Julian Rubel

The ups and downs of psychotherapy: Sudden gains and sudden losses identified with session reports

Abstract Psychotherapy does not always follow a linear path. The present study explores the frequency of sudden gains and losses during the course of outpatient psychotherapy. The sample includes 1500 patients treated at three different outpatient centers. The patients were 57.4% female, and suffered primarily from anxiety and depressive disorders. Progress was measured by session reports. Significant sudden shifts in both directions were prevalent for 28.9% of the patients. Patients with early sudden gains showed the highest effect sizes and patients with sudden losses showed the smallest at the end of treatment. The therapeutic relationship was significantly better after the sudden gain sessions. Results suggest further investigation of the occurrence of sudden gains in relation to early response as well as further exploration of sudden losses during the course of treatment with respect to differential patterns of change and outcome.

Patient-focused and feedback research in psychotherapy: Where are we and where do we want to go?

Abstract In the last 15 years feedback interventions have had a significant impact on the field of psychotherapy research and have demonstrated their potential to enhance treatment outcomes, especially for patients with an increased risk of treatment failure. This article serves as an introduction to the special issue on “Patient-focused and feedback research in psychotherapy: Where are we and where do we want to go?” Current investigations on feedback research are concerned with potential moderators and mediators of these effects, as well as the design and the implementation of feedback into routine care. This introduction summarizes the current state of feedback research and provides an overview of the three main research topics in this issue: (1) How to implement feedback systems into routine practice and how do therapist and patient attitudes influence its effects?, (2) How to design feedback reports and decision support tools?, and (3) What are the reasons for patients to become at risk of treatment failure and how should therapists intervene with these patients? We believe that the studies included in this special issue reflect the current state of feedback research and provide promising pathways for future endeavors that will enhance our understanding of feedback effects.

Benefits and challenges in practice-oriented psychotherapy research in Germany: The TK and the QS-PSY-BAY projects of quality assurance in outpatient psychotherapy

Abstract Objective: Two patient-focused long-term research projects performed in the German outpatient psychotherapy system are focused on in this article. The TK (Techniker Krankenkasse) project is the first study to evaluate a quality assurance and feedback system with regard to its practical feasibility in German routine care. The other study (“Quality Assurance in Outpatient Psychotherapy in Bavaria”; QS-PSY-BAY) was designed to test a new approach for quality assurance in outpatient psychotherapy using electronic documentation of patient characteristics and outcome parameters. In addition this project provides the opportunity to analyze data on health-related costs for the patients undergoing outpatient psychotherapy. Method: Both projects and their results indicating high effect sizes are briefly described. Results: From the perspectives of the research teams, advisory boards and other stakeholders, the experiences with these projects are discussed focusing on obstacles, challenges, difficulties, and benefits in developing and implementing the studies. The triangle collaboration of therapists, researchers, and health insurance companies/health service institutions turned out to be fruitful in both studies. Conclusions: Despite some controversies between the partners the experiences indicate the importance of practiced-research collaborations to provide relevant information about the delivery of outpatient psychotherapy in the health system.

Feedback and therapist effects in the context of treatment outcome and treatment length

Abstract Objective: This study estimates feedback and therapist effects and tests the predictive value of therapists’ and patient attitudes toward psychometric feedback for treatment outcome and length. Methods: Data of 349 outpatients and 44 therapists in private practices were used. Separate multilevel analyses were conducted to estimate predictors and feedback and therapist effects. Results: Around 5.88% of the variability in treatment outcome and 8.89% in treatment length were attributed to therapists. There was no relationship between the average effectiveness of therapists and the average length of their treatments. Initial impairment, early alliance, number of diagnoses, feedback as well as therapists’ and patients’ attitudes toward feedback were significant predictors of treatment outcome. Treatments tended to be longer for patients with a higher number of approved sessions by the insurance company, with higher levels of interpersonal distress at intake, and for those who developed negatively (negative feedback) over the course of their treatment. Conclusions: Therapist effects on treatment outcome and treatment length in routine care seem to be relevant predictors in the context of feedback studies. Therapists’ attitudes toward and use of feedback as well as patients’ attitudes toward feedback should be further investigated in future research on psychometric feedback.

Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies

This paper aims to provide researchers with practical information on sample sizes for accurate estimations of therapist effects (TEs). The investigations are based on an integrated sample of 48,648 patients treated by 1800 therapists. Multilevel modeling and resampling were used to realize varying sample size conditions to generate empirical estimates of TEs. Sample size tables, including varying sample size conditions, were constructed and study examples given. This study gives an insight into the potential size of the TE and provides researchers with a practical guide to aid the planning of future studies in this field.

Exploring the Idiographic Dynamics of Mood and Anxiety via Network Analysis

Individual variation is increasingly recognized as important to psychopathology research. Concurrently, new methods of analysis based on network models are bringing new perspectives on mental (dys)function. This current work analyzed idiographic multivariate time series data using a novel network methodology that incorporates contemporaneous and lagged associations in mood and anxiety symptomatology. Data were taken from 40 individuals with generalized anxiety disorder (GAD), major depressive disorder (MDD), or comorbid GAD and MDD, who answered questions about 21 descriptors of mood and anxiety symptomatology 4 times a day over a period of approximately 30 days. The model provided an excellent fit to the intraindividual symptom dynamics of all 40 individuals. The most central symptoms in contemporaneous systems were those related to positive and negative mood. The temporal networks highlighted the importance of anger to symptomatology, while also finding that depressed mood and worry—the principal diagnostic criteria for GAD and MDD—were the least influential nodes across the sample. The method’s potential for analysis of individual symptom patterns is demonstrated by 3 exemplar participants. Idiographic network-based analysis may fundamentally alter the way psychopathology is assessed, classified, and treated, allowing researchers and clinicians to better understand individual symptom dynamics.

Dynamic models of individual change in psychotherapy process research.

Objective: There is a need for rigorous methods to study the mechanisms that lead to individual-level change (i.e., process-outcome research). We argue that panel data (i.e., longitudinal study of a number of individuals) methods have 3 major advantages for psychotherapy researchers: (1) enabling microanalytic study of psychotherapeutic processes in a clinically intuitive way, (2) modeling lagged associations over time to ensure direction of causality, and (3) isolating within-patient changes over time from between-patient differences, thereby protecting against confounding influences because of the effects of unobserved stable attributes of individuals. However, dynamic panel data methods present a complex set of analytical challenges. We focus on 2 particular issues: (1) how long-term trajectories in the variables of interest over the study period should be handled, and (2) how the use of a lagged dependent variable as a predictor in regression-based dynamic panel models induces endogeneity (i.e., violation of independence between predictor and model error term) that must be taken into account in order to appropriately isolate within- and between-person effects. Method: An example from a study of working alliance in psychotherapy in primary care in Sweden is used to illustrate some of these analytic decisions and their impact on parameter estimates. Results: Estimates were strongly influenced by the way linear trajectories were handled; that is, whether variables were “detrended” or not. Conclusions: The issue of when detrending should be done is discussed, and recommendations for research are provided.

Clinical effectiveness of cognitive behavioral therapy for depression in routine care: A propensity score based comparison between randomized controlled trials and clinical practice

BACKGROUND The efficacy of cognitive behavioral therapy (CBT) for the treatment of depressive disorders has been demonstrated in many randomized controlled trials (RCTs). This study investigated whether for CBT similar effects can be expected under routine care conditions when the patients are comparable to those examined in RCTs. METHOD N=574 CBT patients from an outpatient clinic were stepwise matched to the patients undergoing CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). First, the exclusion criteria of the RCT were applied to the naturalistic sample of the outpatient clinic. Second, propensity score matching (PSM) was used to adjust the remaining naturalistic sample on the basis of baseline covariate distributions. Matched samples were then compared regarding treatment effects using effect sizes, average treatment effect on the treated (ATT) and recovery rates. RESULTS CBT in the adjusted naturalistic subsample was as effective as in the RCT. However, treatments lasted significantly longer under routine care conditions. LIMITATIONS The samples included only a limited amount of common predictor variables and stemmed from different countries. There might be additional covariates, which could potentially further improve the matching between the samples. CONCLUSIONS CBT for depression in clinical practice might be equally effective as manual-based treatments in RCTs when they are applied to comparable patients. The fact that similar effects under routine conditions were reached with more sessions, however, points to the potential to optimize treatments in clinical practice with respect to their efficiency.

Defining early positive response to psychotherapy: An empirical comparison between clinically significant change criteria and growth mixture modeling.

Several different approaches have been applied to identify early positive change in response to psychotherapy so as to predict later treatment outcome and length as well as use this information for outcome monitoring and treatment planning. In this study, simple methods based on clinically significant change criteria and computationally demanding growth mixture modeling (GMM) are compared with regard to their overlap and uniqueness as well as their characteristics in terms of initial impairment, therapy outcome, and treatment length. The GMM approach identified a highly specific subgroup of early improving patients. These patients were characterized by higher average intake impairments and higher pre- to-posttreatment score differences. Although being more specific for the prediction of treatment success, GMM was much less sensitive than clinically significant and reliable change criteria. There were no differences between the groups with regard to treatment length. Because each of the approaches had specific advantages, results suggest a combination of both methods for practical use in routine outcome monitoring and treatment planning.

Therapist Effects on and Predictors of Non-Consensual Dropout in Psychotherapy.

BACKGROUND Whereas therapist effects on outcome have been a research topic for several years, the influence of therapists on premature treatment termination (dropout) has hardly been investigated. Since dropout is common during psychological treatment, and its occurrence has important implications for both the individual patient and the healthcare system, it is important to identify the factors associated with it. METHOD Participants included 707 patients in outpatient psychotherapy treated by 66 therapists. Multilevel logistic regression models for dichotomous data were used to estimate the impact of therapists on patient dropout. Additionally, sociodemographic variables, symptoms, personality style and treatment expectations were investigated as potential predictors. RESULTS It was found that 5.7% of variance in dropout could be attributed to therapists. The therapists effect remained significant after controlling for patients initial impairment. Furthermore, initial impairment was a predictor of premature termination. Other significant predictors of dropout on a patient level were male sex, lower education status, more histrionic and less compulsive personality style and negative treatment expectations. CONCLUSIONS The findings indicate that differences between therapists influence the likelihood of dropout in outpatient psychotherapy. Further research should focus on variables, which have the potential to explain these inter-individual differences between therapists (e.g., therapists experience or self-efficacy). Copyright