Telephone delivery of psychological interventions: Balancing protocol with patient-centred care.

Common mental health problems of anxiety and depression affect significant proportions of the global population. Within the UK, and increasingly across western countries, a key policy response has been the introduction of high volume, low intensity psychological assessment and treatment services, such as the NHS's Improving Access to Psychological Therapies (IAPT) service, the largest service delivery model yet to be implemented at a national level (England). IAPT may be delivered in face-to-face meetings or over the telephone, as well as through other media. In order to increase access and achieve wide reach with efficient use of resources, IAPT's service models utilise relatively structured and standardised protocols, whilst aiming simultaneously to deliver a tailored and personalised experience for patients. Previous research has revealed that this can be a challenging balance for front-line practitioners to strike. Here we report research into the telephone delivery of guided self-help, low intensity interventions within IAPT, examining the challenges faced in remote delivery when combining structure with personalisation during assessment and treatment sessions. We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient's story, thereby compromising the personalisation and responsiveness of the service. Our study contributes new insights to our understanding of the association between personalisation, engagement and patient experience within high volume, low-intensity psychological treatment services. Our research on the telephone delivery of IAPT is particularly timely in view of the current global Covid-19 health crisis, as a result of which face-to-face delivery of IAPT has had to be (temporarily) suspended.

A review and critical appraisal of measures of therapist-patient interactions in mental health settings.

OBJECTIVES: To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures. DATA SOURCES: Major electronic databases (including PsycINFO) were searched from inception to 2002. REVIEW METHODS: A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated. RESULTS: The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard. CONCLUSIONS: The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

A preliminary study of a measure of role-play competence in psychodynamic interpersonal therapy.

We report a 15-item role-play competence measure. Ratings by three judges of 34 role plays from psychodynamic interpersonal therapy training showed good inter-rater (.73-.79) and internal reliability (.84-.96). Validity was supported as scores were statistically significantly associated with psychotherapy experience. Most participants achieved satisfactory ratings supporting the training.

The effectiveness of computerized cognitive behavioural therapy in routine care.

OBJECTIVES AND DESIGN: The efficacy of a Computerized Cognitive Behavioural Therapy (CCBT) package, Beating the Blues, has been demonstrated in a large randomized controlled trial. The current study tests the generalizability of this finding in a naturalistic non-randomized trial. METHOD: 219 patients with anxiety and/or depression were recruited to receive CCBT in routine care. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) and Work and Social Adjustment scale (WSA) were administered pre-treatment, immediately on completing treatment and at 6 months post-treatment. Single-item self-report measures of anxiety and depression were also collected during each treatment session. RESULTS: Completer and intention-to-treat analysis demonstrated statistically and clinically significant improvements on the CORE-OM, WSA and in self-reported anxiety and depression. Intention-to-treat analysis indicated an average 0.29-point drop on the CORE-OM, equating to an uncontrolled pre-post effect size of 0.50. Research completers achieved an average 0.61-point drop equating to an uncontrolled pre-post size of 1.00 on the same measure. Where data was available (18%), these benefits were maintained at week 32 (6 months follow-up). CONCLUSION: CCBT can be an effective first line tool within a stepped care framework for the management of common mental health problems.

The shape of change in psychotherapy: longitudinal assessment of personal problems.

We propose 4 parameters that describe the course of change in the subjective intensity of personal problems during psychotherapy: (a) the problem's initial severity; (b) its rate of change (deterioration or improvement); (c) its instability (day-to-day variability in intensity); and (d) its curve (change in the rate of change during treatment). We constructed indexes of these parameters for 10 individualized personal problems rated 3 times per week by each of 40 clients (most were diagnosed as depressed) over the course of their 16-session treatment and associated assessment periods. Initial severity predicted problems' reported salience to clients. The rate of change parameter was correlated (across clients) with traditional pretreatment to posttreatment outcome measures. Instability was high, and problems dealing with tension symptoms and mood were more unstable than were problems dealing with relationships or self-esteem. Cutting across problem content were large individual differences among clients in the patterns of change.

The therapeutic alliance in psychodynamic-interpersonal and cognitive-behavioral therapy.

The quality of the therapeutic alliance was compared in sessions of psychodynamic-interpersonal and cognitive-behavioral therapy, and the alliance's relationship to various session impacts was investigated. As part of the Sheffield Psychotherapy Project 2 (D. A. Shapiro, M. Barkham, A. Rees, G. E. Hardy, S. Reynolds, & M. Startup, 1994), 57 clients diagnosed with major depression received 16 sessions of either psychodynamic-interpersonal or cognitive-behavioral therapy. Coders used the Working Alliance Inventory to rate 1 high-impact and 1 low-impact session from each client. Results indicated significantly greater alliance scores for cognitive-behavioral therapy sessions on the whole. Also, for the samples as a whole, high-impact sessions were characterized by higher alliance scores than those for low-impact sessions, and alliance was positively related to therapists' ratings of session depth and smoothness and to clients' ratings of mood.

Acceleration of changes in session impact during contrasting time-limited psychotherapies.

Following the suggestion that therapeutic change is accelerated in time-limited psychotherapy, this study investigated the across-session patterns of session impact in the treatments of 117 depressed clients who were randomly allocated to 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) therapy. After each session, all clients completed the Session Evaluation Questionnaire and 75 of the clients completed the Session Impacts Scale. Session ratings indicated that sessions were perceived increasingly positively on most impact dimensions (e.g., session depth and smoothness, relationship with the therapist, feelings of understanding and problem solving, postsession positive mood) as treatment progressed. Early in treatment, PI therapy sessions were less smooth (i.e., more tense and uncomfortable) and less focused on problem solving, but PI sessions changed more rapidly than CB sessions on these dimensions, so that later in treatment, sessions of both treatments were equivalently positive. In both treatments, the trend toward more positive sessions was more rapid (i.e., the across-session slope was steeper) in 8-session treatments than in 16-session treatments. Such accelerated changes in session impact may reflect the suggested acceleration of therapeutic change associated with shorter time limits.

Psychotherapy in two-plus-one sessions: outcomes of a randomized controlled trial of cognitive-behavioral and psychodynamic-interpersonal therapy for subsyndromal depression.

A total of 116 clients with a range of subsyndromal depression received 3 therapy sessions: 2 sessions 1 week apart followed by a 3rd session 3 months later (the 2 + 1 model). Clients were stratified for severity on the Beck Depression Inventory (BDI) as stressed, subclinical, or low-level clinically depressed. In a 2 x 2 design, they received either cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) therapy, either immediately or after a 4-week delay. An initial advantage for the immediate condition disappeared once the delayed-condition clients received treatment. Improvement rates at the end of treatment were 67% (stressed), 72% (subclinical), and 65% (low-level clinically depressed). There were no significant differences between CB and PI treatment methods, with the exception at 1-year follow-up, when the BDI showed a significant advantage for CB. Implications for designing very brief planned interventions are discussed.

Therapist responsiveness to client interpersonal styles during time-limited treatments for depression.

Effective treatment involves therapists responding appropriately to their clients' varying requirements, including clients' predominant interpersonal styles. In 2 manualized time-limited treatments for depression, psychodynamic-interpersonal (PI) and cognitive-behavioral (CB) clients were assigned to 1 of 3 interpersonal style groups. Therapists, who were not told their clients' interpersonal style, nevertheless responded with systematically different interventions depending on clients' interpersonal style. Consistent with predictions, therapists tended to use more affective and relationship-oriented interventions with overinvolved clients, particularly in PI therapy. Therapists tended to use more cognitive treatment methods with underinvolved clients, particularly in CB therapy. Outcomes of the interpersonal style groups were approximately equivalent, consistent with a view that the differences in treatment implementation reflected appropriate responsiveness to clients' interpersonal styles.

Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy.

A total of 117 depressed clients, stratified for severity, completed 8 or 16 sessions of manualized treatment, either cognitive-behavioral psychotherapy (CB) or psychodynamic-interpersonal psychotherapy (PI). Each of 5 clinician-investigators treated clients in all 4 treatment conditions. On most measures, CB and PI were equally effective, irrespective of the severity of depression or the duration of treatment. However, there was evidence of some advantage to CB on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). There was no evidence that CB's effects were more rapid than those of PI, nor did the effects of each treatment method vary according to the severity of depression. There was no overall advantage to 16-session treatment over 8-session treatment. However, those presenting with relatively severe depression improved substantially more after 16 than after 8 sessions.

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression.

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance.

Impact of Cluster C personality disorders on outcomes of contrasting brief psychotherapies for depression.

Twenty-seven of 114 depressed clients, stratified for severity of depression, obtained a Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) diagnosis of Cluster C personality disorder--that is, avoidant, obsessive-compulsive or dependent personality disorder (PD clients)--whereas the remaining 87 did not (non-personality-disorder [NPD] clients). All clients completed either 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. On most measures, PD clients began with more severe symptomatology than NPD clients. Among those who received PI therapy, PD clients maintained this difference posttreatment and at 1-year follow-up. Among those who received CB therapy, posttreatment differences between PD and NPD groups were not significant. Treatment length did not influence outcome for PD clients. PD clients whose depression was also relatively severe showed significantly less improvement after treatment than either PD clients with less severe depression or NPD clients.

Dose-effect relations in time-limited psychotherapy for depression.

Criteria for reliable and clinically significant improvement were applied to standard and individually tailored outcome measures data from 212 depressed clients who had been randomly assigned to receive either 8 or 16 sessions of time-limiting psychotherapy. The data were used to address 2 questions: (a) Is the dose-effect curve for psychological symptoms negatively accelerated? and (b) is there a differential rate of response for acute, chronic, and characterological/interpersonal components of depression? The results supported the differential rate of response of different components of depression and suggested qualifications to the acute, chronic, and characterological/interpersonal components and evidence that both supported and qualified previous suggestions that the dose-effect curve is negatively accelerated.

Effects of treatment duration and severity of depression on the maintenance of gains after cognitive-behavioral and psychodynamic-interpersonal psychotherapy.

One hundred four clients completed a mailed follow-up 1 year after completing 8 of 16 sessions of treatment, either cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. Although mean scores on outcome measures at 1 year suggested that gains were, in general, well maintained, only 29% of clients were asymptomatic on all 3 occasions of testing (end of treatment, 3 months and 1 year later) without recourse to further treatment. However, only 11% of those asymptomatic at end of treatment experienced relapse or recurrence of depression, albeit on the limited evidence of just two follow-up assessments. The results of comparisons among treatment conditions at 1 year differed substantially from those obtained earlier: Eight-session PI treatment now appeared less efficacious than the other 3 treatment conditions, and there was now no measurable benefit of 16-session over 8-session CB, irrespective of initial severity of depression. These findings confirm the importance of follow-up in evaluation of psychotherapies for depression.

Relations of the alliance with psychotherapy outcome: findings in the Second Sheffield Psychotherapy Project.

Clients (n = 79) and therapists (n = 5) rated their alliance using parallel forms of the Agnew Relationship Measure (ARM) after every session of their time-limited psychodynamic-interpersonal or cognitive-behavioral treatments for depression. The ARM assesses 5 dimensions of the alliance: Bond, Partnership, Confidence, Openness, and Client Initiative. Treatment outcome was assessed as residual gain from pretreatment assessment to end of treatment, 3-month follow-up, and 1-year follow-up on 6 standard measures. Some aspects of the alliance as measured by the ARM were correlated with clients' gains in treatment. The strength of the association varied across assessment measures, occasions of outcome assessment, ARM scales, and the session number when the alliance was measured.

Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures.

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Outcomes of time-limited psychotherapy in applied settings: replicating the Second Sheffield Psychotherapy Project.

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Lack of synchronized seasonal variation in the intensity of psychological problems.

Temporal variation in the subjective intensity of psychological problems identified by 40 psychotherapy clients (most diagnosed as depressed) was investigated longitudinally. Each client rated the intensity of 10 individualized problems 3 times per week (on Tuesdays, Thursdays, and Sundays) for an average of 6 months. Ratings from all clients were spread over 3 years. When scores were statistically adjusted for client differences and average rate of improvement, no significant variation among months was found, regardless of problem content or client gender. Standard assessment measures administered 4 times to each client also failed to show systematic seasonal variation.

Components of major depression examined via the Beck Depression Inventory.

Although more than 20 factor analytic studies have been published on the Beck Depression Inventory (BDI), only Steer and co-workers (1987) have used a sample composed exclusively of patients diagnosed with depression. The component structure found in their study of depressed patients differs in important respects from the structure summarised in several reviews. The main aim of the present study was to investigate whether this structure could be confirmed with the BDI responses of an independent sample of 139 patients diagnosed with DSM-III Major Depressive Episode. Three principal components were extracted and rotated to maximum congruence with a target based on the results of Steer et al. (1987). The significance of the fit to this target was then evaluated by rotating the same matrix of loadings to 5000 random permutations of the target. The fit was found to be highly significant, though some possible improvements could be identified ad hoc. An alternative factor structure for the BDI, derived from covariance structure analysis by Tanaka and Huba (1984), was also tested but could not be confirmed.

Covariance in the measurement of depression/anxiety and three Cluster C personality disorders (avoidant, dependent, obsessive-compulsive).

One hundred and eight-four clients referred to a research outpatient psychological clinic, and meeting the acceptance criterion of 16 or more on the BDI at screening, were diagnosed as either-depressed and/or anxious using both Present State Examination and the Diagnostic and Statistical Manual of Mental State Disorders criteria. Clients were assessed for the presence of Cluster C personality disorders using the Personality Disorder Examination of Loranger et al. (1985). Twenty-two per cent made diagnosis of avoidant, dependent or obsessive-compulsive personality disorder. Significant correlation was found between screening/intake depression index scores and total scores on the three Cluster C personality disorders, although little correlation was found between diagnostic criteria for affective and personality disorders. Some association was shown between the clinical components of personality disorder traits in the anxious-fearful group and current anxiety symptoms, although not as clearly as expected.