The practice-orientated
research clinician –
reality or myth?
Prof Anthony W Bateman
Importance of topic for practice based
evidence (n>1000 psychotherapists)
Importance of topic
Category
%
Mechanism of change
Intervention and process
88.5
Therapeutic relationship
Outcomes
84.4
Effective training
Professional and practice
78.4
Use of reflection
Professional and practice
77.3
Therapeutic ruptures
Intervention and process
76.4
Tailoring therapy
Therapeutic imputs
75.9
Symptoms
Outcomes
74.6
Psychotherapy with eating
disorders/professional group (%) ( N=118)
Couns
Psychol Social
work
Nutrition Nurse
Dr
Other
12 Step
2.7
8.3
0
0
0
20
0
Alternative
2.7
0
0
0
50
0
10.7
CBT
29.7
41.7
11.1
40.0
0
20.0
17.9
Eclectic
45.9
41.7
51.9
40.0
25.0
20.0
39.3
EMDR
0
0
3.7
0
0
0
0
Feminist
5.4
0
0
0
0
0
3.6
Hypno
2.7
0
0
0
0
0
0
IPT
2.7
0
3.7
0
0
0
0
Psychodynamic
0
0
0
0
0
40.0
0
The Impact of
Therapists on
Treatment
Outcome
Odds of a clinical episode in MBT by therapist
Variance due to Tx and Therapists in
NIMH study of Depression (CBT & IPT)
Kim et al., 2006, Psychother Res, 16:161
Variable
Treatment
Therapist
BDI
0%
5% to 11%
HRSD
0%
1% to 12%
HSCL-90
0%
3% to 10%
GAS
0%
8% to 12%
Variance due to therapists in practice
Wampold & Brown, JCCP, 2006
581 Therapists, 6146 heterogeneous
patients
 Diagnosis, degree, experience: 0% variance
 Medication: 1% (but also dependent on
psychotherapist)
 Provider: 5%
 Top quartile produced twice the effect of the
lowest quartile in subsequent year

Impact of individual therapists in routine practice
Okiishi et al. 2006 (J Clin Psychol 62:9, 1157)

6,499 patients seen by 71 therapists

therapists had to see at least 15 clients
 on average saw 92

number of sessions: range 1-203; mean 8.7

therapists saw equivalent range of clients in
terms of disturbance & presentation

HLM used to compare ‘trajectories’ (recovery
curves) of patients using OQ45
Clients of Some Therapists Improve
Faster or Slower Than Others
Session number

Slope of Improvement Across Therapists
Unaffected by:
•
therapist experience
•
gender
•
type of training
 counselling psychology, clinical psychology, social
work, marital/family therapist
•
orientation
 CBT, humanistic, psychodynamic
Outcomes for Best and Worst
Performing Therapists
recovered
improved
deteriorated
top 10%
therapists
22.4%
21.5%
5.2%
bottom 10%
therapists
10.6%
17.4%
10.5%
Incidence of Harmful Effects

estimates are that 5-10% of therapy clients
deteriorate
• across all orientations, client groups, modalities
• in RCTs of ‘empirically supported treatments’

rates higher than in control groups
• e.g. NIMH reanalysis (Ogles et al. 1995)
• 13/162 (8%) deteriorated, all in active treatments

in Lambert’s work therapists tend to be poor at:
 predicting who will do badly
 recognising failing therapies
Do no harm… outcomes
informed care

Most therapists see themselves as better than
average:
Dew & Riemer (2003, 16th Annual Research Conference,
University of South Florida)
• 143 counselors asked to grade their job
performance on scale from A+ to F
• 66% rate themselves as A or better
• none rated themselves as below average

Outcomes informed care may be a critical way of
linking the EBP approach and practice based
evidence
Therapist predicted treatment success compared
to actual treatment outcomes after psychotherapy
Hannan, C et al (2005) A Lab Test and Algorithms for Identifying Clients at Risk for Treatment Failure.
Journal of Clinical Psychology 61, 155-163
500
450
400
350
Number
300
Therapist predicted
outcome
Actual Treatment
Outcome
250
200
150
100
50
0
Positive
No Change Deteriorated
Percentage of patients, by site, who achieve clinically
meaningful improvement within median treatment length
Hansen, N et al The Psychotherapy Dose-Response Effect and its Implications for Treatment Delivery
Services. Clin Psychol Sci Prac 9:329–343, 2002
Site
Sample Size
Median
sessions
% Recovered
% Improved
Employee
Assistance
3,269
3
7.4
18.3
University
Counseling
1,188
4
5.9
15.2
Local HMO
595
2
5.7%
14.3
National HMO
536
4
9.1
24.4
Training CMH
123
8
6.5
20.3
State CMH
361
4
5.8
17.7
Total 6,072
6072
3
6.5
16.6
Randomized trial on the effectiveness of long and short-term
psychodynamic psychotherapy and solution-focused therapy
(Knekt et al., 2008 Psychol Med, 38(5), 689-703.
•
•
A total of 326 outpatients (20-46 years) with
mood (84.7%) or anxiety disorder (43.6%) or
both
Three treatment groups



long-term psychodynamic psychotherapy (up to 3 years),
short-term psychodynamic psychotherapy (5-6 months),
solution-focused therapy (up to 8 months)
•
A randomized trial with a 3-year follow-up,
carried out from 1994-2005.
•
Primary outcome depressive symptoms measured by
self-report (BDI) and observer-rated (HDRS)
RCT of long and short-term psychodynamic psychotherapy and solution-focused
therapy for mixed anxiety & depression: HDRS
18
SFT (n=97)
17
SPP (n=101)
16
LTP (n=128)
Mean HDRS
15
14
13
12
11
10
9
8
0
7
Months
12
36
Source (Knekt et al., 2008) Psychol Med, 38(5), 689-703.
RCT of the effectiveness of long and short-term psychodynamic
psychotherapy and solution-focused therapy: BDI
21
19
SFT (n=97)
17
SPP (n=101)
LTP (n=128)
Mean BDI
15
13
11
9
7
5
0
3
7
9
Months
12
18
24
36
Source (Knekt et al., 2008) Psychol Med, 38(5), 689-703.
Recovery from depressive symptoms (BDI)
and no auxiliary treatment
Knekt et al.Nord J Psychiatry 2013;67:59–68.
Adequate work ability (Work Ability Index ,WAI36) and no
auxiliary treatment.
Conclusions concerning evidence base for long
term psychodynamic therapy
• Good pre-post treatment effects
• Moderate between group effects (promising)
• Hard to demonstrate superiority of intensive
over non-intensive treatments
Probably measuring wrong things
And not for long enough
• Most promising
Anorexia, complex depression, PD
• Weaker evidence
Anxiety, somatic problems, simple
depression
Developing the
research based
practice clinician
Effect of service re-organisation on
outcomes in PD
Criticisms from clinicians
Research population differs from clinical
population
 Reliance on diagnostic criteria
 Inappropriate outcomes
 Lack of clinical detail eg moderators
 Outcome scales do not reflect functioning
 Evidence based treatment does not equal
evidence based practice

Criticisms from researchers






Clinical decision making unreliable and
unrepeatable
Integrating research evidence with clinical
expertise too varied
Patient moderators used by clinicians impossible
for generalisation
No consistency over time and no validity that
clinical decisions make a difference
Eclectic therapy is not transferable across
clinicians
Poor collection of systematic observations
Moderators of outcomes


Limited information e.g. gender, ethnicity, age
No information about how moderators work within a
treatment of across treatments
Which patients are affected
Are all patients affected
Is moderator a proxy for e.g. ethnicity for
patient/therapist mismatch
Effects may be due to highly correlated
component eg stress level of group, severity,
social issues
Introducing practice orientated
research



Patient problems
 A chore
 Usefulness for them
 Focus and attention
 Social responsibility
Clinician concerns
 Usefulness for treatment
 Sensitivity to monitoring
 Time
 Interference with treatment process
Practicality and logistics
Reducing the Harmful Effects of
Psychotherapy: The work of Lambert (2009)



Across studies the rate of observed deterioration in
psychotherapy was 10-25% with young people
Some therapists have rates of deterioration of
around 50% and their treatment is NEVER
associated with recovery
Introduction of outcome tracking (session by
session monitoring)
 Early warning when patient goes off trajectory

Therapists randomized to feedback vs no-feedback
 Deterioration reduced by 50%
 Recovery improves by 50%
 Average therapy is shorter
 Patients who show early negative response receive
longer and more effective treatment
Using Client Feedback to Improve Couple Therapy Outcomes: A
Randomized Clinical Trial in a Naturalistic Setting.
Anker, Morten; Duncan, Barry; Sparks, Jacqueline Journal of Consulting & Clinical Psychology. 77(4):693-704,
August 2009.
2
Patient-Focused Research: Using Patient
Outcome Data to Enhance Treatment Effects.
Lambert, Michael; Hansen, Nathan; Finch, Arthur Journal of Consulting & Clinical Psychology. 69(2):159-172,
April 2001.
Patient-Focused Research: Using Patient Outcome
Data to Enhance Treatment Effects.
Lambert, Michael; Hansen, Nathan; Finch, Arthur Journal of Consulting & Clinical Psychology. 69(2):159-172, April
2001.
2
Time to improvement using reliable change
index.
Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Lambert, Michael;
Hansen, Nathan; Finch, Arthur Journal of Consulting & Clinical Psychology. 69(2):159-172, April 2001.
Time to recovery measured by clinically
significantly improved criteria.
2
Pattern of Change: Sum of Mood Ratings and Hours Spent Outside of
the House During a 31-Week Treatment
Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis.
Borckardt, Jeffrey; Nash, Michael; Murphy, Martin; Moore, Mark; Shaw, Darlene; ONeil, PatrickAmerican Psychologist.
63(2):77-95, February/March 2008.
2
Directional and Temporal Relationship of Change in Mood With Change in
Social Engagement During Therapy
Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis.
Borckardt, Jeffrey; Nash, Michael; Murphy, Martin; Moore, Mark; Shaw, Darlene; ONeil, Patrick American Psychologist. 63(2):77-95,
February/March 2008.
2
Opportunistic Benefit Study: Mean Weekly Blood Pressure (BP)
Readings (Taken at Work) Across Baseline, Medication-Only, and
Medication-Plus-Psychotherapy Phases
Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis.
Borckardt, Jeffrey; Nash, Michael; Murphy, Martin; Moore, Mark; Shaw, Darlene; ONeil, Patrick. American Psychologist.
63(2):77-95, February/March 2008.
2
Hypothetical Results Demonstrating a Typical Data Stream Encountered
in Time-Series Studies: A Five-Week Intervention for Pain
Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis.
Borckardt, Jeffrey; Nash, Michael; Murphy, Martin; Moore, Mark; Shaw, Darlene; ONeil, Patrick. American Psychologist.
63(2):77-95, February/March 2008.
2