Psychotherapy Outcomes Research. Bob Bertolino, Ph.D.

Transcription

1 Psychotherapy Outcomes Research Bob Bertolino, Ph.D.

2 Primary Research Agendas

3 Primary Agendas in Research and Practice 1. Empirically-Supported Treatments (ESTs); Evidence-Based Practices (EBPs) 2. Empirically-Supported Relationships (ESRs) 3. Common Factors (Meta-analysis) 4. Outcome Management

4 EBP/EST Division 12 of APA Committee on Science and Practice (formerly TFPP) Viewing models, methods, and techniques as the primary causal agents of change (as proven though RCTs) Increased relevance and dissemination to the professions and public Developing a single list of Empirically Supported Treatments (EST) Comparative Analyses Allegiance effects Efficacy vs. effectiveness settings

5 Empirically-Supported Relationships (ESR) APA Division 29 Task Force Formed to identify elements of effective therapy relationships that affect treatment outcomes and determine efficacious methods of customizing therapy to individuals on the basis of their characteristics Includes client and therapist factors and variables that influence relationships and affect change Efforts to promulgate practice guidelines or evidence- based lists of effective psychotherapy without including the therapy relationship are seriously incomplete and potentially misleading on both clinical and empirical grounds. (Div. 29 TF)

6 The Therapeutic Relationship in Context Even for those who are convinced that the therapeutic relationship is healing by and of itself, there are strategies that can foster its impact. In other words, since not all kinds of relationships are likely to bring about change, one needs to be aware of interventions (including modes of relating) that should be encouraged or avoided for the relationship to become a corrective experience. (Castonguay & Beutler, 2006, p. 353) Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeutic change: What do we know and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp ). New York: Oxford University Press.

7 Meta-Analytic/ Common Factors 15% 15% 40% 30% Client Factors Relationship Factors Expectancy and Placebo Model and Technique Factors Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.) (1999). The heart and soul of change: What works in therapy. Washington, D.C.: American Psychological Association. Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp ). New York: Basic Books.

8 Effects on Outcomes 22% General Effects 8% Specific Effects 70% Unexplained Variance Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. New Jersey: Lawrence Erlbaum.

9 Outcomes Management Dose-Response Effect All major meta-analytic studies indicate the most significant portion of change occurs earlier in treatment (within the first 5 sessions) The client s rating of the therapeutic relationship is the most consistent predictor of outcome The average length of time that clients attend counseling is 6-10 sessions (regardless of the model employed) One of the best predictors of negative outcome is a lack of structure in therapy Real-time (outcomes and alliance) feedback can improve outcome between 40-65%

10 Outcomes Management (cont.) Real-Time Feedback Mechanisms Alliance (WAI, HAq-II, SRS, etc.) : client ratings of relationship Outcomes (OQ Family, ORS, etc.): individual (well-being), interpersonal, and social role functioning Used on an ongoing basis Increases Factor of Fit Practice-Based Evidence

11 Points of Change Intersection and Convergence

12 Outcomes Management (OM) Empirically- Supported Relationships (ESR) Principles of Change (POC) Common Factors (CF) Evidence- Based Practices (EBP/EST)

13 APA on EBP The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273

14 Principles of Change 1. Client Contributions 2. The Therapeutic Relationship and Alliance 3. Cultural Competence 4. Change as a Process 5. Expectancy and Hope 6. Model and Factor of Fit

15 Principles of Change in Motion Strategies for Change

16 Strategies for Change View the client(s) as a primary factor in change (i.e., identify and build on internal strengths and social support systems) Consider that the strength of the therapeutic relationship and alliance from the client s perspective is most important Convey empathy Convey positive regard Be congruent and genuine Consider the client-practitioner match

17 Strategies for Change (cont.) Be sensitive and respectful to the unique cultural and contextual characteristics of each client Create a respectful therapeutic climate in which clients are able to explore and express their personal stories or narratives and associated emotions Include clients in processes (i.e., preferences, service planning, goal setting, tasks, etc.) Select and match methods with clients according to factors such as preferences, level of need, state of readiness, level of distress/impairment, and coping style

18 Strategies for Change (cont.) Use educational and developmental processes that increase social skills, coping skills, and self-regulation Incorporate client-practitioner feedback loops (i.e., monitor the strength of the alliance and outcome/the subjective impact of therapy) Attend to alliance ruptures Pay attention to practitioner contributions to change (e.g., expectations, preferences, level of personal awareness, patience, etc.) Employ structure/focus in sessions/meetings/interactions Explore client expectations Create or rehabilitate hope and a future focus Use self-disclosure

19 Responsiveness in Therapy

20 Responding to Alliance Ruptures Discuss the here-and-now relationship with the client. Ask for feedback about the therapeutic relationship. Create space and allow the client to assert any negative feelings about the therapeutic relationship. Engage in conversations about the client s expectations and preferences. Discuss the match between the therapist s style and client s preferred ways to relate. Spend more time learning about the client s experience in therapy. Readdress the agreement established about goals and tasks to accomplish those goals. Accept responsibility for his or her part in alliance ruptures. Normalize the client s responses by letting him or her know that talking about concerns, facing challenges, taking action, and/or therapy in general can be difficult.

21 Responding to Alliance Ruptures (cont.) Provide rationale for techniques and methods. Attend closely to subtle clues (e.g., nonverbal behaviors, patterns such as one-word answers) that may indicate a problem with the alliance. Offer more positive feedback and encouragement (except when the client communicates either verbally or nonverbally that this is not a good match). Engage in further supervision and/or training Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp ). New York: Oxford University Press.

22 Negotiating Impasses Revisit the current stage of the client s change. (Ask: What is the client s state of readiness for change?) Focus more on the client s view of the problem or situation this will not require action. Ask open-ended questions that will allow the client to notice one or more aspects that have been downplayed or have gone unnoticed about the situation (take care not to imply that the client s perspective is wrong ; try only to introduce other ways of viewing that may offer new possibilities or will encourage the client to talk about the problem or situation differently). Help the client to weigh the possible positive and negative effects of his or her behavior. Help the client to weigh the possible benefits and drawbacks of change. Demonstrate genuine confidence that the client has the strength to face his or her challenges. Reorient to the client s concerns to ensure that you and the client are focusing on the same issue.

23 Negotiating Impasses (cont.) Offer straightforward feedback without imposing it (for example, From where I am standing, I m concerned about what might happen if this continues. Of course, that is for you to decide, but I believe it s my responsibility to speak about it. ) (Note: Always provide more directive feedback and make necessary safeguards if there is risk of harm to self or other.) Avoid a solution-forced situation when the client s conversational preference is to talk more about problems and his or her ambivalence. Acknowledge further ensure that the client feels heard and understood and verifies this either verbally or nonverbally (ask questions or use an alliance measure as needed). Discuss with the client whether the level of services is a good fit and/or whether he or she is ready to be in therapy. Bertolino, B. (2010). Strengths-based engagement and practice: Creating effective helping relationships. Boston: Allyn & Bacon.

24 What Do the Most Effective Therapists Do? Maintain a posture of awareness, being alert, observant, and attentive in each encounter Compare new information and what is learned with what is already known Remain acutely attuned to the vicissitudes of client engagement actively employ processes of gaining and incorporating ongoing formal feedback Consistently achieve lower scores on standardized alliance measures at the outset of services because they are more persistent and perhaps, more believable, when assuring clients that they seek honest feedback, enabling them to address potential problems in the alliance (workers with lower rates of success, by contrast, tend to receive negative feedback later in services, at which point clients have already disengaged)

25 What Do the Most Effective Therapists Do? (cont.) Spend more time on strategies that might be more effective and improve outcomes as opposed to hypothesizing about failed strategies and why methods did not work Expand awareness when events are stressful and remaining open to options Evaluate and refine strategies and seek outside consultation, supervision, coaching, and training specific to particular skill sets

26 Resources

27 Resources Beutler, L. E., & Clarkin, J. (1990). Systematic treatment selection: Toward targeted therapeuticinterventions. New York: Brunner/Mazel. Beutler, L. E., & Harwood, T. M. (2000). Prescriptive psychotherapy: A practical guide to systematic treatment selection. New York: Oxford University Press. Bertolino, B. (2010). Strengths-based engagement and practice: Creating effective helping relationships. Boston: Allyn & Bacon. Bertolino, B. (2003). Change-oriented psychotherapy with adolescents and young adults: The next generation of respectful and effective therapeutic processes and practices. New York: Norton. Bertolino, B., Kiener, M. S., & Patterson, R. (2009). The therapist s notebook for strengths and solution-based therapies. New York: Routledge. Bertolino, B., & O Hanlon, B. (2002). Collaborative, competency-based counseling and therapy. Boston: Allyn & Bacon. Bertolino, B., & Schultheis, G. (2002). The therapist s notebook for families: Solutionoriented exercises for working with parents, children, and adolescents. New York: The Haworth Press. Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work. New York: Oxford University Press.

28 Resources (cont.) Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client directed, outcome-informed therapy [Revised paperback edition]. San Francisco: Jossey-Bass. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore: Johns Hopkins University Press. Horvath, A. O., & Greenberg, L. S. (1994). The working alliance: Theory, research, and practice. New York: Wiley. Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association. Lambert, M. J. ((Ed.). 2004). Bergin and Garfield s handbook of psychotherapy and behavior change (5th ed.). New York: Wiley. Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration (2nd ed.). New York: Oxford. Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press. O Hanlon, B., & Bertolino, B. (1998). Even from a broken web: Brief, respectful solutionoriented therapy for sexual abuse and trauma. New York: John Wiley & Sons. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum.

29 Resources (cont.)