Comparative Naturalistic Study on Outpatient Psychotherapeutic Treatments Including Gestalt Therapy

Comparative Naturalistic study on outpatient psychotherapeutic treatments including Gestalt therapy

Presentor:Peter Schulthess Co-authors: Volker Tschuschke, Margit Koemeda-Lutz, Agnes von Wyl, Aureliano Crameri

Introduction

• The Swiss Charter for Psychotherapy • Scientific declaration: Members obligation to do research • PAP-S: Process-outcome study in naturalistic design: Co-created with scientific Committee of Charta, delegates of member institutes, University of Cologne and School for Applied Psychology Zurich (University for Applied Science, Zurich)

2 The PAP-S Study - Investigated Treatment Concepts

Therapy Concepts Label / Author Abbreviation Analytical Psychology SGAP C.G. Jung Art and Expression Oriented Therapy ISIS P.J. Knill Bioenergetic Therapy SGBAT A. Lowen Client-Centered Therapy CCT C. Rogers Gestalt Therapy SVG F. Perls Integrative Body Therapy IBP J.L. Rosenberg Logotherapy and Existential Analysis ILE V. Frankl Personal Existential Analysis IGEAP A. Längle Psychoanalysis Psa S. Freud Process Oriented Therapy FG-POP A. Mindell Transaction Analysis SGTA E. Berne

psychodynamic body-oriented humanistic

3 Participants of the PAP-S Study

Participating psychotherapy schools No of No of therapists patients Transactional Analysis 14 63 Process-Oriented Psychology (A. Mindell) 10 61 Integrative Body Psychotherapy (J.L. Rosenberg) 20 83 Existential-Analytical Psychotherapy (A. Längle) 6 19 Logotherapy and Existential Analysis 2 13 Expressive Arts Therapy 3 16 Psychoanalysis (S. Freud) 2 10 Analytical Psychology (C.G. Jung) 6 13 Bioenergetic Analysis and Therapy (A. Lowen) 14 49 Gestalt Therapy 9 35 Total 81 362

4 Design

Design

Naturalistic (effectiveness) study

5 Outcome measurment I

Selfrating by the patient

• OQ-45* (Outcome Questionnaire; Lambert et al, 1996; Lambert et al, 2002): This scale measures essential parts of psychotherapeutic changes as amount and intensity of symptoms, interpersonel relations and social integration. The questionnaire is constructed for outcome measurement, but also for changes during the proces of therapy and allows statements about time-dosage-effect relations according to the phase modell of Howard et al. (1993) (Effort: 5 Min.). • BSI* (Brief Symptom Inventory; Franke, 2000): Questonaire to rate subjectiv experienced handicaps because of physical and psychic symptoms on 9 skales: somatisation, compulsivity, unsecurity in social contacting, depressivity, anxiety, aggressivity, phobic fear, paranoid thinking and psychoticism (Effort: 12-15 Min.).

6 • BDI-II (Beck Depression Inventory; Beck et al, 2006): Questinnaire to measure affective, cognitive, motivational, somatic and behavioural components of depression. (Effort: 10 Min.).

• SOC-9 (Sense of Coherence; Antonovsky, 1987): Selfconfidence and confidence to the environment. (Effort 5 Min.).

• K-INK (Inkongruenzfragebogen Kurzversion; Grosse-Holtforth & Grawe, 2003): Motivational inkongruency according to Grawe’s consistence- theory is regarded as unsufficiant reaching of aims in interaction with the environment. (Effort: 5 Min.).

• FMP (Fragebogen zur Messung der Psychotherapiemotivation; Schneider et al., 1989): This questionnaire asks for 4 aspects of therapymotivation: intensity of suffering, expectations on treatment, attitude towards psychotherapy and initiative (Effort: 10 Min).

7 Outcome measurement II External rating by independent assessor

• SKID-I und -II* (Strukturiertes Klinisches Interview für DSM-IV; Wittchen et al., 1997): Interview to clarify Diagnosis for psychic disturbances according to DSM IV (Effort SKID-I 70 min.; SKID-II about 35 min. )

• GAF * (Global Assessment of Functioning; Sass et al., 2003): Skale with a 100-points-continuum to estimate psychic, social and professional capacity of patient.

• GARF * (Global Assessment of Relational Functionning; Sass et al., 2003; Endicott et al., 1976): Variation of GAF-skale, to rate the niveau of functionning in relation in family and partnership towards affektive and lifepractical aspects.

• OPD-2 (Operationalisierte Psychodynamische Diagnostik; Arbeitskreis OPD, 2006) Achse 3 und 4: Guided Interview to rate unconcious types of conflicts and dimension of structural disturbance (Effort: 60 Min.)

8 Other documentations

• Basic documentation about patient, entrance and exit: General informations about patient as age, profession, capability to work, medications, who pays therapy, prior psychotherapeutic treatments a.s.o.. Registration in the basic documentation will be done once at the beginning and once at the end of the therapy by the therapist.

• Basic documentation about therapist: General informations about therapist as professional education(s), professional experience a.s.o.

9 Process measurement Selfrating by the patient • patients-questionnary after every 5th session, minimal version (Grawe & Braun, 1994) and HAQ-S * (Helping Alliance Questionnaire; Bassler et al., 1995): Both questionnaires ask for aspects as satisfaction in therapeutic relation, widening perspectives, intensity of working on problems, positive and negative emotions during session (effort 5 min.)

external rating by the therapist • List of sessions: Each date of session is registered. • HAQ-F, every 5th session (Gross und Riedel, 1995): Therapist-version of HAQ-S. • Interventionslist after each session: A set of approach-specific interventions and general interventions in form of rating skale. Elaborated in cooperation with the participating institutes or organisations of professionals. There is a manual with definitions and examples for these interventions. The therapist estimates after each session her/his interventions with this skale. Tapes of three randomised selected sessions will be rated from external raters that do not know, what aproach the therapist was practicing.

10 Rating Manual

• 100 Interventions described for external rater to identify blindly the therapists interventions from audiotyped sessions. • 20 general interventions • 8-10 modality specific interventions per represented modality

11 Rating Manual - Example: Category 60 60. Confrontation (Psychoanalysis) DEFINITION:

Therapist confronts (directively) patient with recurring (stereotyped) dysfunctional patterns in relationships or with - presumably neurotic - behavioral inconsistencies.

OPERATIONAL:

Therapist • addresses patient’s behavioral inconsistencies • addresses recurrent problems in patient’s relationships • points out instances of incongruence on different levels of expression

DISCRIMINATION:

. 1 (Confronting defense or resistance): Therapist addresses distorted perceptions (defense) and specimen of resistance . 27 (Interpretation): Making a connection / pointing out a relationship between previously unconscious aspects . 30 (Insight towards to be changed behavior): Motivation for gaining insight . 51 (Fostering the process of individuation): Therapist addresses discrepancies or disruptions between desires and reality, not in a confronting way . 55 (Clarifying): Therapist stays on a factual level, inquires, without drawing conclusions

EXAMPLES:

• Th: „You seem to repeatedly slither into such situations.“ • Th: „This is something, you experience quite often, don’t you.“ • Th: „This doesn’t fit with what you said before at all!“ • Th: „You seem to be more popular than you believe you are.“ • Th: „Every time someone approaches you, you pretend being in a hurry. Acting like this will prevent you from ever getting closer to anyone!” 12 Exampel of modality specif interventions: Gestalt therapy

13 Effectiveness Results over all therapists and modalities

The Importance of Psychotherapists with Regard to Treatment Outcome

14 Assignment of therapists to effectiveness clusters

• all pre- and post-scores of the four outcome measures were transformed into T-scores (multiple outcome criteria): • Brief Symptom Inventory (BSI) • Outcome Questionnaire-45 (OQ-45.2) • Beck Depression Inventory-II (BDI-II) • Global Assessment Functioning Scale (GAF) • sum of T-scores at post-measurement was subtracted from sum of T-scores at pre- measurement • the change scores were then factor analyzed: • a one factor-solution with an Eigenvalue of 2.699 resulted • each of the 237 therapies resulted in a factor score • factor scores of all patients from the same therapist were averaged resulting in 68 scores (68 therapists) • these 68 factor scores were then cluster analyzed (hierarchical cluster analysis) • a 3-cluster solution emerged • 13 very successful therapists (group A) • 33 moderately successful therapists (group B) • 22 least successful therapists (group C) • boxplots of the 237 cases grouped by therapists‘ effectiveness (N = 68 therapists)

15 Boxplots of the three differently effective clusters of therapists

16 3 differently effective groups of therapists

• 44 cases of 13 group A therapists‘ (very successful)

• 132 cases of 33 group B therapists (moderately successful)

• 61 cases of 22 group C therapists‘ (least successful)

17 Outcome of the 3 groups in outcome measures

A, B, and C therapies and response status (in percent) 18 1st Conclusions

• there are clearly differently effective psychotherapists. More effective therapists have • higher response rates • less dropout rates

• but no therapist is successful throughout all his cases and no therapist is unsuccessful at all

• approximately two thirds of group A therapist patients have a chance to be clinically significantly changed

• approximately one third of group C therapist patients have a chance to benefit clinically significantly from the treatment

• thus, approx. 33% of group A therapists patients may not benefit and approx. 33% of group C therapists may benefit significantly

19 Pretreatment scores in outcome measures of A, B, and C therapy patients

Measure N Mean SE F p pairwise comparisons p* BSI-GSI A therapies 13 1.15 .41 A B .002 B therapies 33 .76 .28 9.445 .000 A C .000 C therapies 22 .67 .35 B C .607 OQ-45-2 A therapies 13 77.66 18.12 A B .004 B therapies 33 60.12 11.81 9.220 .000 A C .000 C therapies 22 54.93 18.41 B C .479 GAF A therapies 13 58.45 9.55 A B .111 B therapies 33 65.10 7.84 2.402 .099 A C .205 C therapies 22 64.44 11.59 B C .969 BDI-II A therapies 13 21.19 7.87 A B .007 B therapies 33 13.69 5.25 7.920 .001 A C .001 C therapies 22 11.69 8.62 B C .584 Severity of psychological problems (T-scores) at entrance A therapies 13 216.71 19.87 A B .006 B therapies 33 197.99 13.57 9.262 .000 A C .000 C therapies 22 191.27 19.96 B C .367 20 2nd Conclusions

• patients seen by group A therapists had more severely psychological burden prior to treatment than B and C group patients – but not B therapists‘ patients compared to C therapists‘ patients

• this result may suggest that patients‘ severity of psychological problems was critical for the differences in therapists‘ effectiveness

21 Univariate Analysis of Variance

Tests of Between-Subjects Effects

Type III df Mean F p Partial Eta Source Sum of Squares Square Squared

Cor rected M odel 52737.111a 10 5273.711 10.882 .000 .660 Intercept 79.194 1 79.194 .163 .688 .003 Main Orientation (Approach) 547.426 3 182.475 .377 .770 .020 Therapist-Effectiveness- 5908.090 2 2954.045 6.096 .004** .179 Grouping Professional Experience .114 1 .114 .000 .998 .000 Therapeutic Alliance 183.151 1 183.151 .378 .541 .007 Severity of Psychologi cal 9266.096 1 9266.096 19.121 .000**** .255 Problems Therapist Effectiveness- 8171.621 1 4085.810 8.431 .001*** .231 Group * Severity of Psychologi cal Problems Error 27137.959 56 484.606 Total 2773528.750 67 Cor rected Total 79875.070 66 Table 12: Dependent Variable: Treatment Outcome (Univariate Variance Analysis) a R Squared = .660 (Adjusted R Squared = .600) ** p < .01 *** p < .001 **** p < .000 22 3rd Conclusions

• both variables – therapists‘ effectiveness and patients‘ severity of psychological problems at treatment entrance – predict independently treatment outcome • patients‘ severity of psychological problems explains approx. 25.5% of the outcome variance • therapists‘ effectiveness explains approx. 18% of the outcome variance • the interaction between both variables explains approx. 23% of the outcome variance

• thus, one can resume that – although both variables are statistically independent from each other – that an interaction effect between both variables explains more of the outcome variance than therapists‘ effectiveness alone

• quality of treatment alliance as well as professional experience of therapists‘ did not play a significant role with regard to treatment outcome

23 Clinical Implications

• there are differently effective psychotherapists

• psychotherapists‘ effectiveness is not due to their theoretical orientation or their school affiliation

• therapists‘ effectiveness cannot be sufficiently explained by the degree of their professional experience

• also therapists‘ degree of treatment adherence did not play an important role as we have shown in another paper (Tschuschke et al., 2014)

• other factors such as therapists‘ competence may account for the difference between psychotherapists‘ effectiveness (this will be one of our next steps in our project)

• patients with more severe psychological problems (with a higher psychological strain) have a better prognosis to benefit from psychotherapy

• patients with more severe psychological problems have a better prognosis if treated by more effective psychotherapists – no matter what their diagnoses may be

24 Treatment Adherence and Outcome over all therapists and modalities

25 Random Selection of Sessions for Objective Ratings

Session 7 Session 19 Session 34

Session-No. 5 10 15 20 25 30 35 ..… n

OQ-45 OQ-45 OQ-45 OQ-45 OQ-45 OQ-45 OQ-45 OQ-45 HAQ HAQ HAQ HAQ HAQ HAQ HAQ HAQ

26 Interrater-Reliabilities

Intraclass Correlation Coefficient (< 0.01) bottom limit ceiling limit

.81 .72 .87

27 Modality specific interventions (%)

20 18 16 14 12 10 specific 8 6 4 2 0 SGTA FG-POP ISIS SGBAT SVG IGEAP Psa + IBP SGAP

6 x 3 7 x 3 6 x 3 8 7 4 x 3 4 x 3 12 2 x 1 2 x 5 1 x 2 4 x 3 5 x 3 11 x 3 2 x 5 54 therapies 165 sessions 28 Therapeutic Interventions

40 specific 30 nonspecific other concept 20

0 SGTA FG-POP ISIS SGBAT SVG IGEAP Psa + IBP SGAP

SGTA Transactional Analysis SGBAT Bioenergetic Therapy FG-POP Process Oriented Therapy ISIS Art and Expression Oriented Therapy IGEAP Personal Existential Analysis IBP Integrated Body Therapy SVG Gestalt Therapy Psa + SGAP Psychoanalysis and Analytical Psychology 29

Interventions from Other Concepts (Percentage of total other concept interventions, percentage of most preferred other concept, and mostly used other concept intervention category) Process IBP Logother Expressi Psa Jung Bioenerg Gestalt TA oriented apie ve Arts etic Therapy Therapy

32,7 28,9 23,7 30,9 14,1 30,3 22,1 31,3

1. CCT 16,0 1. Psa 26,9 1. CCT 50,8 1. Psa 35,1 1. CCT 46,7 1. Psa 46,4 1. Psa 40,6 1. Psa 31,5

Verbalization Interpretation Verbalization Confrontation Verbalization Interpretation Confrontation Confrontation of emotional of emotional of emotional experience experience experience 2. Psa 14,6 2. CCT 15,1 2. Psa 33,8 2. 2. SGAP 20,0 2. CCT 19,1 2. CCT 25,2 2. Systemic 14,9 Systemic 19,1 Interpretation Verbalization Interpretation Working with Verbalization Verbalization Reframing of emotional Metaphor complex of emotional of emotional experience work episodes experience experience

2. SGBAT 14,6 3. SGAP 11,7 3. SGAP 4,6 3. 3. SVG 17,8 3. 3. 3. ILE 13,1 Behavior Systemic 14,8 Systemic 11,4 Focussing on Imagination Search for Therapy 12,0 Focussing on Reframing body impulses sense and actual emotion Metaphor Reframing meaning Reinforcement work

30 Treatment Specifity and OQ-45-total Scores

40 Session 5 Last Session 30

0 unspecific treatments moderately unspecific relative specific treatments treatments

10 mild 5 mild 1 mild 5 moderately 4 moderately 3 moderately 15 severely distressed patients 7 severely distressed patients 7 severely distressed patients Th exp: 12.7 yrs. Th. exp 12.0 yrs. Th. Exp. 6.8 yrs. 31 Conclusions

• Across modalities we identified and operationalized a wide variety of intervention categories. They range from “intitiative towards behavioural interaction” to “recommending imaginative work”, from “direct assignment” to “free floating attention”. • There is a spectrum of overlapping categories: “Nonspecific” or „essential but not unique“. Therapists predominantly work with these (50% - 70%). • „Essential and unique“ interventions across all modalities amount to less than 20%. • Techniques from other concepts are being used to an approximate extent of 10% - 35%. • Most of these latter intervention techniques („other concepts“) come from Psychoanalysis and Client-Centered Therapy. • However, treatments are successful on average. • No correlation between treatment adherence and outcome could be found. • Thus, it can be speculated that the outcome equivalence paradox in psychotherapy is due to the relatively high proportion of unspecific interventions which are seemingly shared by all psychotherapists. • So far we find a trend that intervention specificity seems to be higher (> 30%) with less experienced therapists, and only moderate (10% - 30%) with more experienced therapists. • Further data analysis may reveal if specific disorders, the severity of patients‘ distress, additional therapist variables or certain phases of therapy are related to high versus low intervention specificity. Results of Gestalttherapists

• 7 therapists (5 female, 2 male) • 23 therapies (1-7 per therapist) • Average age: 49.3 (35-65) • Average prof. experience: 11 years (2-32)

33 Patients

Therapist Diagnosis Severity-Cluster Outcome-Cluster 1 2 3 4 1 2 3 1 2 3 1 5 1 1 - - 3 4 2 5 - 2 1 - 2 2 3 2 - - 2 3 3 1 - - - 1 1 - - 1 1 4 3 - 1 1 - 3 2 2 1 2 5 - 1 1 - 1 1 - - 2 - 6 - 1 - - 1 - - - 1 - 7 1 - - - 1 - - - 1 - Summ 11 3 5 3 7 10 6 4 13 6

Diagnosis Severity-Cluster Outcome-Cluster 1 = F3 1 = low 1 = very good 2 = F4 2 = middle 2 = rel. good 3 = mixed depr/anxiety 3 = high 3 = no change or 4 = F 6 negative 34

Differenz-Effektstärke: -.06 35

Differenz-Effektstärke: .17 36 Differenz-Effektstärke: .12 37 Differenz-Effektstärke: .01 38 MWEffektstärke = .75

39 MWEffektstärke = 1.57 40 MWEffektstärke = .33 41 Conclusions

• The effects over all diagnosis groups are quite good and comparable with the other investigated modalities and other reported results in international literature. • The effects in group F 3 (affective disturbances) are highly signifcant high, specially for patients suffering on depressions. Depressive patients seem to benefit highly from Gestalt therapy, better then from any other investigated modality and reported in international literature. • Depressed patients showed at begin of the therapy a higher severity of psychological problems, which makes these results even more important. • The effects in other disturbances (F4, F 6) are much lower, on middle effect size (Score .33) and lower then in other modalities and research projects. • The results can not be generalized, because the sample of therapists and patients was statistically not really big.

42 Provisional coherences (Basis: n = 83 evaluated treatments)

Stay with Less amount of experienced modality therapists specific intervent. Higher severity of psychol. problems at begin of therapy

Reduce More amount of experienced modality therapists specific intervent.

43 PATIENT THERAPIST

Difficult lower relation specifity Better outcome result

good higher relation specifity

Difficult higher relation specifity Lower outcome result Lower Good relation secifity

44 Last remarks

• There is more research needed, especially für Gestalttherapy • We did not succeed in motivating enough Gestalt colleagues to participate in this project • A naturalistic design for outcome-process studies is a more adequate design then RCT designs • We will publish in the near future in several journals results to different aspects • There will also be case studies on longitudinal process over whole therapies based on tape recorded sessions

45 Thank You for Your interest

For further informations:

• See our website: www.psychotherapieforschung.ch

• Contact: Peter Schulthess [email protected]