Psychotherapy Dropout: Using the Adolescent Psychotherapy Q-Set to Explore the Early In-Session Process of Short-Term Psychodynamic Psychotherapy

Research suggests that short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression in adolescence, yet treatment dropout is a major concern and what leads to dropout is poorly understood. Whilst studies have begun to explore the role of patient and therapist variables, there is a dearth of research on the actual therapy process and investigation of the interaction between patient and therapist. This study aims to address this paucity through the utilisation of the Adolescent Psychotherapy Q-set (APQ) to examine the early treatment period. The sample includes 69 adolescents aged 16–18 years with major depressive disorder receiving STPP as part of the First Experimental Study of Transference Work–in Teenagers (FEST-IT) trial. Of these, 21 were identified as dropouts and were compared to completers on pre-treatment patient characteristics, symptomatology, functioning, and working alliance. APQ ratings available for an early session from 16 of these drop out cases were analysed to explore the patient-therapist interaction structure. Results from the Q-factor analysis revealed three distinct interaction structures that explained 54.3% of the total variance. The first described a process of mutual trust and collaboration, the second was characterised by patient resistance and emotional detachment, the third by a mismatch and incongruence between therapist and adolescent. Comparison between the three revealed interesting differences which taken together provide further evidence that the reasons why adolescents drop out of therapy vary and are multidimensional in nature.

Using technology to understand how therapist variables are associated with clinical outcomes in IAPT

The UK’s Improving Access to Psychological Therapy Programme (IAPT) has improved transparency of primary mental health care in relation to the mandatory reporting of clinical outcomes. However, the data reveal a significant variance in outcomes. These findings have led to a growing body of research investigating to what extent therapist variables account for the difference in clinical outcomes. Previous studies have not had access to sufficient recordings or transcripts of therapy sessions in order to fully address this question. The purpose of this study was to use therapy transcripts derived from internet enabled cognitive behavioural therapy (CBT) treatment sessions in order to investigate whether and how therapist variables are associated with clinical outcome. A hierarchical log-linear analysis examined the relationship between therapist/patient variables and clinical outcome. Therapist fidelity to the CBT model and associated adherence to an evidence-based protocol were significantly related to clinical outcome. A graphical representation of the statistical model suggests that patient recovery is directly linked with fidelity and indirectly with adherence, after adjusting for patient attributes of age, gender and clinical presentation. Corroborating previous research, therapist competence and adherence to an evidence-based treatment protocol appear to be important in improving outcomes. These findings have implications for the continuing professional development of qualified therapists, potentially reinforcing the importance of reducing therapist drift. Key learning aims (1) To develop an understanding in relation to which therapist variables are associated with clinical outcome in IAPT. (2) To reflect on how fidelity to the CBT model and adherence to evidence-based treatment protocols may affect clinical outcomes. (3) To exemplify use of a statistical method for enhanced visual understanding of complex multi-factorial data.

Advice Giving in Psychotherapy

Advice giving in psychotherapy has been an area of interest for theorists and practitioners for a long time. However, clear and distinct answers to questions concerning the role of advice in client outcomes have not been as available as one would expect. This state of art may be related to discrepant theoretical positions and the lack of consistent empirical evidence. This chapter argues that some evidence does support advice giving in psychotherapy, depending on the cultural and social context as well as on client and therapist variables. This chapter reviews the literature, recommends a specific model for advice giving, and outlines future research directions.

Developing Guidelines and Competencies for the Training of Psychedelic Therapists

Research since the 1950s has shown that psychedelic-assisted psychotherapy has had significant positive effects in reductions of specific clinical symptoms and increases in quality of life as measured on a variety of indices. The intensity of focus on evidence-based outcomes, however, has resulted in a paucity of active discussions and research on the core competencies of the therapists themselves. The context of the history of psychedelic research reveals how this neglect of therapist variables occurred. With current discussions of Phase 3 and expanded access research programs for psilocybin-assisted and MDMA-assisted psychotherapies, there will be a great need for competent therapists trained in this clinical specialty. This is particularly the case if less restricted, legal medical use is approved within the next 6 to 10 years. This article is the first review and compilation of psychedelic therapist competencies derived from the psychedelic literature. These six therapist competencies are empathetic abiding presence; trust enhancement; spiritual intelligence; knowledge of the physical and psychological effects of psychedelics; therapist self-awareness and ethical integrity; and proficiency in complementary techniques. A further contribution of this review is a delineation of the 12 fundamental curricular domains of study for the training and development of these therapist competencies. As current legal restrictions evolve, aspects of these training guidelines will develop accordingly.

The World of Expertise in Counseling and Psychotherapy

Research suggests that characteristics and attitudes of the therapist may be a significant contributor to psychotherapy outcome. Researchers using both quantitative and qualitative methods have explored the characteristics of expert practitioners. This chapter provides an overview of the literature on therapist variables and master therapists, describes the validity of the peer nomination process for selecting master therapists, and explains how qualitative meta-analysis is utilized to integrate findings from various countries. Finally, the importance of obtaining an international perspective on master therapists is emphasized. Qualitative studies on the practices of expert therapists in different countries offer rich descriptive narratives for how optimal therapy works in different country and cultural contexts. More qualitative studies are needed to understand old and new constructs from different cultural perspectives.

Therapist Characteristics and Strategies for Enhancing the Therapeutic Alliance and Treatment Outcomes with Adults

In this chapter we focus on how the therapist affects the effectiveness of psychotherapy. We approach this chapter as two researchers who are also practicing therapists and therefore are aware of common challenges regarding the research–practice gap. Our goals are to discuss specific implications of psychotherapy research and to highlight concrete steps for implementing therapist-focused quality improvement strategies in clinical settings. We begin with a discussion of why therapist variables have been neglected in psychotherapy research and review research evidence of therapist effects. We then discuss characteristics of effective therapists and ways in which individual therapists can improve their practice. Finally, we discuss the growing body of research on routine outcome monitoring (ROM) and the role both therapists and systems of care play in improving outcome.

Young clinicians dealing with death: Problems and opportunities

Objective:The formation of a strong bond between patients and therapists can lead to successful treatment outcomes. Yet, little is known about the mechanisms that function to control this relationship. The objective of this case report was to examine the ruptures and repairs in the working alliance between a young therapist and an elderly caregiver, and to suggest ways in which to deal with age-related challenges to such an alliance.Method:In order to examine the ruptures and repairs in a working alliance, this case report reflects on the interdependent relationship among therapist variables, patient variables, and the therapeutic alliance. The clinical experience presented describes a newly educated psychologist's struggles to overcome the challenges in forming a strong working alliance with an elderly dying cancer patient's spouse. The spouse was enrolled in the DOMUS study (Clinicaltrials.gov: NTC01885637), an ongoing randomized controlled trial of a patient-and-caregiver intervention for facilitating the transition from an oncology ward to palliative at-home care, and then bereavement. As part of the DOMUS study, the patient and spouse received a psychological intervention based on existential-phenomenological therapy.Results:A therapist's therapeutic approach to breaking down age-related barriers to communication matters greatly. The existential-phenomenological method of epoché offers a way to effectively address ruptures and repairs in a working alliance, as it enhances the therapist's openness to learning. In addition, the insights of senior supervisors can promote a therapist's openness to learning.Significance of results:In conclusion, the method of epoché benefits the working alliance in several ways, as it enhances personal insight and provides methods for repairing an alliance. The reflections in this paper may be applied to clinical settings in oncology, gerontology, and palliative care, which are likely to be of great interest to young clinicians experiencing age-related challenges in their daily work.