Response processes for patients providing quantitative self-report data: a qualitative study.

OBJECTIVE: To identify factors that influence response processes for patients providing quantitative self-report data. Secondly, due to the lack of integrative and explanatory models in this area, to develop a model of patients' response processes that can guide what to look for when considering validity evidence and interpreting scores on individual items. METHODS: Participants (n = 13) were recruited from a specialized substance use disorder treatment clinic and interviewed while responding to items from a clinical feedback system implemented for routine outcome monitoring in that setting. The interview approach was based on cognitive interviewing. Data collection and analysis were inspired by a grounded theory approach. RESULTS: We identified several variables that influenced the participants' response processes. The variables were organized into five categories: context-related variables; item-related variables; response base variables; reasoning strategies; and response selection strategies. We also found that the participants' responses for many items were affected by different aspects of the response process in ways that are relevant to interpretation but not necessarily discernible from the numerical scores alone, and we developed response categories to capture this. CONCLUSION: The findings suggest that patients providing quantitative self-report data encounter conditions in the response process that challenge and influence their ability to convey meaning and accuracy. This results in responses that for many of the items reflect messages important for interpretation and follow-up, even if it does not appear from the numerical scores alone. The proposed model may be a useful tool when developing items, assessing validity, and interpreting responses.

Psychotherapists' outcome expectations: How are they established?

Therapists' outcome expectations influence the psychotherapy process and outcomes, but little is known about the factors influencing their development. This study explored therapists' experiences with establishing outcome expectations for their patients. The participants were 35 therapists from a public mental health setting, who were interviewed in five different focus groups. Interviews were transcribed and analyzed using thematic analysis. Three themes and 10 subthemes were identified. In Theme 1 (understanding the problem), participants' expectations were influenced by (a) their patients' diagnoses and the diagnostic process, (b) their perceptions of the complexity of the presenting problem, (c) how stable the patients' symptoms and situations were, and (d) whether they experienced familiarity with the patient or the patients' situation. In Theme 2 (the patient's openness to change), participants' expectations were influenced by (a) the patient's stated reason for seeking treatment, (b) the patient's conceptualization of their problem/situation, and (c) their perception of the patient's willingness to invest in the treatment. In Theme 3 (the fit between the therapist and patient), the participants discussed the factors that influenced whether they felt they were a good fit for working with an individual patient and how this perception of personal and professional fit influenced their expectations. We identify several ways that therapists' situational factors and their recognition of the patient through their own past experiences can influence their expectations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Points of departure: A qualitative study exploring relational facilitators and barriers in the first treatment session.

Objective To explore how patients and therapists in an outpatient specialized substance use disorder treatment setting experienced the first treatment session, and to identify relational facilitators and barriers seen from both patient and therapist perspectives.Method: The study is based on a qualitative approach and semi-structured interviews of patients (n = 12) and therapists (n = 12). Interviews were conducted soon after the first treatment session and analyzed in accordance with reflexive thematic analysis.Results: We identified subthemes for patients and therapists, respectively. In addition, we found that patients and therapists described certain comparable experiences and actions which we integrated as core themes: (a) feeling uncertain about what to expect; (b) forming first impressions; (c) balancing multiple concurrent concerns; (d) seeking feedback from the other; and (e) sensing a way forward. The subthemes specify patients' and therapists' unique meanings and approaches to each core theme. Finally, we summarized unique and shared relational facilitators and barriers.Conclusion: Patients and therapists use the first session to form an impression of the other, but they are also concerned with the impression they themselves give. They, therefore, monitor the other's in-session reactions and responses which constitute facilitators or barriers for their own further relational actions.

Routine Outcome Monitoring and Clinical Feedback in Psychotherapy: Recent Advances and Future Directions.

In the past decade, there has been an increase in research related to the routine collection and active use of standardized patient data in psychotherapy. Research has increasingly focused on personalization of care to patients, clinical skills and interventions that modulate treatment outcomes, and implementation strategies, all of which appear to enhance the beneficial effects of ROM and feedback. In this article, we summarize trends and recent advances in the research on this topic and identify several essential directions for the field in the short to medium term. We anticipate a broadening of research from the focus on average effects to greater specificity around what kinds of feedback, provided at what time, to which individuals, in what settings, are most beneficial. We also propose that the field needs to focus on issues of health equity, ensuring that ROM can be a vehicle for increased wellbeing for those who need it most. The complexity of mental healthcare systems means that there may be multiple viable measurement solutions with varying costs and benefits to diverse stakeholders in different treatment contexts, and research is needed to identify the most influential components in each of these contexts.

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.

Initial quantitative development of the Norse Feedback system: a novel clinical feedback system for routine mental healthcare.

PURPOSE: As routine outcome monitoring has become prevalent in psychological practice, there is need for measurement tools covering diverse symptoms, treatment processes, patient strengths, and risks. Here we describe the development and initial tests of the psychometric properties of a multi-scale system for use in mental healthcare, Norse Feedback. METHODS: In Study 1, we present the item-generation process and structure of the Norse Feedback, a 17-scale digital-first measurement tool for psychopathology and treatment-relevant variables. In Study 2, we present analyses of this initial measure in a nonclinical sample of 794 healthy controls and a sample of 222 mental health patients. In Study 3, we present the analysis of a revised 20-scale system in two separate samples of patients. In each analysis, we investigate item and test information in particular, including analysis of differential item functioning on gender, age, site, and sample differences where applicable. RESULTS: Scales performed variably. Changes to items and scales are described. Several scales appeared to reliably discriminate individuals entering mental health treatment on severity, and others are less reliable. Marked improvements in scale internal consistency and measurement precision were observed between the first and second implemented versions. CONCLUSION: This system includes some scales with reasonable structural validity, though several areas for future development are identified. The system was developed to be iteratively re-evaluated, to strengthen the validity of its scales over time. There are currently a number of limitations on inferences from these scores, which future developments should address.

Continuous quality improvement in measure development: Lessons from building a novel clinical feedback system.

PURPOSE: While the use of clinical feedback systems has become commonplace in psychological treatment, many of the most common instruments used for this purpose have not changed in decades. This paper describes the first four cycles of a measure development method designed to embrace continuous quality improvement. METHODS: Using techniques and philosophies developed in business management and academia-lean continuous quality improvement, action research, and practice research networks-we iterated through multiple cycles of development with the goal of creating an optimal clinical feedback system. These cycles emphasize building capacity to receive and implement feedback from a variety of stakeholders, especially patients and providers of behavioral health services, while also being responsive to quantitative findings from measure development. RESULTS: Iterating measure development with stakeholder feedback over the course of 5 years has resulted in a novel measurement system with 19 subscales administered via branching logic, and a supporting practice research network to sustain development. CONCLUSION: In developing a new clinical feedback system, the less-frequently-discussed practical aspects of measure development require close attention. Specifically, being willing to embrace change, planning for iteration, and systematically seeking stakeholder feedback are identified as central methods for improving clinical feedback systems.

Understanding routine outcome monitoring and clinical feedback in context: Introduction to the special section.

The practice of routine outcome monitoring and providing clinical feedback has been widely studied within psychotherapy. Nevertheless, there are many outstanding questions regarding this practice. Is it an evidence-based adjunct to ongoing psychotherapies, or an ineffective complication of treatment? If it is effective, through what mechanism(s) does it act? Is it effective with all patient populations, treatment types, and service delivery mechanisms, or does its impact vary across context? What choices in the implementation process affect the utility of patient-reported data feedback on psychotherapy outcomes? The studies in this special section explore these questions using a wide variety of methods and significantly expand the reach of studies on feedback. Together, these studies represent a snapshot of a maturing field of study: Initial discoveries are developed into more robust theories and applied in a wider range of contexts, while the limits of that theory are tested. They also signal directions for future clinical and research work that may improve patient care in psychosocial interventions into the future.

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?

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.

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.

Building a practice research network: obstacles faced and lessons learned at the Center for Collegiate Mental Health.

OBJECTIVE: The Center for Collegiate Mental Health (CCMH) was created through a grass-roots initiative among university and college counseling centers to standardize assessment procedures, conduct empirical studies, and advocate clinical services. METHOD: At present, CCMH has over 240 college counseling center members and oversees a research infrastructure based on these centers' routine services, describing approximately 90,000 individual clients annually. These data are used to provide clinical tools, which can be useful for ongoing clinical services as well as program evaluation, quality assurance, and advocacy on behalf of the counseling centers and clients. RESULTS: There have been substantial obstacles to overcome, and there remain numerous challenges in day-to-day operations. This article provides a brief overview of the challenges and current solutions. CONCLUSIONS: Large-scale collaborations between researchers and practitioners are possible, and some recommendations can be made based on the experience of CCMH.

Case report: A dual case study of how clinical feedback can be a communication aide and influence therapeutic work.

Background: While routine outcome monitoring and clinical feedback may improve outcomes after psychotherapy, results from efficiency studies have been mixed. Moreover, how clinical feedback is implemented influences how it works for patients and clinicians, and working mechanisms are hitherto not thoroughly explored. Researchers have argued that inviting and using feedback from patients is best conceived of as a clinical skill. In this paper, we use case study methodology to explore and describe feedback's functions within three clinical skill themes: actualizing alliance work, concretizing change and stagnation and verbalizing the non-verbal. Case presentation: Sonja is a young adult patient with a trauma background. She has a history of serious suicide attempts and distrust in relationships. She attended psychotherapy for eight months. Harald is a middle-aged man with a stable family. Traumatic events in his past has made him conceal own needs and developing depression. He attended psychotherapy for 19 months. Case material include the patient's clinical feedback over a range of life areas, medical health notes and the therapist's process notes. Conclusion: Clinical feedback can be a positive supplement to the therapeutic work and process. The importance of making this as a joint tool between the client and the therapist is significant.

Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND: Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes. METHODS: Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode]. RESULTS: One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease. CONCLUSIONS: The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

Bringing mental health to the frontlines: A proactive team-based model for healthcare workers during the COVID-19 pandemic.

OBJECTIVE: A novel team-based service was developed at the beginning of the pandemic in which sixty liaisons were assigned to provide proactive, tailored psychological support for healthcare workers (HCWs) across three of NewYork-Presbyterian's Weill Cornell affiliated hospitals. METHOD: The program took the proactive approach of bringing mental health awareness to every department and major division that interfaced with COVID-19 patients. Virtual and in-person team-based "town hall" meetings were offered to provide psychoeducation, facilitate discussion, foster adaptive coping and social cohesion, and identify employees who would benefit from further individualized support. RESULTS: The program's success was reflected in the number of town halls (1000+) and attendees (6000+) and in qualitative feedback from departments who requested ongoing services. CONCLUSIONS: This article presents the development, implementation, challenges, and opportunities in designing a team-based support model for HCWs. This model may be useful for organizations that seek to develop similar programs.

A proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist for PTSD: Design, methods, and recruitment.

Background: Almost eight million Americans suffer from Posttraumatic Stress Disorder (PTSD). Current PTSD drug therapies rely on repurposed antidepressants and anxiolytics, which produce undesirable side effects and have recognized compliance issues. Vasopressin represents a promising and novel target for pharmacological intervention. Logistical issues implementing a clinical trial for a novel PTSD pharmaceutical are relatively uncharted territory as trials concerning a new agent have not been published in the past several decades. All published trials have repurposed FDA-approved psychoactive medications with known risk profiles. Our recruitment challenges are discussed in this context. Methods: An 18-week proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist (SRX246) for PTSD was conducted. All participants received SRX246 for 8 weeks, the placebo for 8 weeks, and the drug vs. placebo arms were compared. Participants were assessed every 2 weeks for PTSD symptoms as well as other medication effects. Results were expected to provide an initial demonstration of safety and tolerability in this clinical population and potentially clinical efficacy in SRX246-treated patients measured by Clinician Administered PTSD Scale (CAPS) score changes, clinical impression, and other indices compared to placebo. The primary hypothesis was that SRX246 would result in a clinically meaningful 10-point reduction in mean CAPS score compared to placebo. Discussion: This study is the first to investigate an oral vasopressin 1a receptor antagonist for PTSD. As a wave of PTSD clinical trials with new pharmaceutical compounds are beginning now, lessons learned from our recruitment challenges may be invaluable to these endeavors.

Previous mental health service utilization and change in clients' depressive symptoms.

Although a potentially important factor in case conceptualization and treatment planning, the impact of previous treatment on subsequent counseling response has received little empirical attention. Using archival data, this study aimed to (a) report the prevalence of previous treatment utilization in a counseling population, (b) examine potential differences in symptom severity by treatment history, and (c) test whether the rate of change in symptoms over a course of counseling is moderated by previous treatment utilization, when also accounting for initial severity. A sample of 1,262 college students presenting for treatment in university/college counseling centers across the United States provided information on previous treatment history and completed the Counseling Center Assessment of Psychological Symptoms, administered at intake and up to 4 additional time points, with an average of 3-5 weeks between assessments. Data from the 13-item Depression subscale were used for the present study. Half the clients reported previous counseling, one third psychotropic medication, and one tenth psychiatric hospitalization. Previous treatment was associated with increased baseline depressive symptom severity. Results from latent growth curve models showed that previous counseling and medication correlated with a slower rate of symptom response, and previous counseling reduced the probability of being labeled a treatment responder. Previous counseling remained a significant predictor of counseling response when controlling for baseline severity. Hypothesized mechanisms through which previous treatment experience impacts subsequent treatment response remain largely theoretical and should be the focus of future research.

Clinical validity of the counseling center assessment of psychological symptoms-62 (CCAPS-62): further evaluation and clinical applications.

Self-report instruments of psychological symptoms are increasingly used in counseling centers but rely on rigorous evaluation of their clinical validity. Three studies reported here (total N = 26,886) investigated the validity of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62; Locke et al., 2011) as an assessment and screening instrument. In Study 1, initial evidence regarding the concurrent validity of the CCAPS-62 was replicated and extended in a naturalistic clinical sample of clients from 16 counseling centers. Using this sample, convergent validity of the subscales was examined in counseling center clients, the range of sensitivity of the subscales was investigated using item-response theory, and the presence of 2nd-order factors was preliminarily examined. In Study 2, 7 of the 8 CCAPS-62 subscales statistically significantly differentiated between students in counseling and those who were not, using data collected from a large national survey, although most differences were small and the groups' distributions overlapped considerably. Cut scores based on the differences between these clinical and nonclinical populations showed limited utility due to overall similarities between these broadly defined groups. In Study 3, therapist-rated diagnoses collected from 5 university counseling centers were used to further examine the validity of subscale scores. In addition, cut points for diagnostic screening using receiver operating characteristic curves were evaluated. Overall, these studies support the use of the CCAPS-62 as an initial measure of psychological symptoms in college counseling settings, provide additional information about its psychometric performance, develop cut scores, and illustrate the potential for collaboration between practitioners and researchers on a large scale.