Change processes underlying 'good outcome' : a qualitative study on recovered and improved patients’ experiences in psychotherapy for major depression

Aim: Exploring change processes underlying "good outcome" in psychotherapy for major depression. We examined the perspectives of patients who "recovered" and "improved" (Jacobson & Truax) following time-limited CBT and PDT. Method: In the context of an RCT on the treatment of major depression, patients were selected based on their pre-post outcome scores on the BDI-II: we selected 28 patients who recovered and 19 who improved in terms of depressive symptoms. A grounded theory analysis was conducted on post-therapy client change interviews, resulting in an integrative conceptual model. Results: According to recovered and improved patients, change follows from an interaction between therapy, therapist, patient, and extra-therapeutic context. Both helping and hindering influences were mentioned within all four influencing factors. Differences between recovered and improved patients point at the role of patients' agency and patients' internal and external obstacles. However, patients marked as "improved" described heterogeneous experiences. CBT- and PDT-specific experiences were also observed, although our findings suggest the possible role of therapist-related influences. Conclusion: From patients' perspectives, various change processes underlie "good outcome" that do not necessarily imply an "all good process". This supports a holistic, multidimensional conceptualization of change processes in psychotherapy and calls for more fine-grained mixed-methods process-outcome research

Validity beyond measurement : why psychometric validity is insufficient for valid psychotherapy research

In psychotherapy research, “validity” is canonically understood as the capacity of a test to measure what is purported to measure. However, we argue that this psychometric understanding of validity prohibits working researchers from considering the validity of their research. Psychotherapy researchers often use measures with a different epistemic goal than test developers intended, for example when a depression symptom measure is used to indicate “treatment success” (cf. outcome measurement for evidence-based treatment). However, the validity of a measure does not cover the validity of its use as operationalization of another target concept within a research procedure, nor the validity of its function toward an epistemic goal. In this paper, we discuss the importance of considering validity of the epistemic process beyond the validity of measures per se, based on an empirical case example from our psychotherapy study (“SCS”, Cornelis et al., 2017). We discuss why the psychometric understanding of validity is insufficient in covering epistemic validity, and we evaluate to what extent the available terminology regarding validity of research is sufficient for working researchers to accurately consider the validity of their overall epistemic process. As psychotherapy research is meant to offer a sound evidence-base for clinical practice, we argue that it is vital that psychotherapy researchers are able to discuss the validity of the epistemic choices made to serve the clinical goal

What 'Good outcome' means to patients : understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective

This study explored the meaning of "good outcome" within and beyond the much-used statistical indices of clinical significance in standard outcome research as developed by Jacobson and Truax (1991). Specifically, we examined the experiences of patients marked as "recovered" and "improved" following cognitive- behavioral therapy and psychodynamic therapy for major depression. A mixed-methods study was conducted using data gathered in an RCT, including patients' pre-post outcome scores on the Beck Depression Inventory-II and posttreatment client change interviews. We selected 28 patients who showed recovery and 19 patients who showed improvement in self-reported depression symptoms. A grounded theory analysis was performed on patients' interviews, ultimately resulting in a conceptual model of "good outcome." From patients' perspectives, good outcome can be understood as feeling empowered, finding personal balance and encountering ongoing struggle, indicating an ongoing process and variation in experience. The Jacobson-Truax classification of "good outcome" could not account for the (more pessimistic) nuances in outcome experiences, especially for "improved" patients, and did not grasp the multidimensional nature of outcome as experienced by patients. It is recommended that statistical indications of clinical meaningfulness are interpreted warily and ideally contextualized within personal narratives. Further research on the phenomenon of change and good outcome is required, aiming at integrating multiple perspectives and methods accordingly the multidimensional phenomenon under study

No change? A grounded theory analysis of depressed patients' perspectives on non-improvement in psychotherapy

Aim: Understanding the effects of psychotherapy is a crucial concern for both research and clinical practice, especially when outcome tends to be negative. Yet, while outcome is predominantly evaluated by means of quantitative pre-post outcome questionnaires, it remains unclear what this actually means for patients in their daily lives. To explore this meaning, it is imperative to combine treatment evaluation with quantitative and qualitative outcome measures. This study investigates the phenomenon of non-improvement in psychotherapy, by complementing quantitative pre-post outcome scores that indicate no reliable change in depression symptoms with a qualitative inquiry of patients' perspectives.Methods: The study took place in the context of a Randomised Controlled Trial evaluating time-limited psychodynamic and cognitive behavioral therapy for major depression. A mixed methods study was conducted including patients' pre-post outcome scores on the BDI-II-NL and post treatment Client Change Interviews. Nineteen patients whose data showed no reliable change in depression symptoms were selected. A grounded theory analysis was conducted on the transcripts of patients' interviews.Findings: From the patients' perspective, non-improvement can be understood as being stuck between knowing versus doing, resulting in a stalemate. Positive changes (mental stability, personal strength, and insight) were stimulated by therapy offering moments of self-reflection and guidance, the benevolent therapist approach and the context as important motivations. Remaining issues (ambition to change but inability to do so) were attributed to the therapy hitting its limits, patients' resistance and impossibility and the context as a source of distress. “No change” in outcome scores therefore seems to involve a “partial change” when considering the patients' perspectives.Conclusion: The study shows the value of integrating qualitative first-person analyses into standard quantitative outcome evaluation and particularly for understanding the phenomenon of non-improvement. It argues for more multi-method and multi-perspective research to gain a better understanding of (negative) outcome and treatment effects. Implications for both research and practice are discussed

The Ghent Psychotherapy Study (GPS) on the differential efficacy of supportive-expressive and cognitive behavioral interventions in dependent and self-critical depressive patients : study protocol for a randomized controlled trial

Background: Major depressive disorder is a leading cause of disease burden worldwide, indicating the importance of effective therapies. Outcome studies have shown overall efficacy of different types of psychotherapy across groups, yet large variability within groups. Although patient characteristics are considered crucial in understanding outcome, they have received limited research attention. This trial aims at investigating the interaction between therapeutic approach (pre-structured versus explorative) and the personality style of patients (dependent versus self-critical), which is considered a core underlying dimension of depressive pathology. Methods/design: This study is a pragmatic stratified (dependent and self-critical patients) parallel trial with equal randomization (allocation 1: 1) conducted in Flanders, Belgium. One hundred and four patients will be recruited and randomized to either 16-20 sessions of cognitive behavioral therapy for depression (pre-structured approach) or 16-20 sessions of short-term psychodynamic psychotherapy for depression (explorative approach) conducted by trained psychotherapists in private practices. The primary outcome is the severity of depression as measured by the Hamilton Rating Scale for Depression at completion of therapy. Secondary outcome measures include self-reported depressive and other symptoms, interpersonal functioning, idiosyncratic complaints, and the presence of the diagnosis of depression. Additional measures include biological measures, narrative material (sessions, interviews), and health care costs. Discussion: This trial presents the test of an often-described, yet hardly investigated interaction between important personality dimensions and therapeutic approach in the treatment of depression. Results could inform therapists on how to match psychotherapeutic treatments to specific personality characteristics of their patients

The story of ‘the data’ : on validity of data and performativity of research participation in psychotherapy research

This dissertation is focused on the validity of “the data” that are collected in psychotherapy research for the purpose of evidencing treatment efficacy. In the ‘Evidence Based Treatment’ (EBT) paradigm, researchers rely on the so-called ‘gold standard methodology’ to gather sound and trustworthy evidence, which increasingly influences the organization of mental health care worldwide (Kazdin & Sternberg, 2006). In the gold standard, data are collected by quantified self-report measures, to assess the presence and severity of symptoms before and after treatment. When the pre-post difference is larger for a group of people that received the treatment of interest and a group of people who received no or an alternative treatment (Chambless & Ollendick, 2001), the treatment of interest is called effective. In this methodological procedure, researchers tend to assume that when this gold standard methodology is conducted properly, “the data” will speak for themselves. However, when evidence is based on data, that evidence is principally limited by that data. In other words: output depends on input. That implies that when input is flawed, output will be flawed, even when the very best methods of analysis would be used. So what if “the data” yield validity issues despite (or because of) being collected by validated measures? When “the data” do not straightforwardly evidence treatment effects, will the subsequent steps in the analysis of these data be enough to secure that the evidence in the end does evidence treatment efficacy? In this dissertation, the focus is turned to validity of “the data” that are concretely provided by patient-participants by scoring their own experienced symptoms in self-report questionnaires, in function of evidencing treatment efficacy. A series of empirical case studies were conducted to scrutinize how patient-participants in a randomized controlled psychotherapy study (‘The Ghent Psychotherapy Study’; Meganck et al., 2017) experienced the process of data collection, and how these experiences affected the data that they provided. Each of the studied patient-participants experienced a substantial effect of the questionnaire administration on their complaints. This impacted the level (presence and severity) of complaints, but also changed the way in which the complaints were understood at all, and how patient-participants perceived themselves. Thus, rather than neutrally measuring symptoms, questionnaire administration changed the experienced complaints ‘performatively’ (Cavanaugh, 2015), which turned measurement into a clinical intervention of its own. Consequently, what is measured cannot straightforwardly be called ‘treatment efficacy’, as it may be entangled with, enabled by or even obstructed by effects of measurement and research. Therefore, the act of measurement itself can pose a vital threat to the validity of “the data”. This way, the empirical case studies exhibited that data can yield validity problems despite (or because of) the use of validated measures. Consequently, the validity of a measure as such is no guarantee for the validity of data. Nonetheless, in gold standard research, the data are straightforwardly taken as input for analyses of general treatment efficacy. The question is what happens with those validity issues on the level of individual data, when they pursue their journey towards becoming evidence. In this dissertation, it was argued that the validity issues are not sufficiently solved in the methodological steps after data collection, so when data are invalid in the beginning, these validity issues will simply become part of the data set that forms the input for analysis of the final evidence. This urges that validity issues should be solved on the level of individually provided data, as the validity issues will otherwise become inherent to “the data”. Put formally: valid data is a precondition for evidence in EBT. In conclusion, it is crucial for a sound evidence-base to scrutinize the validity of data in function of the overall goal and utility of the research. For this, it is important not to take “the data” as speaking for themselves, but to regard them as clinical narratives, which are framed in a specific format to be communicated between researcher and respondent in a research context. This emphasizes that the choice for a certain format determines what can be evidenced, so it is vital that these choices indeed allow for obtaining evidence that is useful and valid to serve the clinical goal of EBT

Do the numbers speak for themselves? A critical analysis of procedural objectivity in psychotherapeutic efficacy research

Psychotherapy research is known for its pursuit of Evidence-Based Treatment (EBT). Psychotherapeutic efficacy is assessed by calculation of aggregated differences between pre treatment- and post treatment symptom levels. As this 'gold standard methodology' is regarded as 'procedurally objective', the efficacy number that results from the procedure is taken as a valid indicator of treatment efficacy. However, I argue that the assumption of procedural objectivity is not justified, as the methodology is build upon a problematic numerical basis. I use an empirical case study to show (1) how measurement problems practically occur in the first step of data collection, i.e. in individual symptom measurement. These problems have been discussed and acknowledged for decades, but still measurement is regarded as the best epistemic means to gain evidence on psychotherapeutic efficacy. Therefore, I show (2) how initial measurement problems are overlooked in the remainder of the methodological procedure, which harms the 'evidence-base' of psychotherapeutic EBT. Via this applied analysis, I exhibit concerns that are increasingly raised in the literature in an empirical way, to emphasize the need for a non-idealized consideration of the 'gold standard methodology' as a means towards its clinical end

Objectivity in psychotherapy research: Do the numbers speak for themselves?

Psychotherapy research is characterized by a quest for evidence-based treatment. Systematic numerical comparison by means of randomized controlled trials is held as objective methodology resulting in evidence on efficacy of psychological treatments. In this pursuit, numbers are taken as speaking for themselves. However, I argue that the assumed procedural objectivity does not yield objectivity of evidence resulting from the method of choice. This discussion I base on the analysis of a clinical case example from our own mixed method psychotherapy research, in which the numbers could speak for themselves, yet the conclusion does not at all