L6 - Theories in Practice Flashcards
What are the learning objectives?
+ lecture overview
- Describe different forms of cognitive behavioral therapy, including their (contra-) indications and practical considerations [paraphrasing]
- Describe the phenomenon of ‘therapist drift’, including its manifestations and causes [paraphrasing].
- Critically reflect on common factors of psychotherapy in relation to evidence based practice [analysing, scientific thinking].
- Reflect on whether there is a gap between science and clinical practice and its possible implications [analysing, scientific thinking]
- implementation science and therapeutic drift
- insights from Duygu Yakin
Theories
- help us better understand the world, and intervene in this world (e.g. bridge building)
- psychological theories work less than more concrete theories
> they are more complex
> models are not fomalized well (there are relations but we don’t know how)
> all basic models still used in clinical practice
what is the current debate in the psychology field, regarding models?
- some say that models are really there for the therapist
> models don’t actually work because they don’t predict the future so well
> many meta-analyses show that there is an average effect of all therapies, but models are mainly for therapist to have a ritual with the patient
> patient comes in with expectations, and the working mechanism of psychotherapy is the relation between patient’s expectations and therapy setting - others argue that there is evidence that psychotherapy is effective; if there is evidence that is not as effective, it’s because people are critical about it
Eclectic forms of therapy - what does it mean?
Eclectic = “composed of elements drawn by various sources”
- in psychotherapy, many clinicians pick facets of treatments that work and create personalized treatments (especially after practicing for a while)
How long does it take for research to be implemented into practice?
- 17 years
> psychiatry → 11 years
Why is that important to consider? (that it takes a while for research to be implemented into practice)
- idea is that we use evidence-based treatment to have the best option for patients to recover, so if patients don’t get treatments that are based on evidence, they might not have no effect/efficient treatment
- evidence-based randomized trials is something that the government needs in order to give fundings (no fundings if no scientific evidence)
Dealing with suicidal behavior, in the past
- how was suicide dealt with, in practice?
- there was a legal document that the patient had to sign, that he wouldn’t hurt himself
- no clear guideline until 2012
- clinicians don’t deal with this topic
- patients are ashamed of themselves
Dealing with suicide in the past
In theory vs in practice
- guideline states that suicidal behavior should be actively discussed
- risk assessment tools should not be used in clinical practice
- they went straight to the solution (advice), instead of listening and understanding (why and how intense…)
- professionals do not deal much with the topic of suicide, but why?
Dealing with suicide in the past
Why didn’t clinicians deal with the topic of suicide?
- not well trained
- afraid of increasing risk by talking about it
- afraid of legal and organizational consequences
Dealing with suicide in the past
the Guideline on suicide prevention
- what was the problem with that?
- more than 300 pages → people don’t read it
- difficult to translate guideline to practice
> so trainings + e-learning were introduced
Dealing with suicide in the past
Core of the Guideline
- making contact
- physical safety
- continuity of care
- involving significant others (interpersonal processes are super important for recovery, despite privacy of therapy)
Dealing with suicide in the past
Chronological Assessment of Suicidal Episodes (CASE)
- interview technique to ask for suicidal thoughts
1. actual suicidal thoughts (understanding what and how intense)
→ 2. recent events (why, what happened recently)
→ 3. earlier episodes (family history, previous history)
→ 4. hopes for the future
Dealing with suicide in the past
CASE - how was the model intended?
- when someone makes a suicide attempt, this model is supposed to help to understand all the factors
- not every section should be asked necessarily
> no real evidence that this model would work
> shows that models can be tailored and changed
Suicide prevention
What study did the lecturer make on dealing with suicide?
- he made a huge study throughout the Netherlands, with therapists (randomized trial)
- condition 1: therapists are trained on suicide prevention
- condition 2: therapists are not yet trained (trained in follow-up condition)
Suicide prevention
RQ of study for suicide prevention
- if people do not get trained (control condition), do they actually read the guideline? Will they do better if they are actually in the trained condition?
- the guideline was discussed in both conditions, but does getting the training actually increase the confidence of working with a suicidal patient?
- do patients of therapists in training condition recover more quickly from suicide ideation?
Suicide prevention
what did they assess in the suicide prevention study?
In therapists:
- self-confidence
- knowledge
- guideline adherence
In patients:
- suicide ideation
- suicide attempt
- treatment satisfaction
- cost-effectiveness
Suicide prevention
Results - professionals
(after 3 months)
- reading the guideline:
> 85% in training condition
> 20% in control condition
- training condition:
> more guideline adherence
> more self-reported knowledge
> more self-reported confidence
Suicide prevention
Results - Patients
- 881 patients, 567 with suicidal thoughts at baseline
> no effect for the intervention for all patients
> post-hoc effect for the patients with diagnosis of depression
> suicide ideation decreased quicker when patients were treated by professionals that followed the traning
Suicide prevention
What happened to the Guideline since then?
- much research happened, and the guideline had to be updated:
> group of experts from both science and clinical practice
> psychiatry is the lead field to update it
> there is support from research group to look for meta-analytic evidence
> people are assigned to chapters of the guideline, usually in pairs or trios
Suicide prevention
the Guideline-modification
- what were the results of the meta-analysis?
- while updating the guideline, a meta-analysis was created: “Suicidal Ideation and Suicide Attempts after direct or indirect psychotherapy
→ results: - both direct and indirect psychotherapies can be used to reduce the severity of suicidal ideation and risk of suicidal attempts
Suicide prevention
what was the consequence of this meta-analysis?
- since the difference of direct & indirect psychotherapies is approximately equal, a choice can be made, in consultation with the patient and their loved ones
- direct, indirect, combination
= recommendations are not clear, guideline is still in progress
so, why does it take so long for research to come into practice?
- guidelines need to be studied
→ randomized controlled trials
→ updates
→ meta-analyses
→ unclear recommendations
→ replications and more studies
→ …
The implementation and adherence of… (article in lecture)
What and how?
- CBT vs IPT on adherence to protocols
- videotaped therapies
- interviewed therapists and asked them about the adherence to protocols
- created themes based on answers
The implementation and adherence of… (article in lecture)
Results
→ modifications are common practice
→ people don’t follow protocols (e.g. not trained enough), and personalize treatments all the time
The implementation and adherence of… (article in lecture)
Why don’t therapists follow protocols?
→ limited educational programs
→ tendency to use more popular interventions, but that are less evidence-based (e.g. mindfulness, emdr, …)
→ organizational structure that therapists work in often doesn’t help with adherence to protocols (e.g. insurance, …)
The implementation and adherence of… (article in lecture)
What are the themes of the findings? (+ comments)
- modifications as the common practice
- this is tricky, because psychological treatment is luckily always in evolution, but it’s hard to adhere strictly to protocol if patient (e.g.) has comorbid disorders, … - Professional and patient factors influencing the decision to adhere to or modify protocols
- professionals and patients don’t behave as they should during treatments (both need discipline): easy to go in topics that are not strictly adherent to protocol
- sometimes it is challenging for therapists to make patients feel comfortable, and hard for patient to follow protocol if they are in a crisis (hard to change mindset to treatment being effective) - organizational boundaries and flexibility
- you need to have time, structure, rules, top-down drive, supervision
The implementation and adherence of… (article in lecture)
What are general implications of this study?
- hard to study this because even in trials to study efficacy of treatment, therapists don’t adhere to protocols→ so what are you really testing?
- limitations of treatments are not considered, and effectiveness of treatment is hard to study
What is the Therapist Drift?
- tendency for psychologists to move away from the delivery of the evidence-based practices in which they are trained (even when resourced to implement them)
→ why does this happen?
Therapist Drift
Why does the therapist drift happen?
- when becoming clinicians, therapists rely more on discussions with colleagues and on experiences with clients than on research findings to guide practice
- therapists tend to include in their practice the approaches they were trained in, even if newer research suggests that other approaches are more effective
- awareness of treatment manuals is low
- misconceptions about the content of treatment manuals associated to higher “negative process” score, and lower “positive outcome” score
> + beliefs that use of treatment manuals would inhibit therapeutic freedom and therapeutic relationship
> - beliefs that manuals would enhance therapeutic outcomes
Therapist Drift
what are treatment manuals?
what are they used for?
- methodized approaches to treatment based on empirical evidence
→ intended to guide therapists in the delivery of validaded interventions
Therapist Drift
Why does the therapist drift happen? (in simpler words)
- when they start to work, clinicians pay more attention to what their colleagues and their experience teaches them, compared to what they learnt in schoool
- when working with/learning about a treatment for a long time, it’s hard to change even if new research show that other treatments are better
- clinicians don’t know much about protocols (depends a bit on country and rules)
- clinicians feel like protocols restrict them (see therapy as form of art)
→ they think there should be degrees of freedom
Therapist Drift
Attitudes toward research
- even if clinicians are trained as scientists-practitioners, they tend to dislike/not follow all the research and rules (not take science for granted)
- clinicians are more open about treatments they were taught about (e.g. more evidence-based vs more psychodynamical)
- hard to generalize studies to all the patients (every patient is unique)
- clinicians hate manuals more than they hate research (even if they are research-based)
Therapist Drift
Therapist Anxiety
- what is it and what does it lead to?
- therapist anxiety leads to avoiding/minimizing the use of treatements that may cause anxiety in patients (and vicariously in therapists themselves)
- protocols should be put in place to minimize this anxiety
- therapists want to avoid hurting the patient, and avoid getting into harder topic (e.g.) at the end of session/week
(see graph)
→ learn how to endure the stress, as a therapist
→ therapists feel that they do a better job than others (you need to stay critical, that’s why there’s a lot of supervision)
From this point, the flashcars are about the second part of the lecture (guest lecturer)
What are the steps of evidence-based practice?
- formulate a clinical research question
- search the literature for the best evidence
- critically appraise (evaluate the value of) the evidence
- integrate the appraised evidence with clinical experise, and the preferences and values of the patients
- evaluate outcomes of practice decisions and revise if necessary
- disseminate results
What are the more general, correct steps for new research?
- great to start with creative thinking (e.g. find a RQ)
- look at what’s already there (check if it has already been done, how, …)
- look at evidence (why it should work in a certain way, look for things that might have gone wrong in research, check for bias and mistakes)
> we have to be open to all factors (e.g. the ones we cannot control for) and wait for new research to confirm our findings (we can’t reach important conclusion with one study only - be critical)
Integrate appraised evidence with clinical expertise
- how is this tricky?
- a lot of clinicians trust their experience more than research, but this could be dangerous to the efficiency of the treatement
- experience is important of course, but it is not enough to use it as instruction book
- therapist drift happens often, and often leads to problems
what are some problems with the therapist drift?
- things might be going well with a patient, but in next session the patient comes back with huge problems and the therapist doesn’t know anymore what to do, because there is no manual anymore to go back to
→ very important for therapists to look introspectively: what happened? what went wrong? what did I miss? - maybe we have great evidence of our new methods with multiple patients, but then it doesn’t work anymore with another one and it’s hard to adjust
- common supervision problem (therapist drift even when supervising other therapists)
50-50 debate: evidence-based or clinician-based?
- there are issues with both!
> e.g. sometimes even randomized controlled trials present mistakes, so it’s important for clinicians to deal with them and practice the right approach
Discredited Psychological Treatments
- a panel of 101 experts participated in a 2-stage survey, reporting familiarity with 59 treatments and 30 assessements
> angel therapy
> crystal healing
> past-lives therapy
> future-lives therapy
> treatments for PTSD caused by alien abduction
→ easy to say that in the past we did lobotomy and it was stupid, but right now there are still a lot of therapies like the ones above
→ some psychologists still believe in the above therapies, that’s why we really need scientific background and evidence-based treatments when practicing therapy
Discredited Tests
- thematic apperception test (personality assessment)
- Rorschach (comprehensive system) (for specific disorders)
- sentence completion tests (personality assessment)
- bender visual motor gestalt test (for neuropsychological impairment assessment)
What is the main take-away from these examples of discredited therapies/tests?
Creativity as clinicians is good, but we still need to be critical and apply scientific standards to our practice, because we are responsible for other people’s well-being
How did the treatment scene change in the past 40 years?
- big rise in CBT, psychodynamic, eclectic therapy, …
> eclectic therapy: clinicians pick different parts of different therapies
→ how does that work?
> e.g. behavioral + cognitive, mindfulness + acceptance, dialectical for borderline, …
→ when do we put the limit? should it be a theory or should we put it in practice?
How does eclectic therapy come about?
- from therapist drift
> e.g in crisis situation we create new forms of therapies, but this is what forms new eclectic therapies
→ what does it really mean? - it’s tricky: it might leaed to overdoing the therapies and lose the efficiency of the treatment
What are the four most common eclectic therapies?
- cognitive behavioral
- acceptance and commitment
- mindfulness-based
- dialectical behavioral
Schema Therapy
- integrated approach to work with clients with personality disorders or those who are resitant to treatment
→ treating the infamous untreatable - “it encourages personal, customized language/labels that capture the essence of the thoughts, feelings and sensations experienced, along with the expression of behaviors, when in a specific mental state”
How is Schema Therapy eclectic?
How is this different from all the eclectic therapies we have mentioned before?
- psychoanalysis + CBT + Gestalt therapy
> schema therapy is a combination of different therapies and theories, but it has been studied and analysed
> it is different from “doing what works”
! many times there is much evidence about the fact that a therapy works, but not about how/why it works
! eclectic therapies should not be free from all the rules of evidence-based treatments
Insight
- what are they?
- how are they linked to the importance of protocols?
- what the therapist thinks about what the client says
- this is also what is on the report that the client gets at the end of the sessions
- it depends on the therapist’s personal opinion, and what he deems is important of what the client is saying
- insights are complicated, they keep changing, that’s why it’s important to understand that all the “boring manuals” are necessary
what is a common therapist pitfall?
- “I know it better than the patient”
→ keep listening to the patient!
→ keep balance in your practice
from this point on, the flashcards are about the article on Adherence to Protocols
- title of the article
The implementation and adherence to evidence-based protocols for psychotherapy for depression: The perspective of therapists in Dutch specialized mental healthcare
Fidelity-consisten modifications
- what are they?
- modifications that do not alter core elements of treatment enough to reduce adherence to a protocol
- do not reduce ability to differentiate between treatments
General information of the article
- what did it investigate?
- Research article (2018)
- investigated the application of CBT and IPT models to the treatment of depression
> should treatments be modified? - found three themes:
1. Modification as common practice
2. Professional and patient factors
3. Organizational factors
Methods
- qualitative approach
- focus group (x2)
- 200 patients + 46 therapists
- 4 conditions:
> 16 twice-weekly CBT/IPT sessions vs once-weekly CBT/IPT sessions
what quesions/topics were investigated in the study?
- adherence to treatment protocols
- which type of modifications are applied to daily practice
- which patient and therapist characteristics influence the modification of the protocols chosen by the therapist
- in what way the organizational context influences the way therapists adhere to protocols
Findings - Modification as Common Practice
> The researchers found different ways in which modifications were applied to protocols:
- Strict adherence to protocol
- Combination of different treatment methods from the start
- Start with one protocol and switch to different method (without finishing the first one)
- Flexible adherence to protocol (small adjustments)
Findings - Professional and Patient Factors
> the researchers found different factors of the professionals and the patients, which influence the adherence to protocols
Professional:
- Type of training and supervision
- Years of work and experience
- Characteristics of therapist as a person
Patient:
- Being in a crisis
- Low cognitive abilities
- Suicidal behaviour
- Not accepting the protocol
- Low motivation for treatment
- Presence of comorbid problems
Findings - Organizational Factors
- Attitude of manager towards protocol
- Reorganization
- Planning capacity and workspace
- Coherent team vision on protocols
- Main focus on production targets
What recommendations did the article propose?
- Therapist should not act on what they personally think or combine protocols from the start of treatment
- Avoid switching to other protocol / remove elements from protocol
- Distinguish fidelity-consistent modifications and apply them to practice
- Observational material (external motivation, e.g. 100€)
- Supervision and regular meetings
→ more adherence
→ better work environment
→ more support
What factor was NOT mentioned, among the ones that can promote proper adherence and flexibility to protocols?
a) incorporating the patient’s personal characteristics into the protocol
b) utilize consistent observation and evaluation of measurements for the therapist’s performance
c) Discussing protocol alternatives with the other therapists
A
from now on, the flashcards will be on the article on the therapist drift
- title of the article
Correlates of therapist drift in psychological practice: A systematic review of therapist characteristics
Correlates of therapist drift (article)
what does Evidence-based Psychological Practice (EBPP) require?
- the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences
→ however, much evidence that many treatments without empirical support are provided (therapist drift)
Correlates of therapist drift (article)
what is the evidence around Empirically Supported Treatment (EST)?
- significantly greater symptom reduction
- fewer sessions needed
Correlates of therapist drift (article)
why do many therapist use non-EST?
- undue reliance on personal experience
- misconceptions about nature and operationalization of EST
- difficulty comprehending the increased technical complexity of the studies
Correlates of therapist drift (article)
what was the aim of the study?
+ methods
- identify potential correlates of therapist drift across psychologists, focusing on therapist characteristics
> they reviewed hundreds of scientific articles
Correlates of therapist drift (article)
What factors were overall found to influence the therapist drift?
(1) therapist knowledge
(2) attitudes toward research
(3) therapist anxiety
(4) clinical experience
(5) therapist age
(6) theoretical orientation
(7) critical thinking
(8) personality traits
(9) cultural competency
Correlates of therapist drift (article)
Results
- positive correlation between therapist’s knowledge and fidelity of EST
- failure to implement EST is due to:
> lack of knowledge and training
> uncertainty for the empirical status of treatments (if therapist knows that the treatment is empirically supported, he will use it more)
> therapists may tend to include in their practice the approaches they were trained in, even if subsequent research had suggested that other approaches were more effective
> misconceptions about the content of treatment manuals is associated with higher “negative process” scores (i.e.,
beliefs that use of treatment manuals would inhibit therapeutic freedom and the therapeutic relationship) and lower “positive outcome” scores (beliefs that manuals would enhance therapeutic outcomes)
Correlates of therapist drift (article)
Summary of findings
- Therapists generally have low awareness of ESTs
- Difficulty in differentiating between ESTs and non-ESTs
- Ignore recent treatment developments in favor of the treatments in which they may have been trained
- Skeptical about the use of therapy manuals, believing that they inhibit the therapeutic relationship
Correlates of therapist drift (article)
Clinician Anxiety
- leads clinicians to avoid or minimize the use of treatments that may cause anxiety in patients (and vicariously in therapists themselves)
- greater prospective anxiety among CBT therapists associated with less willingness to engage patients in behavioral experiments, behavioral activation, and exposure therapy
- (more anxious therapists were less likely to ask patients to complete food diaries, engage in structured eating, or undertake behavioral experiments, when working with patients with eating disorders)
- anxiety sensitivity was positively associated with therapists’ exclusion of patients from exposure therapy, notwithstanding that exposure therapy is well tolerated by anxious patients
> relationship between therapist anxiety and fidelity to ESTs
relationship between negative beliefs about exposure and reduced use of this EST
Correlates of therapist drift (article)
Clinical experience
- more clinical experience (and more time spent in the same job) negatively associated with willingness to adopt ESTs (when required to do so by administrators)
- More years of clinical practice also associated with less favorable attitudes toward the use of treatment manuals, more frequent use of non-ESTs, poorer adherence to ESTs, less frequent use of treatment manuals and a tendency to believe that research is not applicable to clinical decision-making
- therapists with more clinical experience were more likely to perceive psychological practice as an art rather than a science, and to be confident in their skills as therapists
> negative relationship between length of clinical practice and attitudes toward research and use of ESTs
Correlates of therapist drift (article)
Therapist Age
- therapist age may be negatively related to adherence to ESTs
> might be because of clinical experience
Correlates of therapist drift (article)
Theoretical orientation
- relationship between a cognitive-behavioral
orientation and EST use (e.g. instead of eclectic therapies) - an intuitive thinking style associated with negative attitudes toward the use of research in clinical practice, less openness to research-based treatments, and greater resistance to the use of ESTs (when use is required)
> the literature indicates that those with higher critical thinking skills are more likely to use ESTs
Correlates of therapist drift (article)
Cultural competency
- ethnic match between therapist and patient caregiver associated with greater adherence to an EST for treatment
Correlates of therapist drift (article)
What recommendations are brought forward to reduce therapist drift?
- screening psychology students based on personality traits or other predictors of drift and increasing adherence monitoring throughout therapists’ careers (tricky)
- enhancing learning opportunities across the professional lifespan
Correlates of therapist drift (article)
Training and Supervision as Core Areas for Improvement
Training Enhancements:
- didactic training + competence-based training (practical skills for treatment fidality)
- clinical supervision (fostering key competencies in supervisors and supervisees
Supervision Quality and its Impact on Drift:
- crucial but often inconsistent in quality
- future focus on improving supervision competencies, better supervision practices, and ensuring supervision is treated as a distinct professional competency
Correlates of therapist drift (article)
Continuing Professional Development (CPD) and Its Shortcomings
- Most regulatory agencies mandate ongoing professional development (CPD) for psychologists (+ formal courses and informal activities like peer learning and literature review)
- however, the content of CPD programs is often loosely regulated, and assessments of learning outcomes are inconsistent
> Lack of Regulation→ CPD activities may reinforce biases, skepticism toward evidence-based practice, and misconceptions about ESTs
> Resistance to Updating Knowledge (therapists tend to integrate new information alongside outdated concepts rather than replacing older ideas with more robust evidence-based approaches)
Correlates of therapist drift (article)
Take-aways of recommendations
Reducing therapist drift requires a shift from punitive measures (e.g., screening or excessive monitoring) to proactive strategies that improve therapist learning and competence across their careers
- Strengthening clinical supervision practices
- Enhancing training programs with a focus on skill acquisition and practical application
- Regulating CPD activities to ensure they align with current evidence-based practices
