For whom, when, and how does Routine Outcome Monitoring (ROM) improve psychotherapy outcomes? A randomized clinical trial and a qualitative study at a hospital mental health center

Norsk sammendrag For hvem, når, og hvordan forbedrer tilbakemeldings-verktøy behandlingsutfall? En randomisert kontrollert og en kvalitativ studie på et distrikstpsykiatisk senter Tilbakemeldings-verktøy, som Klient- og Resultatstyrt behandling eller Feedback- Informerte Tjenester (KOR/FIT), skal gjøre det lettere å følge med på hvordan det går med pasienter som er i samtalebehandling for psykiske lidelser. Dermed kan behandlingen tilpasses underveis, slik at pasienten får nytte av den. Det er det for stor og økende interesse for slike verktøy. Resultatene fra tidligere forskning har imidlertid vært blandede. Formålet med denne avhandlingen var å undersøke hvorvidt systematiske tilbakemeldinger forbedrer behandlingen i spesialisthelsetjenesten. I tillegg utforsket vi noen faktorer som kan påvirke og forklare effekten av slike verktøy. Studie 1 var en randomisert kontrollert studie der vi sammenlignet behandling med og uten KOR/FIT. Vi fant at flere pasienter fikk nytte av behandlingen når de brukte tilbakemeldings-verktøy. Dette gjaldt uavhengig av hvor dårlig pasientene var ved oppstart, og hvem behandleren var. Tilbakemeldings-verktøyet var mer virksomt mot slutten av en fireårig implementeringsperiode, enn det var i begynnelsen. Noe av effekten av verktøyet kunne forklares av at det hadde en positiv virkning på pasientenes opplevelse av arbeidsalliansen med sine behandlere. Studie 2 var en kvalitativ undersøkelse av terapeuters erfaringer med å motta negative tilbakemeldinger fra pasienter. Resultatene tyder på at det kan være utfordrende og komplekst å forholde seg til misfornøyde pasienter, men at konkrete og direkte tilbakemeldinger gir behandlerne en mulighet til å endre sin atferd. Terapeutens forståelse og emosjonelle reaksjon på tilbakemeldingen, strategien deres i møtet med pasienten, og refleksjonene de gjorde seg i etterkant så ut til å påvirke hvorvidt de greide å forbedre den påfølgende terapiprosessen og/eller lære noe av tilbakemeldingene. Avhandlingen bidrar til å nyansere vår forståelse av når, for hvem og hvordan tilbakemeldings-verktøy forbedrer behandlingsutfall. Denne kunnskapen kan brukes til å forbedre den kliniske bruken av slike verktøy, slik at flere pasienter får nytte av dem. Funnene tyder på at implementering av tilbakemeldings-verktøy kan forbedre behandling i spesialisthelsetjenesten. Det kan imidlertid kreve systematisk innsats over tid å oppnå denne effekten, og implementeringsarbeid, som opplæring og veiledning i bruken av tilbakemeldingsverktøy, bør prioriteres. Behandlere kan med fordel bruke slike verktøy til å få konkrete og direkte tilbakemeldinger om hvordan pasienten opplever behandlingsprosessen, og å jobbe aktivt med å utvikle en god arbeidsallianse

An apprenticeship model in the training of psychotherapy students. Study protocol for a randomized controlled trial and qualitative investigation

Background One approach towards advancing the quality of mental health care is to improve psychotherapists\u27 skills through education and training. Recently, psychotherapy training has benefitted from adapting training methods from other professions (e.g., deliberate practice). The apprenticeship model has a long history in skill trades and medicine, but has yet to be adopted in training mental health professionals. This study aims to investigate the impact of apprenticeship training on clinical psychology students\u27 skills. Methods In a pragmatic mixed-methods trial, 120 first year students in a Master\u27s degree clinical psychology program will be randomized to either training-as-usual or training-as-usual plus psychotherapy apprenticeship. In the intervention group, students will participate, over a period of 10 weeks, in weekly treatment sessions together with licensed therapists at outpatient mental health and substance use treatment clinics. Outcomes are assessed post-intervention and at two-year follow-up. The main outcome measure is the Facilitative Interpersonal Skills (FIS) performance test. Additional self-report measures tap self-efficacy, self-compassion, worry, rumination, and stress. Weekly reflection log entries written by the students will be qualitatively analyzed in order to gain an in-depth understanding of the learning process. Students\u27 and therapists\u27 experiences with the intervention will be explored in focus group interviews. Discussion To the best of our knowledge, this is the first controlled study to investigate the impact of apprenticeship as an isolated training component in the education of clinical psychologists. The study is designed so as to yield a comprehensive understanding of an approach which could prove to be a valuable supplement to the existing educational methods in this field and ultimately, contribute to improve the quality of mental health care

The effects of Routine Outcome Monitoring (ROM) in the course of an implementation process - A randomized clinical trial

This study investigated the effects of the Partners for Change Outcome Management System (PCOMS) in adult outpatient treatment at a hospital-based mental health clinic. It also investigated whether the effects differed with the timing of the treatment within a 4-year implementation period, with clients’ initial distress levels, and between therapists. Adult clients (N = 170) were randomized to treatment as usual (TAU) or routine outcome monitoring (ROM). Twenty therapists provided therapy in both conditions. Therapy outcome was measured by the Behavior and Symptoms Identification Scale (BASIS-32). Data were analyzed in a series of multilevel models (MLMs). Clients in the ROM condition were 2.5 times more likely to demonstrate improvement than those in the TAU condition. Controlling for therapist variability, the overall effect size (ES) in favor of ROM was small (d = 0.26, p = .037). The superiority for ROM over TAU increased significantly over the duration of the study. ROM effects were not moderated by clients’ initial distress levels. Differences between therapists accounted for 9%–10% of the variability in outcomes, and there were no significant differences in ROM effects between therapists. ROM was associated with better treatment outcomes independent of clients’ initial distress levels. Clients treated later in the study benefitted more from ROM than those treated earlier

A combined individual and group-based stabilization and skill training intervention versus treatment as usual for patients with long lasting posttraumatic reactions receiving outpatient treatment in specialized mental health care – a study protocol for a randomized controlled trial

Background Suffering linked to previous interpersonal trauma is common among patients in mental health care. Diagnostic labels may vary, but the clinical picture is often characterized by long-lasting and complex psychological and somatic symptoms, subjective distress and reduced quality of health and life. A substantial proportion of patients do not recover after individual treatment in ordinary specialized mental healthcare settings, despite the proven usefulness of individual trauma-specific treatments. The therapeutic factors that arise in group settings, such as normalization, shame reduction and corrective relational experiences, may be particularly useful for trauma survivors. However, evidence in support of group treatment for trauma survivors is scarce. This study aims to test whether combining a novel group intervention to individual treatment is superior to conventional individual out-patient treatment in an ordinary community mental health hospital. Methods: In a single-site, non-blinded, randomized controlled trial (RCT), the effect of a combined group-based stabilization and skill-training (SST) intervention added to individual treatment will be compared to conventional treatment (treatment as usual, TAU) alone. Participants (N = 160) with ongoing and long-lasting reactions related to known adverse life events from the past will be recruited among patients at general outpatient clinics in a community mental health centre at St. Olav’s University Hospital, Trondheim, Norway. Following baseline assessment and randomization, participants will complete follow-up measures at 4, 8, 13 and 19 months post-baseline. The primary outcome is personal recovery (The questionnaire about the process of recovery , QPR). Secondary outcomes include (1) self-reported symptoms of posttraumatic stress, general mental and somatic health symptoms, well-being, functional impairment and client satisfaction, (2) immunological and endocrine response measured in blood samples and (3) national registry data on occupational status, use of mental health services and pharmacological treatment. Additionally, mechanisms of change via posttraumatic cognitions will be examined. Discussion: The addition of a group-based intervention to individual treatment for trauma survivors might prove to be an efficient way to meet the need of long-lasting high-intensity treatment in a large group of patients in mental health care, thereby reducing their suffering and increasing their psychosocial functioning