Frank Margison

Service profiling and outcomes benchmarking using the CORE-OM: Toward practice-based evidence in the psychological therapies.

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

ASSIMILATION OF PROBLEMATIC EXPERIENCES BY CLIENTS IN PSYCHOTHERAPY

DAVID A. SHAPIRO AND GILLIAN HARDYMRC/ESRC Social and Applied Psychology UnitUniversity of SheffieldIn successful psychotherapy,problematic experiences (threatening orpainful thoughts, feelings, memories,etc.) are gradually assimilated intoschemata that are introduced by thetherapist or developed in the therapist-client interaction by modification of oldschemata. As it is assimilated, aproblematic experience passes throughpredictable stages. The client movesfrom being oblivious, to experiencingthe content as acutely painful, then asless distressing, merely puzzling, thenunderstood, and finally as confidentlymastered.

The contribution of reliable and clinically significant change methods to evidence-based mental health

Where outcomes are unequivocal (life or death; being able to walk v being paralysed) clinicians, researchers, and patients find it easy to speak the same language in evaluating results. However, in much of mental health work initial states and outcomes of treatments are measured on continuous scales and the distribution of the “normal” often overlaps with the range of the “abnormal.” In this situation, clinicians and researchers often talk different languages about change data, and both are probably poor at conveying their thoughts to patients. Researchers traditionally compare means between groups. Their statistical methods, using distributions of the scores before and after treatment to suggest whether change is a sampling artefact or a chance finding, have been known for many years.1 By contrast, clinicians are more often concerned with changes in particular individuals they are treating and often dichotomise outcome as “success” or “failure.” The number needed to treat (NNT) method of presenting results has gone some way to bridge this gap but often uses arbitrary criteria on which to dichotomise change into “success” and “failure.” A typical example is the criterion of a 50% drop on the Hamilton Depression Rating Scale score. A method bridging these approaches would assist the translation of research results into clinical practice. Jacobson et al proposed a method of determining reliable and clinically significant change (RCSC) that summarises changes at the level of the individual in the context of observed changes for the whole sample.2, 3–5 Their methods are applicable, in one form or another, to the measurement of change on any continuous scale for any clinical problem, although they have been reported primarily in the psychotherapy research literature. The broad concept of reliable and clinically significant change rests on 2 questions being addressed at the level of each …

Dose-Effect Relations and Responsive Regulation of Treatment Duration: The Good Enough Level

This study examined rates of improvement in psychotherapy as a function of the number of sessions attended. The clients (N=1,868; 73.1% female; 92.4% White; average age=40), who were seen for a variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had planned endings, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and clinically significant improvement (RCSI) on the CORE-OM did not increase with number of sessions attended. Among clients who began treatment above the CORE-OM clinical cutoff (n=1,472), the RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12 sessions (r=-.91). Previously reported negatively accelerating aggregate curves may reflect progressive ending of treatment by clients who had achieved a good enough level of improvement.

The rationale for developing and implementing core outcome batteries for routine use in service settings and psychotherapy outcome research

The Department of Health (DoH; 1996) Strategic Review of Psychotherapy identified the need for practitioners to use sim ilar outcom e m easures as part of the fram ework of clinical effectiveness. In this paper, we present the rationale for developing and im plementing a core outcom e battery in routine clinical practice as well as psychotherapy research. W e outline the forces that have determ ined the current corpus of outcome measures and contrast these with rational criteria for two levels of outcome batteries: a core battery, and problem-specific batteries. In addition, we identify potential referential measures that act as links between a core and problem-specific outcom e batteries. Criteria are set out that a core battery should meet. Em phasis is given to tw o unique criteria: a collaborative approach to instrum ent development between researchers and clinicians, and the collection of a subsequent national database. M eeting such suggestions will benefit researchers and clinicians as w ell as promoting innovation in m easurem ent practice.

Primary therapist response modes: Comparison of six rating systems.

Six therapist response-mode rating systems were compared in order to delineate a set of primary modes that would best summarize the domain of therapist actions. Ratings of seven diverse therapy sessions showed that, in spite of differences in measurement assumptions and rater characteristics, interrater reliabilities generally were similar. When categories in different rating systems were collapsed to the same level of specificity, moderate to strong convergence was found for the six modes rated in all systems: question, information, advisement, reflection, interpretation, and self-disclosure. These modes discriminated among the seven contrasting therapeutic approaches. Each therapist was characterized by a unique pattern of response modes that differed significantly from the others. Researchers interested in assessing therapist in-session behaviors should consider incorporating measures that include these six modes.

Counsellors' experiences of changing their practice: Learning the psychodynamic-interpersonal model of therapy

Seven counsellors were interviewed about their experiences of learning and applying a new approach to therapy: the psychodynamic-interpersonal model. These interviews were analysed using grounded theory — a qualitative approach. Under the core category of ‘changing counselling practice: applying the PI model of therapy’, the material was organised into 10 major categories: difficult feelings; new awareness; therapeutic identity; identifying reasons for choosing how to work; experiencing difficulties in adherence; attributing causes of difficulties; ways through the difficulties; understanding how change in practice occurs; changing interventions; and specific other inputs. Examples from the interviews are used to cast light on the difficulties experienced by counsellors in the process of changing their practice.

Editorial: Cognitive analytic therapy: A case study in treatment development

A summary of the main literature on cognitive analytic therapy (CAT) is given. Ryle first developed CAT over 20 years ago, and use of the model is increasingly widespread in diverse settings and with various conditions. CAT stands as an example of modern dialogical approaches to therapy, and the underlying theory is consistent with that stance. The developments within training stress self-reflexive practice and the maintenance of a collaborative approach. In contrast, however, to the rapid development in training and practice the research summarised here is primarily descriptive with a small number of open trials and one randomized controlled study in a physical disorder (Type I diabetes). The urgent need for randomized controlled research in this treatment is highlighted.

Teaching Psychotherapy Skills to Inexperienced Psychiatry Trainees Using the Conversational Model

A teaching package of three videotapes with accompanying written material was developed to provide introductory teaching in the Conversational Model of psychotherapy. In previous research, conducted within the environment of a teaching hospital, we showed this teaching package to be effective in imparting key skills within the model. However, it has been suggested that this success may have been due partly to our use of a particularly favorable training environment, i.e., the use of our own trainees in a university teaching hospital. Here we report on a comparable training exercise conducted in nonteaching hospitals, and compare the results with those of the earlier study. In both situations the teaching package proved to be effective in imparting the appropriate skills.

A preliminary study of a measure of role-play competence in psychodynamic interpersonal therapy

We report a 15-item role-play competence measure. Ratings by three judges of 34 role plays from psychodynamic interpersonal therapy training showed good inter-rater (.73-.79) and internal reliability (.84-.96). Validity was supported as scores were statistically significantly associated with psychotherapy experience. Most participants achieved satisfactory ratings supporting the training.