THE FUTURE OF PSYCHOTHERAPY IN THE UK: DISCUSSING CLINICAL GOVERNANCE

ABSTRACT 'Clinical governance' is a term coined to denote a requirement that all forms of clinical care should be governed by an attention to the quality of its delivery to the public. Clinical governance has been set as the future for the NHS by the NHS Executive. This paper draws together some of the themes of current discussions concerning clinical governance and other related issues for psychotherapy. Clinical governance has many facets but it can be defined as a commitment to evidence-based quality assurance in relation to clear national standards for practice, the delivery of evidence-based practice and the ongoing monitoring of standards. The paper provides a brief outline of clinical governance and indicates how it might be accomplished within primary and secondary care. A sketch is made concerning the possibility of there being local and national standards for various aspects of psychotherapy provision which is an additional requirement. The term'psychotherapy' is used to cover the full range of psychological interventions. Towards the end of the paper a critical overview of the standard paradigm of quantitative research is presented. This critical stance has been provided by two leading quantitative researchers who have called into question the applicability of the drug trial model for testing efficacy and finding the change-active ingredients of psychotherapy.     

Introduction to the special issue on the placebo concept in psychotherapy

As research on the effectiveness of psychotherapy has flourished over the past two decades, scholars have increasingly borrowed various research strategies, including the placebo concept, from medicine. The recent movement toward evidence-based treatment in mental health has also highlighted psychological placebos as control conditions against which to define empirically supported psychotherapies. Nevertheless, the application of the placebo concept to psychotherapy is fraught with both conceptual and pragmatic problems. This special issue brings together leading psychotherapy scholars to explore the concept of the placebo to psychotherapy. Historical, theoretical, ethical, and practical issues are discussed from various perspectives, and recommendations are offered to guide future research.     

What should we expect from psychotherapy?

In addressing the very general question of what we should expect from psychotherapy, this article begins by discussing what constitutes relevant evidence on which to base the efficacy and effectiveness of psychotherapy. In this context, an important distinction is made between empirically supported treatments and evidence-based practice. Although there is evidence that psychotherapy does indeed work, there are also findings that there are times when our patients are harmed by our interventions. It is noted that the therapeutic alliance plays an extremely important role in the change process, and that ruptures in the alliance can contribute to our therapeutic failures. In pointing to directions for the future, modifications of how we investigate the outcome of treatment, as well as how to close the gap between research and practice, are offered.     

Introduction: The future of psychotherapy training: psychodynamic, experiential, and eclectic perspectives.

What does the future hold with regard to psychotherapy training? We posed that question to experts representing three important therapeutic approaches: Psychodynamic, Experiential, and Eclectic. In what follows we introduce this special section, provide our rationale for putting it together, and briefly highlight some interesting, substantive points made in the subsequent papers.     

Social relationships and social roles

This review draws attention to the broad and diverse theoretical underpinnings of interpersonal psychotherapy (IPT). A plea is made for greater attention to the theoretical influences on IPT in forming our understanding of the techniques and processes and to establish indicators of successful outcome as well as for whom the treatment is most suitable. The paper takes a lifespan perspective that considers the implications of social factors for the different age groups to which IPT has been shown to be effective in the treatment of depression. The main thrust of the paper considers the potential importance of social theory, particularly the research on life events and social support. It is argued that it is these social aspects and particularly a focus on the use of the patient's wider social network that distinguishes IPT from other evidence-based short-term therapies. KEY PRACTITIONER MESSAGE: Interpersonal psychotherapy draws on a broad and diverse range of theoretical influences. The study of the theory underpinning IPT can inform assessment, technique and process in the practice of IPT. Knowledge of aspects of the research on life events and social support is particularly relevant not only for the assessment phase but also for the middle and termination phases. Attention to the theory behind IPT can usefully inform future research on IPT particularly what may determine successful or unsuccessful outcome of this short-term treatment.     

A review of individual psychotherapy outcomes for adult survivors of childhood sexual abuse

This review examines the current literature on individual psychotherapy outcomes with adult survivors of childhood sexual abuse. As compared to the literature on treatment with victims of sexual trauma in adulthood, fewer researchers have explored the field of psychotherapy outcome with this population, particularly with regard to individual treatments. For this reason, a review of psychotherapy outcome for adult survivors of child sexual abuse is needed. This review first presents issues salient to the study of treatment with this population, such as prevalence, short-term impact, and long-term sequelae of childhood sexual trauma. Next, the eight studies that have been published on individual psychotherapy for this population are presented and evaluated according to both efficacy and effectiveness criteria for a methodologically sound study. Last, directions for future research with this population include continued integration of efficacy and effectiveness methodology, use of multi-method/multi-rater assessment data, as well as further investigation of interpersonal variables such as the therapeutic alliance.     

Integrating information technology into the evidence-based practice of psychology

Information technology (IT) is increasingly being used to facilitate, complement, and support the implementation of evidence-based practices (EBP) in psychology. This article reviews recent randomised trials that evaluate the integration of IT applications into the process of delivering EBP. More specifically, we review 11 studies that illustrate how IT has been successfully integrated into traditional clinician-delivered psychotherapy to promote the adoption of EBP. Advantages and disadvantages of this approach are discussed. The paper concludes with practical recommendations for clinicians who are interested in integrating IT into their practice.     

A review of empirical research supporting four conceptual uses of dreams in psychotherapy

The present review consists of a re-conceptualization of the existing empirical literature regarding the use of dreams in psychotherapy into four potential contributions. These four contributions of dreams to psychotherapy are discussed as being particularly relevant for clinicians in applied practice to (I) facilitate the therapeutic process, (II) facilitate patient insight and self-awareness, (III) provide clinically relevant and valuable information to therapists and (IV) provide a measure of therapeutic change. The present review is distinctive in that it emphasizes the pertinence of research regarding dream use to applied clinical practice and it includes previously unreviewed research regarding dreams in psychotherapy on these four specific ways dreams can be useful within the therapeutic process. In addition, this review includes a section discussing the under-researched and largely neglected potential for dreams to provide accurate and efficient information to therapists. Limitations of the research as well as future directions are presented. The generally positive findings of this research suggest that dreams can be considered an alternative type of clinical material that can be useful in psychotherapy. Copyright © 2005 John Wiley & Sons, Ltd.     

What works for whom: Tailoring psychotherapy to the person

This article introduces the issue of the Journal of Clinical Psychology: In Session devoted to evidence-based means of adapting psychotherapy to the patient's (transdiagnostic) characteristics. Practitioners have long realized that treatment should be tailored to the individuality of the patient and the singularity of his or her context, but only recently has sufficient empirical research emerged to reliably guide practice. This article reviews the work of an interdivisional task force and its dual aims of identifying elements of effective therapy relationships (what works in general) and identifying effective methods of adapting treatment to the individual patient (what works in particular). The task force judged four patient characteristics (reactance/resistance, preferences, culture, religion/spirituality) to be demonstrably effective in adapting psychotherapy and another two (stages of change, coping style) as probably effective. Two more patient facets (expectations, attachment style) were related to psychotherapy outcome but possessed insufficient research as a means of adaptation. This special issue provides research-supported methods of individualizing psychotherapy to the person, in addition to his or her diagnosis.     

Psychoanalytic Psychotherapy in Contemporary Mental Health Services: Current Evidence,Future Role and Challenges

Three interacting challenges are facing all aspects of health care in the United Kingdom: financial restraint in the context of a global economic downturn; a move to services being commissioned and decommissioned by primary care Clinical Commissioning Groups; and a need to provide evidence based practice through ‘payment by results’. Psychoanalytic psychotherapy faces more difficulty than most services in mental health, with long and frequent criticisms of it being expensive and under‐researched; and it is not as well understood by GPs as cognitive behavioural therapy, with which it is frequently unfavourably compared. This review provides an overview of the existing evidence for psychoanalytic psychotherapy, identifying strengths and areas that are under explored. We also argue that psychoanalytic psychotherapy has a unique clinical role but this will need to be clearly stated in the future, and promoted by clinicians to encourage future commissioning in the UK.     

Moving from empirically supported treatment lists to practice guidelines in psychotherapy: the role of the placebo concept

The use of placebos is the "gold standard" in studies of investigational drugs, and of other medical procedures as well. Several recent trends have suggested the use of placebos in studies of psychotherapy to isolate effective treatment components, and as a basis for establishing lists of empirically supported treatments. Unlike within the domain of medicine, in which the logic of placebos is relatively straightforward, the concept of placebo as applied to psychotherapy is fraught with both conceptual and practical problems. The evidence-based practice of psychotherapy can best be promoted through the development of practice guidelines, for which psychotherapy placebos are unnecessary. Moreover, even if problems associated with psychological placebos could be overcome, they are not necessary in psychotherapy research.     

Client-centered therapy: where has it been and where is it going? A comment on Hathaway (1948)

We review the article by Hathaway (1948) critiquing nondirective therapy. We summarize Hathaway's concerns about nondirective therapy and psychotherapy research in general and consider the historical context of the article. Then we discuss progress on methodological concerns raised by Hathaway, empirical evidence obtained in the last 50 years about the efficacy of client-centered therapy and other kinds of psychotherapy, the current status of client-centered therapy, and projections for the future.     

Reflecting on homework in psychotherapy: What can we conclude from research and experience?

This article examines the empirical basis of using homework in psychotherapy and then offers a synthesis of the research literature with the preceding clinical articles. We provide a practitioner-friendly review of psychotherapy process and outcome research literature, concluding that there is now sufficient evidence to support the assertion that homework assignments enhance psychotherapy outcomes. It is also clear that homework compliance is a consistently significant predictor of treatment outcome. Limitations of existing studies and future research directions are outlined, and we suggest that more specific questions are required regarding the integration of homework into therapy process. Clinical recommendations and issues in homework administration described in preceding articles are also synthesized. The research evidence and contributors to this issue converge in recommending homework within the broad context of psychotherapy and using creative ways of administering homework that is customized to the client.     

Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression

Depression in youth is prevalent and disabling and tends to presage a chronic and recurrent course of illness and impairment in adulthood. Clinical trial research in youth depression has a 30-year history, and evidence-based treatment reviews appeared in 1998 and 2008. The current review of 42 randomized controlled trials (RCTs) updates these reviews to include RCTs published between 2008 and 2014 (N = 14) and reevaluates previously reviewed literature. Given the growing maturity of the field, this review utilized a stringent set of methodological criteria for trial inclusion, most notable for excluding trials based in subclinical samples of youth that had been included in previous reviews (N = 12) and including well-designed RCTs with null and negative findings (N = 8). Findings from the current review suggest that evidence for child treatments is notably weaker than for adolescent interventions, with no child treatments achieving well-established status and the evidentiary basis of treatments downgraded from previous reports. Cognitive behavioral therapy (CBT) for clinically depressed children appears to be possibly efficacious, with mixed findings across trials. For depressed adolescents, both CBT and interpersonal psychotherapy are well-established interventions, with evidence of efficacy in multiple trials by independent investigative teams. This positive conclusion is tempered by the small size of the interpersonal psychotherapy literature (N = 6) and concern that CBT effects may be attenuated in clinically complicated samples and when compared against active control conditions. Data on predictors, moderators, and mediators are examined and priorities for future research discussed.     

Stages of change

The transtheoretical model, in general, and the stages of change, in particular, have proven useful in adapting or tailoring treatment to the individual. We define the stages and processes of change and then review previous meta-analyses on their interrelationship. We report an original meta-analysis of 39 studies, encompassing 8,238 psychotherapy patients, to assess the ability of stages of change and related readiness measures to predict psychotherapy outcomes. Clinically significant effect sizes were found for the association between stage of change and psychotherapy outcomes (d = .46); the amount of progress clients make during treatment tends to be a function of their pretreatment stage of change. We examine potential moderators in effect size by study outcome, patient characteristics, treatment features, and diagnosis. We also review the large volume of behavioral health research, but scant psychotherapy research, that demonstrates the efficacy of matching treatment to the patient's stage of change. Limitations of the extant research are noted, and practice recommendations are advanced.     

Object relations theory and short-term dynamic psychotherapy: findings from the Quality of Object Relations Scale.

This review focuses on the relevance of object relations theory to short-term dynamic psychotherapy (STDP). From diverse theoretical and research literatures, a small number of core theoretical concepts and assessment dimensions are identified. Specific assessment methods are also highlighted. Research evidence concerning a particular object relations concept (quality of object relations) and a corresponding interview scale (Quality of Object Relations Scale) that has emerged from a series of psychotherapy clinical trials is presented in support of the relevance of object relations theory to STDP. Clinical implications and future research directions are considered.     

Overcoming our resistances to "doing" evidence-based group practice: a commentary

This commentary focuses on how the articles in the group therapy issue of the Journal of Clinical Psychology: In Session can address the resistances that many group practitioners exhibit to "doing" evidence-based practice (EBP). The articles attempt to overcome the resistances to practicing evidence-based group therapy through a process of education and skills training. A major issue cutting across the articles is the narrow focus of incorporating empirical findings only from studies specifically examining psychotherapy groups. The author argues that incorporating research from the whole field of group dynamics research can increase the empirical basis for evidence-based practice.     

The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations

Evidence-based treatments (EBT) are underutilized in community settings, where consumers are often seen for treatment. Underutilization of EBTs may be related to a lack of empirically informed and supported training strategies. The goals of this review are to understand the state of the literature for training therapists in psychotherapy skills and to offer recommendations to improve research in this area. Results of this review of 55 studies evaluating six training methods indicate that multi-component trainings have been studied most often and have most consistently demonstrated positive training outcomes relative to other training methods. Studies evaluating utility of reading, self-directed trainings, and workshops have documented that these methods do not routinely produce positive outcomes. Workshop follow-ups help to sustain outcomes. Little is known about the impact of train-the-trainer methods. Methodological flaws and factors that may influence training outcome and future directions are also reviewed.     

The Current Situation of Treatment Systems for Alcoholism in Korea

Alcoholism is becoming one of the most serious issues in Korea. The purpose of this review article was to understand the present status of the treatment system for alcoholism in Korea compared to the United States and to suggest its developmental direction in Korea. Current modalities of alcoholism treatment in Korea including withdrawal treatment, pharmacotherapy, and psychosocial treatment are available according to Korean evidence-based treatment guidelines. Benzodiazepines and supportive care including vitamin and nutritional support are mainly used to treat alcohol withdrawal in Korea. Naltrexone and acamprosate are the drugs of first choice to treat chronic alcoholism. Psychosocial treatment methods such as individual psychotherapy, group psychotherapy, family therapy, cognitive behavior therapy, cue exposure therapy, 12-step facilitation therapy, self-help group therapy, and community-based treatment have been carried out to treat chronic alcoholism in Korea. However, current alcohol treatment system in Korea is not integrative compared to that in the United States. To establish the treatment system, it is important to set up an independent governmental administration on alcohol abuse, to secure experts on alcoholism, and to conduct outpatient alcoholism treatment programs and facilities in an open system including some form of continuing care.