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

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

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

Children with Autism Spectrum Disorder in Times of COVID-19: Examining Emotional and Behavioral Problems, Parental Well-Being, and Resilience

This longitudinal study assessed the impact of the COVID-19 pandemic on children with autism spectrum disorder (ASD; n = 62; M age = 13 years) by measuring emotional and behavioral problems before and during the pandemic, and by comparing this change to a matched sample of children without ASD (n = 213; M age = 16 years). Moreover, we examined whether indicators of parental well-being promoted resilience of children with ASD. Results showed that the mean change in problems did not differ between children with and without ASD. Importantly, some children showed an increase in problems, while others showed resilience. Parental well-being indicators were not related to resilience among children with ASD. The interindividual variability in responses, particularly among children with ASD, highlights the need for personalized support