The Treatment Planning of Experienced Counselors: A Qualitative Examination

Using consensual qualitative research, the authors examined the treatment planning process of experienced counselors (N = 9). The data analysis resulted in 4 domains: assessment steps, clinical impressions, treatment factors, and treatment strategies. These domains describe the process used by experienced counselors in making clinical decisions and offer insight into the nature of clinical expertise and the need for further research on treatment planning

When life gets in the way: Systematic review of life events, socioeconomic deprivation, and their impact on counselling and psychotherapy with children and adolescents

Background Life events are recognised to link low socio‐economic status (SES) with impaired mental health. Despite attention to patients’ historical environmental circumstances in psychotherapeutic practice, events that occur over the course of counselling and psychotherapy (‘intercurrent’ events) seem to have received little attention in research. Method Life events were defined to include those that are chronic and severe, as well as minor, everyday occurrences. Outcomes were restricted to internalising problems related to depression and anxiety in child, or adolescent participants. Bibliographic databases and citations and review reference lists were searched, and relevant scholars were contacted. The conceptual and methodological nature of the literature is reported. Results This review included 42 studies. Intercurrent events varied in severity and duration. Events were most frequently measured using questionnaires. The same questionnaire was rarely used in more than one study, and questionnaires were often adapted for use for the study's purpose/population. Events included in analyses tended to be analysed as a mediator of change in psychiatric symptomatology, or an outcome of therapy. Conclusions Attention to intercurrent life events appears rare in psychotherapy research. This contributes to a systematic neglect of socio‐economic issues in psychotherapy research and arguably psychotherapy more generally. This neglect is exacerbated by a lack of agreed measures of life events, both intensive and routine in nature. Recommendations are made to improve attention to such events

Is there an evidence-based number of sessions in outpatient psychotherapy? – A comparison of naturalistic conditions across countries

Deciding on the number of psychotherapy sessions to satisfactorily treat a patient is a vital clinical as well as economic issue in most mental health systems worldwide. The length of outpatient psychotherapy in naturalistic conditions ranges from a single session to hundreds of sessions [1]. In randomized clinical trials, the number of sessions is typically fixed to deliver manualized treatments and to control for dosage effects (e.g., in a 16-session format [2]). Using data from Routine Outcome Monitoring studies [3, 4], we investigated whether the treatments under naturalistic conditions were fixed to a particular number of sessions or not (H1), whether naturalistic conditions tended to include unusually long treatments (e.g., >100 sessions) (H2), and how the observed number of sessions was distributed across countries (H3)

Depression and mentalizing: a psychodynamic therapy process study

The present study aimed to explore the relationship between changes in depressive symptoms and the capacity to mentalize over the course of a 3-month inpatient psychodynamic therapy in a sample of 56 patients with depression. Depressive symptoms and mentalizing were assessed weekly during treatment and at 1-year follow-up with the Beck Depression Inventory and the Reflective Functioning Questionnaire. Data were analyzed using latent growth curve modeling with structured residuals. In the total sample, depressive symptoms improved on average from baseline to the end of treatment, while mentalizing skills did not. However, individual variations were observed in mentalizing skills, with some patients improving while others did not. Within-patient residual changes in mentalizing skills did not predict residual changes in depressive symptoms. Accordingly, the results did not support mentalizing as a mechanism of change at this level. Nonetheless, between-patient effects were found, showing that patients with higher levels of mentalizing at baseline and patients whose mentalizing skills improved over the course of therapy also had greater reductions in depressive symptoms. We suggest that the presence of relatively higher mentalizing skills might be a factor contributing to moderately depressed individuals’ ability to benefit from treatment, while relatively poor or absent mentalizing capacity might be part of the dynamics underlying treatment resistance in individuals with severe depression

Examination of overall treatment effect and the proportion attributable to contextual effect in osteoarthritis: meta-analysis of randomised controlled trials

Objective: To examine the overall treatment effect and the proportion attributable to contextual effect (PCE) in randomised controlled trials (RCTs) of diverse treatments for osteoarthritis (OA). Methods: We searched MEDLINE, EMBASE, CENTRAL, Science Citation Index, AMED, CINAHL through October 2014, supplemented with manual search of reference lists, published meta-analyses and systematic reviews. Included were RCTs in OA comparing placebo with representative complementary, pharmacological, non-pharmacological and surgical treatments. The primary outcome was pain. Secondary outcomes were function and stiffness. The overall treatment effect was defined as the improvement from baseline in the treatment group. The contextual effect was defined as that of the placebo group. The PCE was calculated by dividing the contextual effect over the overall treatment effect. The effect size (ES) of overall treatment effect and the PCE were pooled using random-effects model. Subgroup analysis and meta-regression were conducted to examine determinants of the PCE. Results: In total, 215 trials (41,392 participants) were included. The overall treatment effect for pain-reduction ranged from the smallest with lavage (ES=0.46, 95%CI: 0.24, 0.68) to the largest with topical NSAIDs (ES=1.37, 95%CI 1.19, 1.55). On average, 75% (PCE=0.75, 95%CI 0.72, 0.79) of pain reduction was attributable to contextual effect. It varied by treatment from 47% (PCE=0.47, 95%CI: 0.32, 0.70) for intra-articular corticosteroid to 91% (PCE=0.91, 95%CI: 0.60, 1.37) for joint lavage. Similar results were observed for function and stiffness. Treatment delivered by needle/injection and other means but oral medication, longer duration of treatment, larger sample size (≥100 per arm) and public funding source were associated with increased PCE for pain-reduction. Conclusions: The majority (75%) of the overall treatment effect in OA RCTs is attributable to contextual effects, rather than the specific effect of treatments. Reporting overall treatment effect and PCE, in addition to traditional ES over placebo, permits a more balanced, clinically meaningful interpretation of RCT results. This would help dispel the frequent discordance between conclusions from RCT evidence and clinical experience - the “efficacy paradox”

UK Alcohol Treatment trial: client-treatment matching effects

Aim To test a priori hypotheses concerning client–treatment matching in the treatment of alcohol problems and to evaluate the more general hypothesis that client–treatment matching adds to the overall effectiveness of treatment. Design Pragmatic, multi-centre, randomized controlled trial (the UK Alcohol Treatment Trial: UKATT) with open follow-up at 3 months after entry and blind follow-up at 12 months. Setting Five treatment centres, comprising seven treatment sites, including National Health Service (NHS), social services and joint NHS/non-statutory facilities. Treatments Motivational enhancement therapy and social behaviour and network therapy. Measurements Matching hypotheses were tested by examining interactions between client attributes and treatment types at both 3 and 12 months follow-up using the outcome variables of percentage days abstinent, drinks per drinking day and scores on the Alcohol Problems Questionnaire and Leeds Dependence Questionnaire. Findings None of five matching hypotheses was confirmed at either follow-up point on any outcome variable. Conclusion The findings strongly support the conclusion reached in Project MATCH in the United States that client–treatment matching, at least of the kind examined, is unlikely to result in substantial improvements to the effectiveness of treatment for alcohol problems. Possible reasons for this failure to support the general matching hypothesis are discussed, as are the implications of UKATT findings for the provision of treatment for alcohol problems in the United Kingdom

What works for whom: Tailoring psychotherapy to the person

This article introduces the issue of the Journal of Clinical Psychology: In Session devoted to evidencebased means of adapting psychotherapy to the patient's (transdiagnostic) characteristics. Practitioners have long realized that treatment should be tailored to the individuality of the patient and the singularity of his or her context, but only recently has sufficient empirical research emerged to reliably guide practice. This article reviews the work of an interdivisional task force and its dual aims of identifying elements of effective therapy relationships (what works in general) and identifying effective methods of adapting treatment to the individual patient (what works in particular). The task force judged four patient characteristics (reactance/resistance, preferences, culture, religion/spirituality) to be demonstrably effective in adapting psychotherapy and another two (stages of change, coping style) as probably effective. Two more patient facets (expectations, attachment style) were related to psychotherapy outcome but possessed insufficient research as a means of adaptation. This special issue provides research-supported methods of individualizing psychotherapy to the person, in addition to his or her diagnosis

Motivation as a predictor of outcomes in school-based humanistic counselling

Recent years have seen a growth in the provision of counselling within UK secondary schools, and research indicates that it is associated with significant reductions in psychological distress. However, little is known about the moderators and mediators of positive therapeutic benefit. In the field of adult mental health, motivation has been found to be one of the strongest predictors of therapeutic outcomes, and it was hypothesised that this may also be a predictor of outcomes for young people in school-based counselling services. To assess the relationship between young people’s motivation for counselling and its effectiveness within a secondary school setting. Eighty-one young people (12 - 17 years old) who attended school-based humanistic counselling services in Scotland. Clients completed a measure of motivation for counselling at the commencement of their therapeutic work and a measure of psychological wellbeing at the commencement and termination of counselling. Motivation for counselling was not found to be significantly related to outcomes. The results indicate that the association between motivation and outcomes may be weaker in young people as compared with adults. However, a number of design factors may also account for the non-significant findings: insufficient participants, marginal reliability of the motivation measure and social desirability effects

Cytokine concentrations are related to level of mental distress in inpatients not using anti-inflammatory drugs

Objective: Cross-sectional data show elevated levels of circulating cytokines in psychiatric patients. The literature is divided concerning anti-inflammatory drugs’ ability to relieve symptoms, questioning a causal link between inflammatory pathways and psychiatric conditions. We hypothesised that the development of circulating cytokine levels is related to mental distress, and that this relationship is affected by the use of anti-inflammatory drugs. Methods: The study was a longitudinal assessment of 12-week inpatient treatment at Modum Bad Psychiatric Center, Norway. Sera and self-reported Global Severity Index (GSI) scores, which measure psychological distress, were collected at admission (T0), halfway (T1) and before discharge (T2). Other variables known to distort the neuroimmune interplay were included. These were age, gender, diagnosis of PTSD, antidepressants and anti-inflammatory drugs. A total of 128 patients (92 women and 36 men) were included, and 28 were using anti-inflammatory medication. Multilevel modelling was used for data analysis. Results: Patients with higher levels of IL-1RA and MCP-1 had higher GSI scores (p = 0.005 and p = 0.020). PTSD patients scored higher on GSI than non-PTSD patients (p = 0.002). These relationships were mostly present among those not using anti-inflammatory drugs (n = 99), with higher levels of IL-1RA and MCP-1 being related to higher GSI score (p = 0.023 and 0.018, respectively). Again, PTSD patients showed higher GSI levels than non-PTSD patients (p = 0.014). Conclusions: Cytokine levels were associated with level of mental distress as measured by the GSI scores, but this relationship was not present among those using anti-inflammatory drugs. We found no association between cytokine levels and development of GSI score over time