Patient-Focused and Feedback Research in Psychotherapy

Wolfgang Lutz, Kim de Jong, Julian Rubel, Wolfgang Lutz, Kim de Jong, Julian Rubel

• Publisher: Taylor & Francis
• Year: 2018
• eBook ISBN: 9781315515632
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

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. 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. After summarizing the current state of feedback research, this book provides empirical investigations of contemporary feedback research. These efforts aim at answering three overarching questions: 1) How should we implement feedback systems into routine practice and how do therapist and patient attitudes influence its effects?, 2) How can we design feedback reports and decision support tools?, and 3) Why do patients become at risk of treatment failure and how should therapists intervene with these patients? The studies included in this book reflect the current state of feedback research and provide promising pathways for future endeavours that will enhance our understanding of feedback effects.

This book was originally published as a special issue of Psychotherapy Research.

A mixed-method investigation of patient monitoring and enhanced feedback in routine practice: Barriers and facilitators

MIKE LUCOCK¹,², JEREMY HALSTEAD³, CHRIS LEACH¹,², MICHAEL BARKHAM⁴, SAMANTHA TUCKER⁵, CHLOE RANDAL¹, JOANNE MIDDLETON⁵, WAJID KHAN¹, HANNAH CATLOW¹ EMMA WATERS³, & DAVID SAXON⁴

¹South West Yorkshire Partnership NHS Foundation Trust, UK; ²Centre for Applied Psychological and Health Research, University of Huddersfield, Huddersfield, UK; ³Clinical Psychology, University of Leeds, Leeds, UK; ⁴Department of Psychology, Centre for Psychological Services Research, University of Sheffield, Sheffield, UK; ⁵School of Psychological Sciences, University of Manchester, Manchester, UK

Abstract
Objective: To investigate the barriers and facilitators of an effective implementation of an outcome monitoring and feedback system in a UK National Health Service psychological therapy service. Method: An outcome monitoring system was introduced in two services. Enhanced feedback was given to therapists after session 4. Qualitative and quantitative methods were used, including questionnaires for therapists and patients. Thematic analysis was carried out on written and verbal feedback from therapists. Analysis of patient outcomes for 202 episodes of therapy was compared with benchmark data of 136 episodes of therapy for which feedback was not given to therapists. Results: Themes influencing the feasibility and acceptability of the feedback system were the extent to which therapists integrated the measures and feedback into the therapy, availability of administrative support, information technology, and complexity of the service. There were low levels of therapist actions resulting from the feedback, including discussing the feedback in supervision and with patients. Conclusions: The findings support the feasibility and acceptability of setting up a routine system in a complex service, but a number of challenges and barriers have to be overcome and therapist differences are apparent. More research on implementation and effectiveness is needed in diverse clinical settings.

Introduction

There is substantial evidence for the efficacy and effectiveness of psychological therapies (Lambert, 2013). Despite this body of literature, a significant number of patients do not benefit. Hansen, Lambert, and Forman (2002) report that about a third of patients receiving psychotherapy in RCTs either show no benefit or deteriorate. The rates of poor response are reported to be higher in routine services, with Hansen et al. (2002) reporting 56% of patients making no reliable change across studies in routine practice involving over 6000 patients with an additional average reliable deterioration rate of 8%. The importance of deterioration in psychotherapy has been highlighted (e.g., Lilienfeld, 2007) and Mohr (1995), in a review of 46 studies, identified patient, therapist, and therapy variables associated with negative outcome. The patient characteristics identified included borderline personality, obsessive–compulsive problems with severe interpersonal difficulties, poor motivation, and those patients expecting psychotherapy to be painless. This evidence underlines the importance of identifying patients at risk of a poor treatment response.

There is now widespread acknowledgment that an important way of improving outcomes involves monitoring the progress of patients during therapy and providing timely feedback on the monitoring data to therapists. This activity has yielded a burgeoning literature comprising texts (e.g., Lambert, 2010), reviews (e.g., Carlier et al., 2012), special issues (e.g., Fitzpatrick, 2012), and opinion pieces (e.g., Macdonald & Mellor-Clark, 2015). Monitoring progress and providing feedback is consistent with the traditions of patient-focused research (Howard, Moras, Brill, Martinovich, & Lutz, 1996) and the scientist practitioner approach (Hayes, Barlow, & Nelson, 1999). However, only in recent years have patient monitoring and feedback systems become embedded in routine practice. Examples are Lambert's work using the Outcome Questionnaire (Lambert et al., 2004); the Clinical Outcomes in Routine Evaluation (CORE) OM and CORE system in the UK (Barkham et al., 2010); and Miller and Duncan's development and implementation of two 4-item measures of treatment progress and therapeutic alliance (Miller, Duncan, Sorrell, & Brown, 2005). Part of the rationale for using these systems rests on evidence that early response to therapy predicts outcome (Lutz et al., 2006; Lutz, Stulz, & Köck, 2009; Stulz, Lutz, Leach, Lucock, & Barkham, 2007). In particular, there is evidence that poor early response to therapy is a predictor of a poor outcome (Kuyken, 2004; Lambert et al., 2002). Another justification for patient monitoring and feedback systems is the evidence that therapists are poor judges of their patients’ outcomes (Garb, 2005; Sapyta, Reimer, & Bickman, 2005). Moreover, they are poor at predicting which of their patients are likely to deteriorate (Hannan et al., 2005). This finding is consistent with long-standing evidence that clinical judgement can be relatively poor and inferior to statistical predictions (Dawes, Faust, & Meehl, 1989; Meehl, 1954). Tracey, Wampold, Lichtenberg, and Goodyear (2014) argue that a further justification for attending to feedback about patients’ progress is that it is a necessary but not sufficient requirement for developing the expertise of therapists.

Lambert and colleagues introduced the notion of patients who are “not on track” (NOT) as a means of identifying patients who are not achieving the expected recovery trajectory and therefore at risk of treatment failure. They found that providing feedback to therapists on the progress of these patients improved outcomes (Lambert et al., 2001, 2002). The addition of a set of clinical support tools, which provided information to therapists about the quality of the therapeutic relationship, the patient's social support, motivation, and experience of life events, further improved outcomes for NOT patients (Whipple et al., 2003). There is further evidence of moderate effects of feedback on outcome from other settings and countries (e.g., Byrne, Hooke, Newnham, & Page, 2012; Hansson, Rundberg, Ö sterling, Ö jehagen, & Berglund, 2013; Probst et al., 2013).

Set against this promising body of evidence, a recent independent review of patient outcome feedback systems by Davidson, Perry, and Bell (2015) heeded caution in relation to the extent to which findings could be generalized to non-US, and specifically UK, settings. The authors note that only the later studies—post-2009—are likely to represent the diversity and severity of patients seen in the UK National Health Service (NHS) and the impact of feedback in these studies appears to be reduced. Accordingly, the present study investigated the feasibility of setting up an outcome feedback system within a routine UK NHS service setting that met the needs of a more diverse and broad spectrum of patient needs.

Despite this growing body of evidence, there have been few studies investigating mediators related to feedback systems, such as therapist behaviour (e.g., how they act on the feedback) or organizational factors. Boswell, Kraus, Miller, and Lambert (2015) discuss a number of these factors and identify some of the benefits, obstacles, and challenges associated with routine outcome monitoring based on their experience with different systems over many years. They identify issues such as time burden, multiple stakeholders with different needs, and turnover of staff, particularly local “champions,” as well as fear and mistrust by therapists. Further research is required to understand the contribution of such factors to feedback, which might then inform improved methods for presenting feedback, engaging therapists, and understanding how clinicians make use of the feedback provided to them (Sapyta et al., 2005). Boswell et al. (2015) point out that despite research on feedback in psychotherapy, more needs to be learned about the implementation and sustained use of outcome monitoring and feedback systems in order to improve adoption and compliance. This should involve identifying organizational issues that may act as barriers to and facilitators of implementing patient monitoring and feedback systems in routine services. Services will vary in a number of key aspects, all of which may impact on the feasibility of running an effective feedback system. This situation is likely to be more important in complex services, for example, with multiple clinical bases, where a range of therapies is provided (including group work) and where patients receive more than one episode of therapy. Hence, the present stud...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Citation Information
• Notes on Contributors
• Introduction: Patient-focused and feedback research in psychotherapy: Where are we and where do we want to go?
• 1. A mixed-method investigation of patient monitoring and enhanced feedback in routine practice: Barriers and facilitators
• 2. Feedback and therapist effects in the context of treatment outcome and treatment length
• 3. Why do some therapists not deal with outcome monitoring feedback? A feasibility study on the effect of regulatory focus and person–organization fit on attitude and outcome
• 4. The effect of implementing the Outcome Questionnaire-45.2 feedback system in Norway: A multisite randomized clinical trial in a naturalistic setting
• 5. Feedback mechanisms of change: How problem alerts reported by youth clients and their caregivers impact clinician-reported session content
• 6. Predicting outcome of substance abuse treatment in a feedback study: Can recovery curves be improved upon?
• 7. Daily monitoring of temporal trajectories of suicidal ideation predict self-injury: A novel application of patient progress monitoring
• 8. Extreme deviations from expected recovery curves and their associations with therapeutic alliance, social support, motivation, and life events in psychosomatic in-patient therapy
• 9. Using the Assessment for Signal Clients as a feedback tool for reducing treatment failure
• Index