Practice-Oriented Research: An Introduction to New Developments and Future Directions.

Aimed at understanding and improving psychological therapies as they are conducted in clinical routine, practice-oriented research (POR) is now a well-established approach to the scientific foundations of mental health care services. Resting on the accumulation of a wide range of practice-based evidence related to treatment outcome and process, as well as factors associated with the participants of psychotherapy and its context, POR is ripe for new developments - regarding what to investigate and how to investigate it. This paper is the introduction of a series devoted to recent advances and future directions of POR as their pertained to routine outcome monitoring, technologies and artificial intelligence, the integration of constructs and methods from program evaluation and implementation science, and the investigation of populations with limited financial resources across various regions of the world. The series also includes commentaries from two leaders of POR.

The Importance of Conducting Practice-oriented Research with Underserved Populations.

There has been a growing emphasis on dissemination of empirically supported treatments. Dissemination, however, should not be restricted to treatment. It can and, in the spirit of the scientific-practitioner model, should also involve research. Because it focuses on the investigation of clinical routine as it takes place in local settings and because it can involve the collaboration of several stakeholders, practice-oriented research (POR) can be viewed as an optimal research method to be disseminated. POR has the potential of addressing particularly relevant gaps of knowledge and action when implemented in regions of the world that have limited resources for or experiences with empirical research, and/or in clinical settings that are serving clinical populations who are not typically receiving optimal mental care services - specifically, individuals in rural and inner cities that have limited economic and social resources. The establishment and maintenance of POR in such regions and/or settings, however, come with specific obstacles and challenges. Integrating the experiences acquired from research conducted in various continents (Africa, Europe, Latin America, and North America), the goal of this paper is to describe some of these challenges, strategies that have been implemented to address them, as well as new possible directions to facilitate the creation and growth of POR. It also describes how these challenges and ways to deal with them can provide helpful lessons for already existing POR infrastructures.

Reconstructing dropout: Building from multiple definitions, therapist effects, and center effects.

Objective: The literature regarding dropout from psychotherapy has suffered from issues of diverse operationalization of the construct. Some have called for a more uniform definition to aid in generalization across research; this study aimed to assess the viability of such a definition by examining the rate of occurrence for three distinct definitions simultaneously. In addition, therapist and center level variances are explored to further understand the differences between definitions.Method: We compared the prevalence rates and overlap of three distinct operationalizations of dropout (based on last session attendance, therapist judgment, and symptom change) using data gathered from a national practice research network (N = 2977). Higher-order therapist and center-level effects were assessed for each definition.Results: There was very little overlap among definitions, with less than one percent of clients simultaneously meeting criteria for all three definitions. Additionally, therapist and center effects were found for each definition, especially notable for therapist-rated and last-session attendance definitions of dropout.Conclusion: Rather than a singular definition of dropout, these results instead suggest that multiple, specific, and unique definitions more accurately depict clinical reality, and future research might benefit from uncovering predictors of different "classes" of dropouts and examining the different practices of therapists and centers.

Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic.

OBJECTIVE: The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment. METHODS: We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome. RESULTS: Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress. CONCLUSIONS: Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy - in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.

Baseline overly accommodating interpersonal problems in relation to parsed alliance-outcome associations in cognitive behavioral therapy for generalized anxiety disorder.

Given its interpersonal underpinnings, relational factors may be salient in psychotherapy for generalized anxiety disorder (GAD). Supporting this point, research has indicated a positive total alliance-improvement correlation in cognitive behavioral therapy (CBT) for GAD. However, less research has disaggregated this correlation into within- and between-patient components, or examined theory-informed ways in which patient characteristics influence to these components. Thus, we first investigated parsed alliance-outcome associations in CBT for GAD. Second, consistent with theory that alliance may represent a direct interpersonal change correlate, we tested whether within-patient alliance improvements were especially therapeutic for patients with higher levels of an interpersonal problem prototypical of GAD-over accommodation. Also, consistent with theory that between-patient differences in overall alliance may be influenced by patients' preexisting relational characteristics, we tested whether more overly accommodating patients reported poorer average alliances that, in turn, related to worse outcomes.Sixty-nine patients received variants of CBT. Patients rated over accommodation at baseline, and alliance and outcome across treatment.As hypothesized, within-patient alliance improvements correlated with subsequent anxiety reduction, and this association was stronger for more overly accommodating patients. All between-patient associations were nonsignificant.Results help clarify the nuanced role of alliance in CBT for GAD.

Therapeutic techniques and session impact: A practice-research network study in private practice.

Objective: This study investigated the relationship between therapeutic techniques and session impact, by examining the replicability of findings observed in a university-based training clinic (Boswell et al., 2010) in another practice-oriented setting: private practice.Method: N = 8 therapists completed session-level assessments of their technique use for N = 38 clients. The same client sample completed session-level assessments of session outcome. Technique-outcome associations were examined with multilevel models.Results: As in Boswell et al., common factors were associated with positive session impact. For clients who received higher average common factor techniques (relative to their own therapist's caseload), session impact was the poorest in sessions with higher behavioral change techniques use (relative to the client's own average). Moreover, clients with the lowest average common factor techniques (relative to their therapist's caseload) reported better session impact in sessions that involved a higher degree of session-level behavioral change techniques (relative to their own average).Conclusion: In line with Boswell et al., therapists should be mindful of the consistency of their routine technique use between- and within-clients, and this can be aided through collection of their own practice-oriented data.

Client-Therapist Convergence on Sleep Difficulty and its Impact on Treatment Outcomes.

While agreement between clients and their clinicians on therapy goals has frequently been investigated as a process-level variable (i.e., working alliance), dyadic convergence on presenting concerns is also important for initial case formulation. Transdiagnostic presenting problems, like sleep difficulty, pose a particular challenge for client-therapist convergence. The current study describes sleep difficulty in a treatment-seeking college population and investigates the impact of client and therapist baseline sleep problem reports on therapy outcomes.Data were collected through a large practice research network, with the sample comprising 47,023 clients from 99 university counseling centers across the United States.A larger proportion of clients (49.3%) had self-reported high baseline sleep difficulty than those with a clinician-identified sleep concern (16.0%). Clients with baseline sleep difficulty were more likely to end treatment with greater self-reported sleep difficulty and psychological symptom distress, although they may experience larger gross symptom change than clients without baseline sleep difficulty. Clinician-identified sleep concerns were significantly associated with client outcomes, particularly when clients did not report baseline sleep difficulty themselves.Findings from this study suggest that it may be efficacious and efficient with limited time for treatment to address sleep concerns in a college setting.Clinicians' attendance to their clients' transdiagnostic presenting concerns, like sleep difficulty, may increase clients' own awareness of problematic patterns of behavior. When time for therapy is short, as is often the case in college counseling, it may be efficient to prioritize these concerns with the potential to impact a broad range of symptoms.

Predicting future courses of psychotherapy within a grouped LASSO framework.

Objective: There is a paucity of studies examining the experience of clients who undergo multiple courses of psychotherapy. Conducted within a large practice research network, this study demonstrated that returning therapy clients comprise a considerable portion of the clinical population in university counseling settings, and identified variables associated with return to therapy. Method: Utilizing data spanning 2013 to 2017, statistical variable selection for predicting return to therapy was conducted via grouped least absolute shrinkage and selection operator (grouped LASSO) applied to logistic regression. The grouped LASSO approach is described in detail to facilitate learning and replication. The paper also addresses methodological considerations related to this approach, such as sample size, generalizability, as well as general strengths and limitations. Results: Attendance rate, duration of initial treatment course, social anxiety, perceived social support, academic distress, and alcohol use were identified as predictive of return to therapy. Conclusions: Findings could help inform more cost-effective policies for session limits (e.g., extending session limits for clients with social anxiety), referral decisions (e.g., for clients with alcohol use problems), and appointment reminders (based on the association between poor attendance rate and return to therapy). Taking into account the many reasons that can explain why clients do or do not return to therapy, these findings also could inform clinicians' early case conceptualizations and treatment interventions.

Suicide among college students in psychotherapy: Individual predictors and latent classes.

This study sought to identify predictors of suicidal behavior among college students who are psychotherapy clients, as well as to determine underlying classes of clients with suicidal ideation. Data were gathered from 101,570 clients, 391 of whom engaged in suicide behavior during treatment. Regression analyses revealed that suicide behavior was positively associated with 3 pretreatment variables: depression, prior suicide behavior, and prior nonsuicidal self-injury. Four latent classes of clients with suicidal ideation were identified that were named "prior ideation," "extensive risk," "prior treatment," and "circumscribed depression." The number of clients in each class varied widely, as did the relative risk of suicide behavior. Implications for treatment, suicide assessment, and suicide prevention are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effectiveness of routine psychotherapy: Method matters.

OBJECTIVE: Though many studies have shown that psychotherapy can be effective, psychotherapy available in routine practice may not be adequate. Several methods have been proposed to evaluate routine psychological treatments. The aim of this paper is to demonstrate the combined utility of complementary methods, change-based benchmarking, and end-state normative comparisons, across a range of self-reported psychological symptoms. METHOD: Benchmarks derived from randomized controlled trials (RCTs) and normative comparisons were used to evaluate the effectiveness of psychotherapy in a large (N = 9895) sample of clients in university counseling centers (UCCs). RESULTS: Overall, routine psychotherapy was associated with significant improvement across all symptoms examined. For clients whose initial severity was similar to RCT participants, the observed pre-post effect sizes were equivalent to those in RCTs. However, treatment tended to lead to normative end-state functioning only for those clients who were moderately, but not severely, distressed at the start of psychotherapy. CONCLUSIONS: This suggests that although psychotherapy is associated with an effective magnitude of symptom improvement in routine practice, additional services for highly distressed individuals may be necessary. The methods described here comprise a comprehensive analysis of the quality of routine care, and we recommend using both methods in concert. Clinical or methodological significance of this article: This study examines the effectiveness of routine psychotherapy provided in a large network of counseling centers. By comparing multiple established methods to define outcomes in this sample we provide a detailed understanding of typical outcomes. The findings show that, across several different problem areas, routine psychotherapy provided substantial benefit, particularly to clients in the most distress. However, there is room to improve, especially by increasing the number of clients who return to normal functioning by the end of treatment. Using distinct methods provides complementary answers to the question: How effective is routine psychotherapy?

Therapist effects on dropout from a college counseling center practice research network.

Dropout has been a pervasive and costly problem in psychotherapy, particularly for college counseling centers. The present study examined potential predictors of dropout using a large data set (N = 10,147 clients, 481 therapists) that was gathered through a college counseling center practice research network as a replication and extension of recent findings regarding therapist effects on dropout. The final model resulted in a dropout rate of 15.9% and a therapist effect of 9.51% on dropout variance. Therapist demographic variables were investigated, though none were found to be significant. Variables found to be predictive of increased likelihood of dropping out included higher levels of general presenting concerns, alcohol-related distress, and current financial stress. Ultimately, this study showed that therapists may play an important role in the likelihood of client dropout, and that additional research should be conducted to identify additional predictors, particularly at the therapist and center level. (PsycINFO Database Record

Psychotherapists' outcomes with White and racial/ethnic minority clients: First, the good news.

The purposes of this study were to (a) investigate whether psychotherapists differ in their effectiveness with clients, (b) determine whether disparities exist within therapists' caseloads in their outcomes with White and racial and ethnic minority (REM) clients, (c) explore therapist factors that might contribute to observed therapist effects, and (d) identify whether treatment outcomes varied for REM and White clients. A sample of 3,825 clients seen by 251 therapists at 45 college counseling centers completed the Counseling Center Assessment of Psychological Symptoms at the beginning and end of individual psychotherapy. Therapists differed in their effectiveness at reducing general distress across clients, and evidence was found for disparities within therapists' caseloads in their effectiveness with REM and White clients. Effect sizes were small. Disparities within therapists' caseloads were not a function of any therapist variable that was studied. Therapy outcomes were similar for White and REM clients. Therapist multicultural competence can, and should, be considered in terms of measurable outcomes across client racial/ethnic groups. It is possible to identify multiculturally expert therapists who evidence competence with both REM and White clients and who might serve as models from whom the field could learn.

Enhancing feedback for clinical use: Creating and evaluating profiles of clients seeking counseling.

The current study explored the reliability and clinical utility of a method designed to identify latent classes of students seeking counseling, based on 8 symptom domains and their interactions. Participants were over 50,000 college students in counseling, assessed with the CCAPS-62 and -34 as part of routine clinical care. Latent profile analysis was used to group an exploratory and confirmatory sample of students by reported symptoms across the 8 CCAPS subscales. Profiles were evaluated for reliability and clinical utility, in particular for risk assessment and the prediction of treatment duration and success. Nine reliably stable latent profiles, or groups of profiles, emerged from analysis. Profiles differed significantly in reported symptoms, demographic makeup, psychosocial history, and diagnoses. Additionally, profiles appeared to capture meaningful differences between clients that had implications for relative risk of suicide, self-harm, and violence toward others as well as significant differences in the number of sessions in treatment and the effect size of treatment. Latent profiles of patients appear to capture meaningful, stable differences that could be implemented in an automated system of evaluation and feedback, and that might be useful to clinicians, administrators, and researchers.

Fostering collaboration between researchers and clinicians through building practice-oriented research: an introduction.

This paper is an introduction to a special series that attempts to foster collaboration between clinicians and researchers by presenting the experiences of 11 groups of contributors who have conducted practice-oriented research (POR) in various countries and naturalistic settings. Each of these groups was asked to describe the context in which their collaborative initiatives took place, as well as some of the studies conducted, obstacles faced, strategies employed to address these challenges, and benefits earned. Authors were also invited to provide general recommendations to facilitate future POR. In order to integrate the lessons learned so far, as well as to consolidate suggestions for future collaboration of clinicians, researchers, and other stakeholders in the field of mental health, the series ends with a conclusion paper that identifies convergences and particular characteristics that cut across the partnerships featured.

Practice-oriented research: what it takes to do collaborative research in private practice.

The goal of this paper is to describe the authors' experience conducting research in and for private practice. Based on two distinct research programs (one guided by a scientist practitioner leading various groups of clinicians and another from a network of practitioners and researchers), a number of practice-oriented studies are presented. Lessons learned from these collaborative projects are discussed in terms of challenges and strategies to deal with them, as well as benefits that can be earned from conducting empirical studies within clinical routine. General recommendations are then offered to foster the engagement of clinicians in their own working environment and to facilitate partnerships between researchers and practitioners in developing and implementing valid, feasible, and informative clinical studies.

Practice research network in a psychology training clinic: building an infrastructure to foster early attachment to the scientific-practitioner model.

Learning how to conduct clinically meaningful and actionable research while simultaneously training to be a competent clinician may be an optimal way to develop an early attachment to the scientific-practitioner model. In this paper, the transformation of a training clinic into a practice research network (PRN) is presented as a strategy to foster a seamless integration of clinical, training, and research facets of graduate training in psychology. With the hope of providing helpful guidance to trainers and trainees interested in building such an infrastructure, the authors describe the context in which they developed their training clinic PRN, its major components, and some of the studies that have been conducted in this network. Benefits earned and lessons learned (in terms of obstacles faced and strategies implemented to deal with them) are described, as well as general recommendations and future directions regarding the implementation and impact of training clinic PRNs.

Conducting research and collaborating with researchers: the experience of clinicians in a residential treatment center.

This paper describes the experience of clinicians in conducting research and collaborating with academic researchers. As part of clinical routine of a residential program for adolescent substance abusers, empirical data have been collected to assess client's needs before and after treatment, improve clinical practice, and identify barriers to change. Some of the challenges faced and the benefits learned in conducting these studies are presented. In addition to highlighting the convergence of research interests between clinicians and academicians, the conclusion offers general recommendations to foster these partnerships and solidify the scientific-practitioner model.

Research on psychotherapy integration: building on the past, looking to the future.

Integration has become an important and influential movement within psychotherapy practice, reflected by the fact that many treatment providers now identify as integrative. However, integration has not had as great an influence on psychotherapy research. The goal of this paper is to highlight the growing body of research on psychotherapy integration, and to identify future directions for research that may strengthen the integration movement as well as the field of psychotherapy as a whole. We first summarize the past 25 years of research on integration, with a focus on four approaches to integration: theoretical integration, technical eclectic, common factors, and assimilative integration. Next, we identify directions of research within these four areas that could strengthen and support integrative practice. We then propose ways in which the perspective of integrationists could contribute to psychotherapy research in the critical areas of harmful effects, therapist effects, practice-oriented research, and training. We end this paper by suggesting that a greater collaboration between integrationists and psychotherapy researchers will help to create a unified landscape of knowledge and action that will benefit all participants and advance the field.

Building clinicians-researchers partnerships: lessons from diverse natural settings and practice-oriented initiatives.

In this concluding paper, we identify the type of studies conducted by 11 teams of contributors to a special issue on building clinicians-researchers partnerships. Those studies were conducted across a variety of clinical settings. We also integrate the lessons that have emerged from their collaborative initiatives in terms of obstacles faced, strategies adopted to address these challenges, benefits gained, and general recommendations offered to facilitate studies conducted with or by clinicians. The paper ends with the authors' thoughts about the future success of practice-oriented research in general.