Outline of presentation

1. The Process and Outcome of TA Psychotherapy for the Treatment of Depression: A case series using Hermeneutic Single-Case Efficacy Design Mark Widdowson, MSc (TA Psych), TSTA (P), ECP, FHEA University of Leicester

2. Outline of presentation • Background • HSCED Method • The case series (focus on 3 positive outcome cases) • Cross-case Analysis • Discussion

3. Background to the study • How did all this come about? • Why did I decide to do this?

4. Depression- Prevalence and epidemiology • DSM-IV: estimated that between 10% and 25% of women and between 5% and 10% of men will experience Major Depressive Disorder during their lifetime. • The United Kingdom’s Office of National Statistics reported a prevalence of 9.2% of the general population experienced mixed anxiety and depression in the year 2000. • USA: 9% of all adults will experience Major Depressive Disorder in any given year and approximately 16% will experience MDD during their lifetime (Kessler et. al 2003).

5. Hermeneutic Single-Case Efficacy Design (Elliott, 2002) • A systematic case study method • Uses qualitative tools and quantitative outcome measures • Data used to form ‘rich case record’ • Uses quasi-legal method of cross-examination of data and independent adjudication

6. Aims of a HSCED study • ‘Evaluate(s) the efficacy of psychotherapy on a case by case basis by asking… Did the client change substantially over the course of therapy? Is this change substantially due to the effect of the therapy? What factors (including mediator and moderator variables) may be responsible for the change? ‘ (Stephen and Elliott, 2011: 231)

7. A team-based approach • Can be used by trainees • Demystifies the research process and provides experiential training in conducting and analysing research

8. The Affirmative Argument • Changes in stable problems • Retrospective attribution • Outcome to process matching • Links between specific within-therapy events and specific gains/ improvements

9. The Sceptic Argument • Apparent changes are trivial / negative • Statistical artefacts (measurement error etc.) • Relational artefacts: apparent changes are superficial attempts to please the researcher or therapist. • Apparent changes are a result of client expectations or wishful thinking. • Self-correction: apparent changes are the result of self-help or self-limiting easing of short-term or temporary problems. • Apparent changes are due to extra-therapy events (e.g., a new relationship or new job). • Psychobiological factors (e.g. due to medication, recovery from illness) • Apparent changes can be attributed to reactive effects of research

10. Analysis and Adjudication • Cases were analysed by teams of TA therapists/ trainees • Rich case record and affirmative/ sceptic arguments were sent to independent judges who were non-TA therapists with research experience

11. Adjudication questions • Verdict (including what data had shaped their opinion) • Good outcome, Mixed outcome, Poor outcome? • What extent did the client change? • What extent was the change due to therapy? • What therapy processes were helpful? • What client factors were helpful?

12. Protocol in this case series • CORE-OM, Beck Depression Inventory-II, Personal Questionnaire • Working Alliance Inventory, Helpful Aspects of Therapy • Structured Therapist Notes • Adherence forms (therapist, supervisor) • Change Interview

13. Case 1: ‘Peter’ • 28 year-old, unemployed and somewhat socially isolated British male with severe depression and moderate functional impairment • Bullied at school, mother died when he was 13. Awareness of repressed emotions • Intelligent, articulate, psychologically-minded

14. Peter • BDI-II: severe depression, CORE-OM: Moderate global distress and functional impairment • Clinically significant change on CORE and PQ by end of therapy, reliable change on BDI • Improvement at 1 month follow-up, maintained at 6 month • Identified five changes which were important to him and which he felt unlikely to have come about without therapy

15. Peter- Judges’ Verdicts • Peter had experienced clinically significant changes, although had not fully resolved his problems, and that these changes were substantially due to therapy. • Good outcome case with client changing considerably-substantially and these changes were substantially due to therapy

16. Peter- mediator factors • Empathic, genuine therapist who was willing to become emotionally engaged with him • Use of a explanatory and change framework (TA theory) had also been helpful

17. Peter- Moderator Factors • Client commitment to therapy and determination to overcome discomfort • Client motivation • Client belief in effectiveness of therapy (hope) • Matching of therapist and type of therapy with client preferences

18. Case 2: ‘Denise’ • 46 year old, white, British social worker with severe depression and moderate functional impairment • Off sick from work at point of entry into therapy • Feeling very taken for granted by her family – strong sense of ‘I’m not important’

19. Denise • Severe depression (BDI-II) and moderate functional impairment • Clinically significant change on CORE-OM and PQ by end of therapy, reliable change on BDI-II • Continued improvement throughout follow-up • Identified ten changes she felt were extremely important and unlikely without therapy

20. Denise- Judges’ verdicts • Unanimous verdict of the judges that the case was a clearly good outcome case, with mean certainty of 86% • Unanimous verdict that Denise had changed substantially and that this had substantially been due to therapy

21. Denise- Mediator factors • Empathic, non-judgmental stance of the therapist. • Therapist’s willingness to provide a rationale or use theory to explain and support the therapy • Therapist’s focus continued challenging of Denise’s script, an attentiveness to how it might be manifesting in the therapy and avoidance of reinforcing script had also been a significant factor

22. Denise- Moderator factors • Denise’s sense of hopefulness at the outset of therapy • Informed decision in choosing the right therapist • Well-motivated with clear goals for the therapy and a degree of insight from the outset • Courageousness and willingness to address difficult and painful material (e.g. sexual abuse) and her continued attempts to integrate the insights gained in therapy into her everyday life

23. Case 3: ‘Tom’ • 38 year-old, white, Male builder with comorbid moderate depression and social anxiety • Harsh parenting which had left him feeling ‘stupid’ and ‘useless’ and strong self-critical process • Very interested in TA- had read several books and active in use of TA-based self-help strategies

24. Tom • Moderate depression and mild functional impairment • Clinically significant change on all measures by session 8 • Maintained at 3 month, some decline at 6 month follow up • Identified eight ‘extremely important’ changes, unlikely without therapy

25. Tom- Judges’ verdicts • Majority verdict that this was a good outcome case (two clearly good outcome, one mixed outcome) • Majority verdict that Tom had changed substantially and that these changes had substantially been due to therapy

26. Tom- Mediator factors • An empathic, non-judgmental, highly active therapist approach had been important • Use of two-chair methods was pivotal in this case and helped Tom overcome his self-critical process, express emotions and see things from a different perspective • Practical strategies for improving communication were helpful • Use of TA concepts helped Tom to conceptualise his process

27. Tom- Moderator factors • Tom’s pre-therapy reading had been helpful and enabled him to make the most of the therapy • Tom’s motivation and readiness to change had been helpful factors • Tom’s determination and willingness to engage with painful emotions and experiences and actively make use of the therapy were also helpful

28. The next two cases • One mixed outcome case ‘Linda’- HSCED • One poor outcome case: ‘Kerry’ -No HSCED • Despite these outcomes the clients reported that the therapy had been helpful • All cases compared using ‘constant comparison’ (Grounded Theory) method and inductively analysed for cross-case analysis. • Inductively-derived findings generated abductively-derived theory (theory-building)

29. Cross-Case Analysis- A taster of the results • Learning relevant TA theory to understand and conceptualise one’s own process is helpful to clients • Strong and prolonged focus on improving communication and interpersonal relationships is beneficial to outcome • Negotiation and agreement of contract goals by session 3 is beneficial to outcome. Clear agreement of goals is essential to positive outcome

30. Cross-Case Analysis continued • Therapy is more effective when it is consistently based on a clear case formulation and treatment plan • Active and deliberate choice of therapist and positive expectations for therapy beneficially influence outcome

31. Conclusions • Using criteria defined by Chambless and Hollon (1998) TA therapy is Possibly Efficacious for the treatment of depression • TA now meets basic criteria for consideration for ‘Empirically Supported Therapy’ status • TA therapy is a unique and distinctive approach to therapy characterised by an active therapist style