Therapist effects and IAPT Psychological Wellbeing Practitioners (PWPs): A multilevel modelling and mixed methods analysis

Green, Helen; Barkham, Michael; Kellett, Stephen; Saxon, David

doi:10.1016/j.brat.2014.08.009

“…The more effective PWPs facilitated more change per session during low intensity treatment and this presents a potent new avenue for research on therapist effects. Green et al (2014) set out a research agenda for future PWP therapist research highlighting the need to sample the clinical sessions of effective PWPs and define the practice of PWP 'super-coaches. '…”

Section: Discussionmentioning

confidence: 99%

“…To date, two studies have examined therapist effects during the delivery of PWP interventions. Green, Barkham, Kellett, and Saxon (2014) in a multisite study found that PWPs (N=21) accounted for 9-11% of patient (N=1122) outcome variance, but the findings may have been confounded by unmodelled service level effects. Ali et al's (2014) single site study found that PWPs (N=38) accounted for only 1% of patient (N=1376) outcome variance.…”

Section: Introductionmentioning

confidence: 99%

Therapist effects and moderators of effectiveness and efficiency in psychological wellbeing practitioners: A multilevel modelling analysis

Firth

¹

,

Barkham

²

,

Kellett

³

et al. 2015

Behaviour Research and Therapy

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Article available under the terms of the CC-BY-NC-ND licence (https://creativecommons.org/licenses/by-nc-nd/4.0/) eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. TakedownIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. Results: Therapist effects accounted for 6-7% of outcome variance that was moderated by greater initial symptom severity, treatment duration, and non-completion of treatment.Clinically effective PWPs achieved almost double the change per treatment session. As treatment durations increased beyond protocol guidance, outcomes atrophied. Treatment noncompletion was particularly detrimental to outcome.Conclusions: PWPs appear to be differentially effective and efficient despite ostensibly delivering protocol driven interventions. Implications for services, training, and supervision are outlined.

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“…Outcomes can be compared across services, in which case the concerns raised by Fairburn & Cooper (2011) are worthy of consideration, but the prevention of therapist drift requires intra-clinician comparison of outcomes -are we getting better or worse at getting our patients well? Using outcomes to acknowledge that some clinicians do poorly and some do better than the norm allows us to understand which clinicians might be exemplars of best practice, and hence models for enhanced delivery of evidence-based psychotherapies (e.g., Franklin et al, 2004;Green et al, 2014).…”

Section: Training and Maintenance Of Skills: Competence Adherence Ormentioning

confidence: 99%

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Waller

¹

,

Turner

²

2016

Behaviour Research and Therapy

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Article available under the terms of the CC-BY-NC-ND licence (https://creativecommons.org/licenses/by-nc-nd/4.0/) eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. TakedownIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. AbstractTherapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviors and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioral approach for therapists that addresses the cognitions, emotions and behaviors that drive and maintain our avoidance of evidence-based treatments.Keywords: therapist drift; psychotherapies; evidence-based practice; training; cognitivebehavioral therapy Therapist drift redux 3 Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track There are different reasons why evidence-based therapies might be delivered poorly, such as clinicians being inadequately trained in the therapy in question (e.g., Royal College of Psychiatrists, 2013) or working in a setting that does not permit the implementation of the necessary methods (e.g., not being permitted to provide the necessary number of sessions).Among those reasons is one that is centred in our own practice -therapist drift (Waller, 2009). Therapist drift can be conceptualised as our failure to deliver treatments that we have been trained to deliver, or failure to deliver them adequately, even where resources exist to allow us to do so. Such failure can be a consciously or an unconsciously-driven course of action. Regardless, it has the same consequence -the patient receives treatment that deviates significantly from the evidence-base, reducing their chances of improvement or recovery. This paper will review the substantial recent evidence fo...

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“…Richards and Borglin (2011), for example, observed that around a quarter of patients screened as suitable for IAPT treatment failed to attend their initial therapy appointment and another quarter dropped out after starting therapy. Less than half of those who start LiCBT attain reliable and clinically significant improvement (Delgadillo et al, 2014;Green et al, 2014;Firth et al, 2015). It seems hasty to consider patients 'recovered' at the point of discharge without assessing full remission of symptoms over a longer period.…”

Section: Considerations For Policy and Practicementioning

confidence: 99%

How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study

Ali

¹

,

Rhodes

²

,

Moreea

³

et al. 2017

Behaviour Research and Therapy

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Background: Depression and anxiety disorders are relapse-prone conditions, even after successful treatment with pharmacotherapy or psychotherapy. Cognitive behavioural therapy (CBT) is known to prevent relapse, but there is little evidence of the durability of remission after low intensity forms of CBT (LiCBT).Method: This study aimed to examine relapse rates 12 months after completing routinely-delivered LiCBT. A cohort of 439 LiCBT completers with remission of symptoms provided monthly depression (PHQ-9) and anxiety (GAD-7) measures during 12 months after treatment. Survival analysis was conducted to model time-to-relapse while controlling for patient characteristics.Results: Overall, 53% of cases relapsed within 1 year. Of these relapse events, the majority (79%) occurred within the first 6 months posttreatment. Cases reporting residual depression symptoms (PHQ-9 = 5 to 9) at the end of treatment had significantly higher risk of relapse (hazard ratio = 1.90, p < 0.001). Conclusions:The high rate of relapse after LiCBT highlights the need for relapse prevention, particularly for those with residual depression symptoms.Key words: depression; anxiety; relapse; cognitive behavioural therapy 3 IntroductionDepression is known to have a high recurrence rate, even after the successful treatment of acute-phase symptoms (Burcusa & Iacono, 2007;Yiend et al., 2009;Harter et al., 2007;Hardeveld et al., 2010;Gopinath et al., 2007). For example, after a first episode of depression, the probability of a further episode is approximately 50%; this rises to 70% following two episodes and 90% after a third episode (Burcusa & Iacono, 2007;Kessler et al., 1996). It also appears that with each further episode there is an increase in the severity of depressive symptoms and an increased probability that these symptoms will become resistant to treatment (Kendler et al., 2000).Similarly, research on anxiety disorders suggests high recurrence rates between 39% and 56% after treatment (Bruce et al., 2005;Eisen et al., 1999;Vervliet et al., 2013).Literature in the field draws conceptual distinctions between relapsea deterioration after initial response to treatment-and recurrence -a new episode of the disorder following a period of recovery- (Bockting et al., 2015).Meta-analyses of trials in this area show that accessing cognitive behavioural therapy (CBT) reduces the risk of depression relapse (Vittengl et al., 2007; Cuijpers et al., 2013) by comparison to acute-phase pharmacological treatment. The prophylactic effects of CBT appear to be as durable as to those of long-term maintenance on pharmacological treatment, but better at preventing relapse and recurrence compared to acute-phase pharmacological treatment without a maintenance phase (Hollon et al., 2005). Similarly, CBT is associated with sustained maintenance of improvements after the acute phase of treatment in various anxiety disorders (Otto, Smits, & Reese, 2005). It is, however, unclear if this 4 apparent durability of therapeutic effects primarily applies to conventi...

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Therapist effects and IAPT Psychological Wellbeing Practitioners (PWPs): A multilevel modelling and mixed methods analysis

Cited by 68 publications

References 49 publications

Therapist effects and moderators of effectiveness and efficiency in psychological wellbeing practitioners: A multilevel modelling analysis

Therapist effects and moderators of effectiveness and efficiency in psychological wellbeing practitioners: A multilevel modelling analysis

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study

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