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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
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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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Problems evaluating our services
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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Problems evaluating our services
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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How to improve effectiveness?
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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Reflective practiceReflective practice
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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How to improve effectiveness?
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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How to improve effectiveness?
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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Reflective practiceReflective practice
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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Reflective practiceReflective practice
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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How to improve effectiveness?
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
Conrad.Lecomte@UMontreal.ca
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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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