What is the secret of effective psychotherapists? The evaluation of reflective services.

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

2. 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. Conrad Lecomte

3. Problems evaluating our services • To measure and demonstrate the effectiveness of our interventions: a necessity. • Practices: • From research to practice • Meta-analysis • Evidence from RCTs • From practice to research and back to practice • Battery of common measures • Integrating measurement in daily practice Conrad Lecomte

4. 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? Conrad Lecomte

5. Realities 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 Conrad Lecomte

6. Interactive Regulation Situation Clinical expertise Problems CLIENT Subjectivity Therapist Subjectivity Organization and self-regulation Organization and self-regulation Interventions Severity of the problem; Duration; Social support; Expectations; Co-morbidity Evidence from the data Conrad Lecomte

7. 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 Conrad Lecomte

8. 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) Conrad Lecomte

9. Therapist : 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) Conrad Lecomte

10. Therapists : 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- Conrad Lecomte

11. 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 Conrad Lecomte

12. 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 Conrad Lecomte

13. 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 Conrad Lecomte

14. 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 Conrad Lecomte

15. 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% Conrad Lecomte

16. 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. Conrad Lecomte

17. 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 Conrad Lecomte

18. 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 Conrad Lecomte

19. 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 Conrad Lecomte

20. 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? Conrad Lecomte

21. Issues to consider : effective therapists 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 Conrad Lecomte

22. 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% Conrad Lecomte

23. 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 Conrad Lecomte

24. 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? Conrad Lecomte

25. 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? Conrad Lecomte

26. Reflective 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 Conrad Lecomte

27. Reflective 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 : Conrad Lecomte

28. 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) Conrad Lecomte

29. 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… Conrad Lecomte

30. Examples of measures for severe mental disorders Conrad Lecomte

31. 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) … Conrad Lecomte

32. 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 Conrad Lecomte

33. Reflective 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 Conrad Lecomte

34. Reflective 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 feedback • To improve the quality, efficiency, and effectiveness of the services being offered Conrad Lecomte

35. What does the therapist in trouble seek? • 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 Conrad Lecomte

36. 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) Conrad Lecomte

37. Additional information Conrad.Lecomte@UMontreal.ca Conrad Lecomte

38. A 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 Conrad Lecomte 38