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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 1

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Page 1: Comparative Naturalistic study on outpatient ... · outpatient psychotherapeutic treatments including Gestalt therapy ... Gestalt Therapy SVG F. Perls ... Transactional Analysis 14

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

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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)

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Therapy Concepts Label /

Abbreviation

Author

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

The PAP-S Study - Investigated Treatment Concepts

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4

Participating psychotherapy schools No of therapists

No of 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

Participants of the PAP-S Study

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Design

Naturalistic (effectiveness) study

Design

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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.).

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• 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).

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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.)

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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.

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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.

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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

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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!”

Rating Manual - Example: Category 60

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Exampel of modality specif interventions: Gestalt therapy

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Effectiveness Results over all therapists and modalities

The Importance of Psychotherapists with Regard to Treatment Outcome

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Assignment of therapists to effectiveness clusters

15

• 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)

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Boxplots of the three differently effective clusters of therapists

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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)

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Outcome of the 3 groups in outcome measures

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

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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

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

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Measure N Mean SE F p pairwisecomparisons p*

BSI-GSIAtherapiesBtherapiesCtherapies

133322

1.15

.76

.67

.41.28.35

9.445

.000

AB

ACBC

.002.000.607

OQ-45-2AtherapiesBtherapiesCtherapies

133322

77.6660.1254.93

18.1211.8118.41

9.220

.000

AB

ACBC

.004.000.479

GAFAtherapiesBtherapiesCtherapies

133322

58.4565.1064.44

9.557.84

11.59

2.402

.099

AB

ACBC

.111.205.969

BDI-IIAtherapiesBtherapiesCtherapies

133322

21.1913.6911.69

7.875.258.62

7.920

.001

AB

ACBC

.007.001.584

Severityofpsychologicalproblems(T-scores)atentranceAtherapiesBtherapiesCtherapies

133322

216.71197.99191.27

19.8713.5719.96

9.262

.000

ABACBC

.006

.000

.367

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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

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Univariate Analysis of Variance

22

Tests of Between-Subjects Effects

Source

Type III

Sum of Squares

df

Mean

Square

F

p

Partial Eta

Squared

Corrected Model 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-Grouping

5908.090 2 2954.045 6.096 .004**

.179

Professional Experience .114 1 .114 .000 .998 .000 Therapeutic Alliance 183.151 1 183.151 .378 .541 .007 Severity of Psychological Problems

9266.096 1 9266.096 19.121 .000****

.255

Therapist Effectiveness-

Group * Severity of Psychological Problems

8171.621 1 4085.810 8.431 .001***

.231

Error 27137.959 56 484.606 Total 2773528.750 67 Corrected 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

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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

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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

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Treatment Adherence and Outcome

over all therapists and modalities

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5 10 15 20 n

OQ-45

HAQ

OQ-45

HAQ

OQ-45

HAQ

OQ-45

HAQ

OQ-45

HAQ

Session 7 Session 19 Session 34

Random Selection of Sessions for Objective Ratings

Session-No. 25 30 35 ..…

OQ-45 HAQ

OQ-45 HAQ

OQ-45 HAQ

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Interrater-Reliabilities

Intraclass

Correlation

Coefficient (< 0.01)

bottom limit

ceiling limit

.81

.72

.87

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6 x 3 7 x 3 8

2 x 1

4 x 3

2 x 5

7

2 x 5

5 x 3

4 x 3 6 x 3 12

1 x 2

11 x 3

4 x 3

54 therapies 165 sessions

0

2

4

6

8

10

12

14

16

18

20

SGTA FG-POP ISIS SGBAT SVG IGEAP Psa +

SGAP

IBP

Modality specific interventions (%)

specific

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SGTA Transactional Analysis

FG-POP Process Oriented Therapy

IGEAP Personal Existential Analysis

SVG Gestalt Therapy

SGBAT Bioenergetic Therapy

ISIS Art and Expression Oriented Therapy

IBP Integrated Body Therapy

Psa + SGAP Psychoanalysis and Analytical Psychology

0

10

20

30

40

50

60

70

SGTA FG-POP ISIS SGBAT SVG IGEAP Psa +

SGAP

IBP

Therapeutic Interventions

specific

nonspecific

other concept

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Interventions from Other Concepts (Percentage of total other concept interventions, percentage of most preferred other concept,

and mostly used other concept intervention category)

Process

oriented

IBP Logother

apie

Expressi

ve Arts

Therapy

Psa Jung Bioenerg

etic

Therapy

Gestalt TA

32,7

28,9

23,7

30,9

14,1

30,3

22,1

31,3

1. CCT 16,0

Verbalization

of emotional

experience

1. Psa 26,9

Interpretation

1. CCT 50,8

Verbalization

of emotional

experience

1. Psa 35,1

Confrontation

1. CCT 46,7

Verbalization

of emotional

experience

1. Psa 46,4

Interpretation

1. Psa 40,6

Confrontation

1. Psa 31,5

Confrontation

2. Psa 14,6

Interpretation

2. CCT 15,1

Verbalization

of emotional

experience

2. Psa 33,8

Interpretation

2.

Systemic 14,9

Metaphor

work

2. SGAP 20,0

Working with

complex

episodes

2. CCT 19,1

Verbalization

of emotional

experience

2. CCT 25,2

Verbalization

of emotional

experience

2.

Systemic 19,1

Reframing

2. SGBAT 14,6

Focussing on

body impulses

3. SGAP 11,7

Imagination

3. SGAP 4,6

Search for

sense and

meaning

3.

Behavior

Therapy 12,0

Reinforcement

3. SVG 17,8

Focussing on

actual emotion

3.

Systemic 14,8

Metaphor

work

3.

Systemic 11,4

Reframing

3. ILE 13,1

Reframing

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0

10

20

30

40

50

60

70

80

unspecific treatments moderately unspecific

treatments

relative specific

treatments

Treatment Specifity and OQ-45-total Scores

Session 5

Last Session

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.

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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.

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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)

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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

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Differenz-Effektstärke: -.06 35

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Differenz-Effektstärke: .17 36

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Differenz-Effektstärke: .12 37

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Differenz-Effektstärke: .01 38

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MWEffektstärke = .75

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MWEffektstärke = 1.57 40

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MWEffektstärke = .33 41

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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.

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Provisional coherences (Basis: n = 83 evaluated treatments)

Higher severity of psychol. problems at begin of therapy

Less experienced

therapists

More experienced

therapists

Stay with amount of modality specific

intervent.

Reduce amount of modality specific

intervent.

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lower specifity

higher specifity

higher specifity

Lower secifity

Difficult relation

Difficult relation

good relation

Good relation

Better outcome result

Lower outcome result

PATIENT THERAPIST

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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

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Thank You for Your interest

For further informations:

• See our website: www.psychotherapieforschung.ch

• Contact: Peter Schulthess [email protected]

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