consisting of clients’ responses on a number of questionnaires, was evaluated for predictors of drop-out. Predictors of drop-out included symptom severity, substance use and client demographics. Independent-samples t-tests and chi-square cross tabs analyses revealed no significant differences between drop-outs and completers of therapy on any of the variables. This suggests that contrary to common assumptions and previous findings, clients using substances, who are highly anxious, or who experience a greater degree of emotion dysregulation, are not more likely to drop out from ECS programmes compared with other individuals. The clinical implications of these findings and future research are discussed within the wider context of the evidence base.

Key learning aims

(1)

The effect of length, duration, and intensity of psychological therapy on CORE global distress scores

OBJECTIVES

This study explores whether improvements, as measured by the CORE-OM/10, as a result of psychological therapy were related to length of treatment in weeks, number of treatment sessions, or treatment intensity, as well as any effect of diagnostic group.

METHODS AND DESIGN

Pre- and post-therapy CORE-OM/10 scores were extracted from the clinical records of all secondary care adult psychological therapy team patients who undertook psychological therapy between 2010 and 2013 in one mental health trust. Of the 4,877 patients identified, 925 had complete records. Length of therapy was divided by the number of sessions to create 'treatment intensity' (sessions per week). Nonparametric analyses were used, initial score was controlled for, and diagnostic group was explored.

RESULTS

No relationship was found between change in score and the number of sessions, therapy length, or treatment intensity; however, change in score was positively correlated with first-session score. Patients with higher initial scores had longer therapies; however, treatment intensity was similar for patients with lower pre-therapy distress. There were differences in treatment length (weeks) between diagnostic groups. Demographic differences were found between patients with and without complete records, prompting caution in terms of generalizability.

CONCLUSIONS

These findings are consistent with the responsive regulation model (Barkham et al., 1996) which proposes that patients vary in their response to treatment, resulting in no associations between session numbers or treatment intensity and therapeutic gain with aggregated scores. Patients with higher CORE scores at the outset of psychological therapy had longer not more intensive therapy. There was variation in treatment intensity between diagnostic clusters.

PRACTITIONER POINTS

Number of sessions, length of therapy (in weeks), and treatment intensity (the number of sessions per week between the first and last therapy sessions) were not related to therapeutic gains. These results fit with a responsive regulation model of therapy duration, suggesting an individualized approach to therapy cessation as opposed to therapy session limits as the number of sessions a patient experienced was not generally associated with outcome. We found that clients with a diagnosis of a behavioural syndrome (F50-59) had less 'intensive' therapy; they experienced the same number of sessions over a longer time frame. Despite this, there were no associations between diagnosis category and change in score.

Child art psychotherapy in CAMHS: Which cases are referred and which cases drop out?

BACKGROUND

The Vasarhelyi method of child art psychotherapy (CAP) is offered at certain Child and Adolescent Mental Health Services. Children attend three introductory sessions, and then choose to continue weekly CAP or conclude the sessions.

AIMS

This study aims to identify the clinical disorders and characteristics of patients referred to CAP, and to determine who engages with the therapy.

METHODS

A retrospective review of the clinical records of 67 children who attended CAP in DNCC/Mater CAMHS over 13 years was performed. The data was analysed using Microsoft Excel 12.0 and SPSS version 20.

RESULTS

67 children (57 % male and 43 % female) aged 5-17 years participated in CAP with an average age of 10.6 years. Children attended an average of 14 sessions of CAP, with a range of 1-61 sessions (mean of 13.8 ± 12.9 sessions). Anxiety disorder (28 %), behaviour disorder/ODD (25 %), and ADHD (21 %) are the most common diagnoses referred. These diagnoses along with autism spectrum disorder (ASD) had the highest overall engagement, while those with depression engaged the least. Children with ADHD and with ASD attended high numbers of sessions (with a mean of 23 and 19 respectively). Those who experienced acute life events or difficulties in the home engaged well (60 and 40 % respectively). There was no significant difference found in the percentage of appointments attended by males in comparison to females.

CONCLUSION

CAP is generally acceptable to children, with a high average attendance rate. It was noted that children with ADHD and with ASD engaged well with the therapy for prolonged periods, whereas children with depression did not engage so well. We suggest that CAMHS clinics should consider referring children diagnosed with ADHD and children diagnosed with ASD to CAP as an adjunct to other therapies. We suggest that individuals with depression should be referred initially to other therapeutic services as the engagement with CAP was relatively poor.

Psychological therapies versus pharmacological interventions for panic disorder with or without agoraphobia in adults

BACKGROUND

Panic disorder is common and deleterious to mental well-being. Psychological therapies and pharmacological interventions are both used as treatments for panic disorder with and without agoraphobia. However, there are no up-to-date reviews on the comparative efficacy and acceptability of the two treatment modalities, and such a review is necessary for improved treatment planning for this disorder.

OBJECTIVES

To assess the efficacy and acceptability of psychological therapies versus pharmacological interventions for panic disorder, with or without agoraphobia, in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Specialised Register on 11 September 2015. This register contains reports of relevant randomised controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to present), Embase (1974 to present), and PsycINFO (1967 to present). We cross-checked reference lists of relevant papers and systematic reviews. We did not apply any restrictions on date, language, or publication status.

SELECTION CRITERIA

We included all randomised controlled trials comparing psychological therapies with pharmacological interventions for panic disorder with or without agoraphobia as diagnosed by operationalised criteria in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and resolved any disagreements in consultation with a third review author. For dichotomous data, we calculated risk ratios (RR) with 95% confidence intervals (CI). We analysed continuous data using standardised mean differences (with 95% CI). We used the random-effects model throughout.

MAIN RESULTS

We included 16 studies with a total of 966 participants in the present review. Eight of the studies were conducted in Europe, four in the USA, two in the Middle East, and one in Southeast Asia.None of the studies reported long-term remission/response (long term being six months or longer from treatment commencement).There was no evidence of a difference between psychological therapies and selective serotonin reuptake inhibitors (SSRIs) in terms of short-term remission (RR 0.85, 95% CI 0.62 to 1.17; 6 studies; 334 participants) or short-term response (RR 0.97, 95% CI 0.51 to 1.86; 5 studies; 277 participants) (very low-quality evidence), and no evidence of a difference between psychological therapies and SSRIs in treatment acceptability as measured using dropouts for any reason (RR 1.33, 95% CI 0.80 to 2.22; 6 studies; 334 participants; low-quality evidence).There was no evidence of a difference between psychological therapies and tricyclic antidepressants in terms of short-term remission (RR 0.82, 95% CI 0.62 to 1.09; 3 studies; 229 participants), short-term response (RR 0.75, 95% CI 0.51 to 1.10; 4 studies; 270 participants), or dropouts for any reason (RR 0.83, 95% CI 0.53 to 1.30; 5 studies; 430 participants) (low-quality evidence).There was no evidence of a difference between psychological therapies and other antidepressants in terms of short-term remission (RR 0.90, 95% CI 0.48 to 1.67; 3 studies; 135 participants; very low-quality evidence) and evidence that psychological therapies did not significantly increase or decrease the short-term response over other antidepressants (RR 0.96, 95% CI 0.67 to 1.37; 3 studies; 128 participants) or dropouts for any reason (RR 1.55, 95% CI 0.91 to 2.65; 3 studies; 180 participants) (low-quality evidence).There was no evidence of a difference between psychological therapies and benzodiazepines in terms of short-term remission (RR 1.08, 95% CI 0.70 to 1.65; 3 studies; 95 participants), short-term response (RR 1.58, 95% CI 0.70 to 3.58; 2 studies; 69 participants), or dropouts for any reason (RR 1.12, 95% CI 0.54 to 2.36; 3 studies; 116 participants) (very low-quality evidence).There was no evidence of a difference between psychological therapies and either antidepressant alone or antidepressants plus benzodiazepines in terms of short-term remission (RR 0.86, 95% CI 0.71 to 1.05; 11 studies; 663 participants) and short-term response (RR 0.95, 95% CI 0.76 to 1.18; 12 studies; 800 participants) (low-quality evidence), and there was no evidence of a difference between psychological therapies and either antidepressants alone or antidepressants plus benzodiazepines in terms of treatment acceptability as measured by dropouts for any reason (RR 1.08, 95% CI 0.77 to 1.51; 13 studies; 909 participants; very low-quality evidence). The risk of selection bias and reporting bias was largely unclear. Preplanned subgroup and sensitivity analyses limited to trials with longer-term, quality-controlled, or individual psychological therapies suggested that antidepressants might be more effective than psychological therapies for some outcomes.There were no data to contribute to a comparison between psychological therapies and serotonin-norepinephrine reuptake inhibitors (SNRIs) and subsequent adverse effects.

AUTHORS' CONCLUSIONS

The evidence in this review was often imprecise. The superiority of either therapy over the other is uncertain due to the low and very low quality of the evidence with regard to short-term efficacy and treatment acceptability, and no data were available regarding adverse effects.The sensitivity analysis and investigation of the sources of heterogeneity indicated three possible influential factors: quality control of psychological therapies, the length of intervention, and the individual modality of psychological therapies.Future studies should examine the long-term effects after intervention or treatment continuation and should provide information on risk of bias, especially with regard to selection and reporting biases.

What is the minimal dose of cognitive behavior therapy for psychosis? An approximation using repeated assessments over 45 sessions

BACKGROUND

The general efficacy of cognitive behavior therapy for psychosis (CBTp) is well established. Although guidelines recommend that CBTp should be offered over a minimum of 16 sessions, the minimal number of sessions required to achieve significant changes in psychopathology has not been systematically investigated. Empirically informed knowledge of the minimal and optimal dose of CBTp is relevant in terms of dissemination and cost-effectiveness.

METHODS

We approached the question of what constitutes an appropriate dose by investigating the dose (duration of CBTp)×response (symptomatic improvement) relationship for positive symptoms, negative symptoms and depression. Patients with psychotic disorders (n=58) were assessed over the course of 45 sessions of CBTp in a clinical practice setting. At baseline and after session 5, 15, 25, and 45, general psychopathology, psychotic symptoms, symptom distress and coping were assessed with self-report questionnaires. Additionally, individually defined target symptoms and coping were assessed after each session.

RESULTS

Significant symptom improvement and reduction of symptom distress took place by session 15, and stayed fairly stable thereafter. The frequency of positive and negative symptoms reached a minimum by session 25.

CONCLUSIONS

Our findings support recommendations to provide CBTp over a minimum of 16 sessions and indicate that these recommendations are generalizable to clinical practice settings. However, the findings also imply that 25 sessions are the more appropriate dose. This study contributes to an empirically informed discussion on the minimal and optimal dose of CBTp. It also provides a basis for planning randomized trials comparing briefer and longer versions of CBTp.

Effect of a classroom-based intervention on the social skills of pupils with intellectual disability in Southwest Nigeria

BACKGROUND

Studies have demonstrated that social skill interventions and classroom supports are effective for pupils with intellectual disability. Such interventions have been demonstrated to reduce the risk of developing mental disorders, majority of which have their onset during the period of youth. Most young people with intellectual disability in low-resource settings do not have access to interventions that would enable or enhance their participation in society. The aim of this study was to investigate the effect of a social skills training for pupils with intellectual disability attending a special school in Southwest Nigeria.

METHODS

Thirty pupils with mild to moderate intellectual disability participated in the study. Utilising the Explore social skills curriculum, teachers were trained to give lessons to the participants 3-4 times a week for 8 weeks in their classrooms. Social skills level of participants was assessed with the Matson evaluation of social skills for individuals with severe retardation (MESSIER) at baseline and immediately after the intervention. Paired t tests, Wilcoxon signed-rank test, Mann-Whitney U test and the Kruskal-Wallis Test were used to assess for pre and post intervention changes in social skills scores and analysis of changes in social skills across socio-demographic variables at p < 0.05.

RESULTS

The mean age of the participants was 15.70 ± 1.89 years. At baseline, 18 of the participants (63.3 %) had moderate social skills impairment, 2 (6.7 %) had none or minimal impairments and 10 (30 %) had severe impairments. At the end of the intervention, there was a 20 % reduction in the number of participants in the severe social skills impairment category and 13.3 % increase in the number of participants in the 'none or minimal' social skills category. The mean pre and post- intervention total social skills scores were 126.63 ± 17.91 and 135.97 ± 20.81 respectively with a mean difference of 9.34 (t = 3.71; p = 0.001).

CONCLUSION

The social skills of pupils with intellectual disability who participated in this study improved significantly during the 8 weeks the Explore social skills curriculum was administered. Advocacy should be made for the development and incorporation of social skills curricula into routine teaching of pupils with developmental disabilities.

Psychologists' Perspectives on Therapy Termination and the Use of Therapy Engagement/Retention Strategies

Practicing psychologists (n = 269) were surveyed regarding their perspectives on client reasons for termination at different points in therapy and their use of strategies to engage and retain clients in therapy. Psychologists estimated that one-third of their caseload unilaterally terminated (M = 13% before the third therapy session; M = 20% after the third session). They viewed lack of readiness for change/insufficient motivation as the most important barrier to early treatment engagement, and symptom improvement as the most important reason for clients' unilateral decisions to end therapy after the third session. Most psychologists reported occasional use of the majority of engagement and retention strategies. Although some strategies were used by most psychologists (e.g., building the early working alliance), fewer than 25% of psychologists reported the frequent use of time-limited treatment, appointment reminders or case management procedures. As the implementation of these strategies in clinical practice has the potential to greatly influence client retention rates, future research should examine psychologists' perspectives on and barriers to using these strategies. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Therapists tend to underestimate the number of clients who make unilateral decisions to end treatment in their own practices. Therapists are unlikely to take steps to engage and retain clients in treatment unless they believe that unilateral termination is a significant problem. Clients who unilaterally end treatment are often experiencing problems with the process of therapy (e.g., dissatisfaction, lack of fit, feeling as though therapy is going nowhere), whereas therapists often attribute failed therapy to clients. It is important to be aware of this tendency and look for other explanations. It is worthwhile to actively solicit clients' barriers in an effort to mitigate them. The empirical literature provides ample evidence that it is helpful for therapists to deliberately employ strategies to engage and retain clients in therapy. All therapists would benefit from considering which strategies fit with their practices. Although almost all therapists emphasize building the early working alliance, and this is essential to good outcome, other evidence-based methods of engaging clients in therapy are largely underutilized, such as systematically monitoring client progress and barriers, placing time limits on treatment, using appointment reminders, and case management.

'One man's medicine is another man's poison': a qualitative study of user perspectives on low intensity interventions for Obsessive-Compulsive Disorder (OCD)

BACKGROUND

Low intensity interventions based on cognitive-behavioral therapy (CBT) such as computerized therapy or guided self-help can offer effective and accessible care for mild to moderate mental health problems. However, critics argue that by reducing therapist input and the level of experience of the professionals delivering therapy, low intensity interventions deprive users of critical 'active ingredients'. Thus, while demand management arguments support the use of low intensity interventions for OCD, their integration into existing mental health services remains incomplete. Studies of user views of low intensity interventions can offer valuable insights to define their role and optimize their implementation in practice.

METHODS

Qualitative interviews (n = 36) in adults with OCD explored user perspectives on the initiation, continuation and acceptability of two low intensity CBT interventions: guided self-help (6 h of professional support) and computerized CBT (1 h of professional support), delivered within the context of a large pragmatic effectiveness trial (ISRCTN73535163).

RESULTS

While uptake was relatively high, continued engagement with the low intensity interventions was complex, with the perceived limitations of self-help materials impacting on users' willingness to continue therapy. The addition of professional support provided an acceptable compromise between the relative benefits of self-help and the need for professional input. However, individual differences were evident in the extent to which this compromise was considered necessary and acceptable. The need for some professional contact to manage expectations and personalize therapy materials was amplified in users with OCD, given the unique features of the disorder. However, individual differences were again evident regarding the perceived value of face-to-face support.

CONCLUSIONS

Overall the findings demonstrate the need for flexibility in the provision of low intensity interventions for OCD, responsive to user preferences, as these preferences impact directly on engagement with therapy and perceptions of effectiveness.

Psychometric properties of the Spanish version of the Clinical Outcomes in Routine Evaluation - Outcome Measure

OBJECTIVE

The objective of this paper is to assess the reliability and validity of the Spanish translation of the Clinical Outcomes in Routine Evaluation - Outcome Measure, a 34-item self-report questionnaire that measures the client's status in the domains of Subjective well-being, Problems/Symptoms, Life functioning, and Risk.

METHOD

Six hundred and forty-four adult participants were included in two samples: the clinical sample (n=192) from different mental health and primary care centers; and the nonclinical sample (n=452), which included a student and a community sample.

RESULTS

The questionnaire showed good acceptability and internal consistency, appropriate test-retest reliability, and acceptable convergent validity. Strong differentiation between clinical and nonclinical samples was found. As expected, the Risk domain had different characteristics than other domains, but all findings were comparable with the UK referential data. Cutoff scores were calculated for clinical significant change assessment.

CONCLUSION

The Spanish version of the Clinical Outcomes in Routine Evaluation - Outcome Measure showed acceptable psychometric properties, providing support for using the questionnaire for monitoring the progress of Spanish-speaking psychotherapy clients.

Duration of psychotherapy has little association with outcome

Does more psychotherapy deliver better outcomes? The answer to this question has important implications for patients' lives and costs to society. This issue of the BJPsych contains an analysis of data from a large clinical cohort receiving courses of talking therapy of up to 40 sessions in length. Duration of therapy was inversely correlated with outcome. Should we be surprised?