Conrad Lecomte What is the secret of effective psychotherapists? The evaluation of reflective services. Conrad Lecomte, Ph.D. Université de Montréal 1

Conrad Lecomte

What is the secret of effective psychotherapists?The evaluation of reflective services.Conrad Lecomte, Ph.D.

Université de Montréal

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Conrad Lecomte

Problems evaluating our services

Culture of efficiency and profitability Search for efficiency and profitability Which approach is most effective and least

costly? Which treatment? What time frame?

Multiple perspectives: the researcher, clinician, client, manager, professional order.

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To measure and demonstrate the effectiveness of our interventions: a necessity.

Practices: From research to practice

Meta-analysisEvidence from RCTs

From practice to research and back to practiceBattery of common measures

Integrating measurement in daily practice

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Measuring the impact of our interventions: essential for the client and therapist

But measuring what, when and how to improve efficiency while taking into account the complexity of the therapeutic situation?

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Realities of practiceRealities of practice

How to take into account the realities of practice: Of non-linear interactions Therapist X Client X

Problem X Relations X Techniques-Treatment X Context?

Of the diverse criteria for progress according to the different approaches

Of the diverse criteria for progress according to the different problems and contexts

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Interventions

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Interactive Regulation

Situation

TherapistSubjectivity

CLIENTSubjectivity

Clinical Clinical expertiseexpertiseProblemsProblems

Evidence Evidence from the datafrom the data

Severity of the problem; Duration; Severity of the problem; Duration; Social support; Expectations; Co-Social support; Expectations; Co-morbiditymorbidity

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How to improve effectiveness?

How to improve the effectiveness of our services? Path 1 Practice-based evidence:

The use of empirically supported treatments: A guarantee of effectiveness?

145 TSE for 51 of the 397 possibilities of the DSM

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Some data? Whatever the treatment offered:

30 to 40 % of clients either quit or do not report significant changes

5 to 15 % experience a deterioration (Hansen et al. 2002; Lambert et Ogles, 2004)

Terminating treatment : meta-analysis (47,2%, Wierzbicki & Pekarik, 1993)

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Therapist : Ignored variableTherapist : Ignored variable

The therapist : determining variable The “therapist” factor explains the variability in

outcomes more than the specific treatment, diagnosis, experience, and training (Wampold et Brown, 2005)

Some therapists get more positive results with the majority of their clients (Crits-Christoph et al. 1991; Luborsky et al., 1997)

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Therapists : No equivalentTherapists : No equivalent

E.g. therapist: 160 clients = 19% deterioration

Therapist : 300 clients = 1% deterioration (Okiishi et al. 2003, 2006)

The best: 44%+,5- The worst: 28%+,11-

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Therapists : No equivalent Therapists : No equivalent

Research on the psychotherapy practices of 3650 psychotherapists (Orlinsky et Ronnestad, 2005):

Nearly a third report obtaining few positive results. Their practices seem to be characterized by the

following experiences : destabilizing, stressful disengagement

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Path 2: Global measure of the results obtained by the clients Several methods for pre-post outcome measures at

each session (OQ45, TOP, CORE-OM) Method of Lambert and collaborators (OQ 45)

After more than 10 years of research, they developed the OQ 45, which consists of 3 scales:

A measure that is simple, brief, consistent with other approaches, validated, sensitive to change

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Therapist and client feedback following each session Simple feedback + according to the case,

proposing specific tools for interventions Regarding the feedback

Recovered : white Improved: green Inadequate change: yellow Predicted deterioration: red

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Impressive results: Prediction that over 80% of cases of

deterioration from the responses to the OQ 45 questionnaire during pre-treatment and initial sessions

Effects of feedback Effect size increases from.34 to .92

Important variability between therapists

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No feed Feed Fe & out Fe T+C

Deterioration: 20% 15% 8% 12%

No change: 58% 53% 47% 46%

Sig. change: 22% 33% 45% 37%

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Miller and Duncan’s method Similar process:

Shorter measures (ORS and SRS) Assessing results: 4 items, including 3 taken

from Lambert Assessing alliance: 4 items.

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Impressive results: Feedback: results improved by 65% Reduction in the # of sessions by 40%, Reduction in the # of dropouts by 40%

Variability between therapists Best therapists (25%):

Clients improved 50% faster Clients abandon the therapeutic process 50%

less than with the average therapist

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Things to consider Mainly validated with a university

population Mostly CBT and eclectic approaches EAP populations: brief therapy Results are self-reported from a single

source Linear perspective

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Path 3: Methods to assess a therapist’s reflection Results suggest that therapists who have the best

results are those who are: Attentive and responsive to client feedback and

their impact Flexible to adjust their interventions to the needs

of the client Most therapists need external feedback to become

aware of the experiences of their cleints

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What will happen to the client? Will they become more engaged?

What do therapists do after receiving feedback?: Are they more sensitive to the needs of their client? Do they modify their objectives and

interventions…? Do they learn to regulate the therapeutic alliance

and their own internal states? Do they go for supervision?

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Issues to consider : effective Issues to consider : effective therapiststherapists

What are the most common problems faced by the therapist and client in psychotherapy? Items taken from feedback and from tools proposed

by Lambert et al.: superior results Alliance Resistance Support Diagnosis. Review of the treatment Medication

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No feed Feed Fe & out Fe T+C

Deterioration: 20% 15% 8% 12%

No change: 58% 53% 47% 46%

Sig. change: 22% 33% 45% 37%

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How to improve effectiveness?How to improve effectiveness? An effective therapist who has little need for

feedback is… In contact with his or her own emotional experiences Sensitive to the alliance Attentive to the experience of the client Provides tailored interventions that will facilitate

change

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How to impove effectiveness?

Are we ready to conclude That all therapists should use validated methods

for measuring overall results; And that the use of these methodologies becomes

required? Are these measures generalizable? Are the measures of change enough?

Do effective therapists know enough that feedback will have little or no significant effect?

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Underlying questions: How to improve the sensitivity and

emtional availability of the therapist towards the client?

How to help the therapist be sensitive to the experience of the client, their own emotional experience and their mutual impact?

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Reflective practiceReflective practice

A therapist who is… In contact with his or her emotional experiences, Sensitive to the interaction, Attentive to the subjetive experience of the client Able to offer effective interventions that facilitate change

A therapist who… Has command over the theories and techniques, Knows how to use them with flexibility, Always ready to adapt them, Facilitates the process of change

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Paths of reflection : ways of asessing practice: Offer tools that help develop reflection towards the self and others to

improve effectiveness. Consider the overall performance measures e.g. OQ, TOP as an

invitation towards reflection: Provide a conceptual framework that considers the interaction

between the client-therapist-relationship-technique variables. Consider these indicators in inter-subject systems. Do not look for

single causes of change In this context:

In addition to the general measures, if necessary, offer specific measures According to the presenting problem e.g. Hunsley et Mash,2008 According to the approach According to the format

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Global and specific assessments Beyond global measures: e.g. OQ45 and

TOP, Add to the specific measures according to

the presenting problem (Assessments that work Hunsley et Mash, 2008)

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Anorexia: the effectiveness of psychotherapy can be assessed by : weight gain, self-esteem, body image

Boderline personality: effectiveness can be measured by: reduction in suicide attempts or self-mutilation, impulse control, relational stability

Schizophrenia: depending on the goals of therapy…

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Scale Concept measured

SES (Tait et al., 2002)) Engagement of services

SERS-SF (Lecomte et al., 2006) Self-esteem

TLFBC (Mueser et al., 2003) Substance abuse

MADS (Taylor et al., 1994) Delusional thoughts

BAVQ-R (Chadwick, Lees & Birchwood, 2000)

Auditory hallucinations

CASIG (Wallace et al., 2001) Social functioning, rehabilitation goals

SLDS (Baker & Intagliata, 1982) Quality of life

Examples of measures for severe mental disorders

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Measuring what?

Sometimes it is important to choose specific measures that are related to therapy Psychodynamic : measures of object

relation, transference… Humanistic/existential : measures of self

concept, ideal self… Cognitive-behavioral : measures of beliefs,

behaviors (homework) …

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Improve effectiveness Sometimes it is important to choose

specific measures that are related to the format of therapy Group: cohesion, participation… Family/couple: dynamic, system Games (child): emotional regulation, roles

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Paths of reflection : Ways of assessing practice:

Tools of analysis:

Client: e.g. resistance, support Relationship: e.g. alliance Therapist:

Feedback on the results by clients Self-regulation Interactive regulation Mentalization

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Fundamental approach: reflecting on oneself and interactions with others Supervision is a place for reflection

Which contributes to the development of reflection Based on the client’s feedbackTo improve the quality, efficiency, and effectiveness

of the services being offered

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A place for reflection… To share and disclose what is happening with the client : to

learn To understand his or her own internal states, the interaction

with the client and his or her interventions To share his or her reactions with the supervisor To provide appropriate interventions with the help and

support of the supervisor

What does the therapist in What does the therapist in trouble seek? trouble seek?

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Fundamental issues: Is it possible to learn and improve one’s skills in

intervention without feedback and without a space for refleciton with a supportive supervisor?

Recognize, tolerate,contain and accompany the intense emotional experiences of the patient

Interpersonal tensions

We are inexperienced once, but we can be incompetent forever (Sechrest)

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Additional informationAdditional information

[email protected]

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A few references in FrenchA few references in French Lecomte, C. (1999). Face à l'incertitude et la complexité humaine:

l'impossibilité de se défaire de soi. Revue Québécoise de Psychologie. 20(2), 37-63.

Lecomte, C. et Lecomte, T. (1999). Au-delà et en deçà des thérapies cognitives pour les personnes souffrant de troubles mentaux graves: les facteurs communs. La Revue de santé mentale au Québec. 21(4), 5-12.

Lecomte, C. (2002). Pour une pratique responsable du diagnostic. Revue Québécoise de Psychologie, 20 (1), 15-21.

Lecomte, C., Savard, R., Drouin M.S.,et Guillon, V. (2004) Qui sont les psychothérapeutes efficaces? Implications pour la formation en psychologie clinique. Revue Québécoise de Psychologie : 25,(,3) 73-102..

Lecomte,C. & Savard,R. (2004) La supervion clinique : un processus essentiel au développement de la compétence professionnelle. Dans Lecomte,T., et Leclerc,C. Manuel de rédaptation psychiatrique. Montréal : Presses de l’université du Québec.

Lecomte,C. (2009) La supervision clinique : une composante essentielle dans le traitement de la personnalité dite limite. Dans C. Leclerc& C. Labrosse, Trouble de personnalité limite : points de vue de différents acteurs. Montréal : Presses de l’Université du Québec.

Lecomte,C (2009) La clef d’une psychothérapie réussie: le thérapeute. Sciences Humaines: 15, 32-33

Thurin,J.M & Thurin,M.(2007). Évaluer les psychothérapies. Méthodes et pratiques. Dunod: Paris

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Conrad Lecomte What is the secret of effective psychotherapists? The evaluation of reflective services. Conrad Lecomte, Ph.D. Université de Montréal 1