Change processes underlying “good outcome”: A qualitative study on recovered and improved patients’ experiences in psychotherapy for major depression

Abstract

Aim: Exploring change processes underlying “good outcome” in psychotherapy for major depression. We examined the perspectives of patients who “recovered” and “improved” (Jacobson & Truax) following time-limited CBT and PDT. Method: In the context of an RCT on the treatment of major depression, patients were selected based on their pre–post outcome scores on the BDI-II: we selected 28 patients who recovered and 19 who improved in terms of depressive symptoms. A grounded theory analysis was conducted on post-therapy client change interviews, resulting in an integrative conceptual model. Results: According to recovered and improved patients, change follows from an interaction between therapy, therapist, patient, and extra-therapeutic context. Both helping and hindering influences were mentioned within all four influencing factors. Differences between recovered and improved patients point at the role of patients’ agency and patients’ internal and external obstacles. However, patients marked as “improved” described heterogeneous experiences. CBT- and PDT-specific experiences were also observed, although our findings suggest the possible role of therapist-related influences. Conclusion: From patients’ perspectives, various change processes underlie “good outcome” that do not necessarily imply an “all good process”. This supports a holistic, multidimensional conceptualization of change processes in psychotherapy and calls for more fine-grained mixed-methods process-outcome research.

摘要 目標：探討重度憂鬱症在心理治療中“好結果”背後的改變歷程。我們檢視那些透過短期 CBT（認知行為治療）和 PDT（心理動力治療）療法獲得“康復”和“改善”病人的觀點，（Jacobson ＆ Truax）。方法：在針對重度憂鬱症的 RCT（隨機對照試驗）治療中，依據病人在 BDI-II（貝克憂鬱量表-II）上的前測和後測效果分數來選擇病人：我們選擇了 28 例康復的病人和 19 例憂鬱症狀得到改善的病人。針對治療後病人的改善進行訪談，並以紮根理論分析形成一整合性概念架構。結果： 依據康復與改善的病人，改變的發生乃是由於治療、治療師、病人，和治療外環境之間的交互作用所致。整理出四個影響因素的助力和阻力。而康復和改善病人的差異之處，在於病人的主動性以及病人的內在與外在阻礙的影響。然而，標記為“改善”的病人，其經驗較為分歧。此外也觀察到 CBT 和特定的 PDT 的經驗，儘管我們的發現認為這可能是與治療師角色有關的影響。結論：從病人的角度來看，一些被視為是“好結果”底下的改變歷程，不見得“都是好的歷程”。這結果支持了心理治療要從整體和多向度的觀點來看改變歷程，並呼籲要有更多更細緻的混合方法的歷程-效果研究。

Objetivo: Explorar os processos de mudança subjacentes a “resultado de sucesso” em psicoterapia para a depressão major. Examina-se as perspetivas dos pacientes que “recuperaram” e que “melhoraram” (Jacobson & Truax) e que frequentaram CBT e PDT de tempo limitado. Métodos: Os pacientes foram selecionados, no contexto de um RCT no tratamento de depressão major, com base nas suas pontuações de resultado pré-pós no BDI-II: selecionaram-se 28 pacientes que recuperaram e 19 que melhoraram em termos de sintomas depressivos. Uma análise de grounded theory foi conduzida em entrevistas de mudança a clientes pós-terapia, resultando num modelo conceptual integrativo. Resultados: De acordo com os pacientes que recuperaram e pacientes que melhoraram, a mudança resulta de uma interação entre a terapia, o terapeuta, o paciente e o contexto extra terapêutico. Tanto influências que facilitaram como as que dificultaram o processo foram mencionados num total de quatro fatores influenciadores. Diferenças entre pacientes que recuperaram e pacientes que melhoraram apontam para o papel de agência dos pacientes e para os obstáculos internos e externos dos pacientes. No entanto, os pacientes que “melhoraram” descreveram experiências heterógenas. Experiências específicas da CBT e da PDT foram também observadas, embora os resultados sugiram o possível papel de fatores relacionados com o terapeuta. Conclusão: Na perspetiva dos pacientes, vários processos de mudança estão subjacentes a “resultado de sucesso” que não implicam necessariamente um “processo totalmente bom”. Tal resultado suporta uma conceptualização multidimensional e holística dos processos de mudança em psicoterapia e requer metodologias mistas mais refinadas na investigação de processo-resultado.

Obiettivo: Esplorare i processi di cambiamento sottostanti il “buon esito” in psicoterapia per depressione maggiore. Abbiamo esaminato la prospettiva dei pazienti che erano “guariti” e “migliorati” (Jacobson &Truax) seguendo CBT e PDT a tempo limitato. Metodo: Nel contesto di un RCT sul trattamento della depressione maggiore, i pazienti sono stati selezionati sulla base dell'esito sui punteggi pre-post sulla BDI-II: abbiamo selezionato 28 pazienti che erano guariti e 19 che erano migliorati in termini di sintomi depressivi. È stata condotta un'analisi basata sulla grounded theory sulle interviste sul cambiamento dei clienti post-terapia, risultando in un modello concettuale integrativo. Risultati: Secondo i pazienti guariti e migliorati, il cambiamento deriva da un'interazione tra terapia, terapeuta, paziente e contesto extra-terapeutico. Sono state menzionate sia influenze d'aiuto che ostacolanti tra tutti i quattro fattori d'influenza. Le differenze tra i pazienti guariti e quelli migliorati punta al ruolo dell'agency e degli ostacoli interni ed esterni dei pazienti. Tuttavia, i pazienti identificati come “migliorati” hanno descritto esperienze eterogenee. Sono state osservate anche le esperienze specifiche della CBT e della PDT, sebbene i nostri risultati suggeriscano il ruolo possibile del terapeuta in relazione alle influenze. Conclusioni: Dal punto di vista dei pazienti, diversi processi sono sottostanti il “buon esito” che non necessariamente implica “un processo tutto buono”. Ciò supporta una concettualizzazione dei processi di cambiamento in psicoterapia olistica, multidimensionale e richiede per la ricerca di esito e processo metodi misti (mixed-methods) più dettagliati.

Keywords:

• process research
• outcome research
• qualitative research methods
• cognitive behaviour therapy
• psychoanalytic/psychodynamic therapy

關鍵詞：:

• 歷程研究
• 效果研究
• 質性研究方法
• 認知行為治療
• 心理分析/心理動力療法

Palavras-chave:

• investigação de processo
• investigação de resultado
• métodos de investigação qualitativa
• terapia cognitivo-comportamental
• terapia psicanalítica/ psicodinâmica

Parole chiave::

• ricerca di processo
• ricerca sull'esito
• metodi di ricerca qualitativa
• terapia cognitivo comportamentale
• terapia psicoanalitica/psicodinamica

Acknowledgements

We want to thank the patients and therapists who participated in this study. Acknowledgements for their help in the data gathering process go to Goedele Hermans, Kimberly Van Nieuwenhove, Ruth Inslegers, and Vicky Hennissen. We want to thank Andrzej Werbart and Camilla von Below for their instructive feedback on this work.

Notes

1 Throughout this manuscript we deliberately differentiate “processes” from “mechanisms”. The present study aims to explore change processes according to patients’ experiences, which in a later step could inform research on potential operating (causal) mechanisms that could be experimentally tested (cf., Kraemer, Wilson, Fairburn, & Agras, 2002).

2 We rely on the widely used classification as defined by Jacobson and Truax (1991; see below; Note 3).

3 The Jacobson-Truax classification (1991) is the most widely used definition of “clinical significance”, which is a statistical indication of the clinical relevance of measured change in scores on an individual-patient level (i.e., whether a decrease in symptoms would be noticeable in actual clinical care). The JT-method relies on a twofold evaluation of outcome: Reliable change in pre-to-post treatment scores and evolution from dysfunctional to functional distribution (i.e., passing the clinical cut-off). Accordingly, patients are classified into four possible outcome categories: “Recovery” (reliable change and passing the clinical cut-off), “Improvement” (reliable change but remaining in the clinical range), “Non-improvement” (no reliable change) or “Deterioration” (reliable change in the negative direction).

4 Note that the present study is situated within the context of the GPS (Meganck et al., 2017), yet addresses different research questions and therefore differs somewhat from the original design. Firstly, the present study relied on the BDI-II as primary outcome measure (see also footnote 6), while the GPS relies on the interview-based Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967). Findings on patients’ individual outcome could thus differ depending on the measure used. Secondly, given the focus on outcome more generally, the present study did not include patient personality style in the analysis and interpretation of findings. We refer interested readers to more specific literature on this topic (e.g., Werbart, Hägertz, & Nadja Borg, 2018).

5 Other Axis 1 diagnoses present in one or two patients in the recovered group included: secondary substance abuse, eating disorder, dysthymia; and in the improved group: eating disorder, secondary substance abuse, somatic symptoms, pain disorder, hypochondria (according to SCID for DSM-IV-TR; First, Spitzer, Gibbon, & Williams, 2002).

6 A complete overview of the measures used in the GSP can be found in the study protocol of the RCT (Meganck et al., 2017). Given the focus of the current study on patients being treated for major depression, the Beck Depression Inventory (Beck et al., 1996; van der Does, 2002) was selected as the outcome measure for this particular study. As our main focus in this study is on patients’ perspectives, this self-report measure was preferred over the interview-based HRSD.

7 General: ≥ 90% of the participants (25–28 and 17–19 recovered and improved sample respectively); Typical: ≥ 50% and < 90% (14–24 and 10–16 patients); Variant: ≥ 20% and < 50% (6–13 and 4–9 patients); Rare: < 20% (1–5 and 1–3 patients).

8 Note: “confronting mirror” is differentiated from the specific questions mentioned in “insights through talking, (specific) questions and reflection” given the explicit experience of being confrontational, which was not characteristic of the insight-stimulating questions.

Additional information

Funding

This work was supported by Fonds Wetenschappelijk Onderzoek [Grant No. 1127118N].