A preliminary study of a measure of role-play competence in psychodynamic interpersonal therapy.

We report a 15-item role-play competence measure. Ratings by three judges of 34 role plays from psychodynamic interpersonal therapy training showed good inter-rater (.73-.79) and internal reliability (.84-.96). Validity was supported as scores were statistically significantly associated with psychotherapy experience. Most participants achieved satisfactory ratings supporting the training.

Workforce planning. Of one mind.

The NHS is heavily reliant on locum doctors, many of whom trained overseas. It is important they are appropriately trained so they can be integrated into the workforce. A pilot nine-session course for consultant locum psychiatrists was well received by participants. Medical directors have expressed willingness to pay for locums to attend such courses.

Value of HoNOS in assessing patient change in NHS psychotherapy and psychological treatment services.

BACKGROUND: Little research on the value of Health of the Nation Outcome Scales (HoNOS) has occurred in out-patient settings, particularly psychotherapy services. AIMS: To determine whether HoNOS provides an adequate assessment for psychotherapy services which is sensitive to change. METHODS: HoNOS ratings from 1688 patients from eight out-patient psychotherapy services were collected. Of these, 362 also had ratings post-treatment. Mean scores, pre-to post-treatment differences, and reliable and clinically significant change criteria were calculated for HoNOS items and for total scores. RESULTS: The mean total HoNOS rating was 8.93, which is comparable to psychiatric out-patients. Only three items showed sufficient variability to use in assessing pre- to post-treatment change. CONCLUSIONS: Significant limitations were found in rating items that commonly present to psychotherapists. The lack of variability in most items limits HoNOS's usefulness in this population.

Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures.

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Measurement and psychotherapy. Evidence-based practice and practice-based evidence.

BACKGROUND: Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice. AIMS: To review the developments in measurement relevant to psychotherapy. METHOD: Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skillfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement. RESULTS: Modern methods of measurement can support 'evidence-based practice' for psychological treatments. They also support 'practice-based evidence', a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs). CONCLUSIONS: Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.

Cognitive analytic therapy: a case study in treatment development.

A summary of the main literature on cognitive analytic therapy (CAT) is given. Ryle first developed CAT over 20 years ago, and use of the model is increasingly widespread in diverse settings and with various conditions. CAT stands as an example of modern dialogical approaches to therapy, and the underlying theory is consistent with that stance. The developments within training stress self-reflexive practice and the maintenance of a collaborative approach. In contrast, however, to the rapid development in training and practice the research summarised here is primarily descriptive with a small number of open trials and one randomized controlled study in a physical disorder (Type I diabetes). The urgent need for randomized controlled research in this treatment is highlighted.

Cost-effectiveness of brief psychodynamic-interpersonal therapy in high utilizers of psychiatric services.

BACKGROUND: It is known that a small number of patients with mental health problems have chronic disorders and account for a disproportionate amount of mental health costs. This randomized controlled trial evaluated the cost-effectiveness of psychodynamic-interpersonal therapy vs treatment as usual in patients with mental health problems who were unresponsive to usual treatment. METHOD: Subjects (N = 110) with nonpsychotic disorders unresponsive to 6 months of routine specialist mental health treatment were enrolled in a randomized controlled trial. Sixty-three percent were women, the mean age was 41.4 years, the median duration of illness was 5 years, 68% were unemployed or receiving state benefits because of illness, and 75.5% had a depressive illness. Intervention patients received 8 weekly sessions of psychodynamic-interpersonal psychotherapy. Control patients received usual care from their psychiatrist. Outcome measures included ratings of psychological distress and health status and a detailed economic evaluation. Analysis was conducted on an intent-to-treat basis. RESULTS: Subjects randomized to psychotherapy had a significantly greater improvement than controls in psychological distress and social functioning 6 months after the trial. Baseline treatment costs were similar for both groups. Subjects who received psychotherapy showed significant reductions in the cost of health care utilization in the 6 months after treatment compared with controls. The extra cost of psychotherapy was recouped within 6 months through reductions in health care use. CONCLUSION: These preliminary findings suggest that brief psychodynamic-interpersonal therapy may be cost-effective relative to usual care for patients with enduring nonpsychotic symptoms who are not helped by conventional psychiatric treatment.

Attachment and psychotherapy: an overview.

Attachment theory has an important role in clarifying personality development, and attachment style is increasingly recognised as a key intervening variable between personality and the response to psychotherapeutic interventions. Recent developments in attachment theory and its relationship to practice are reviewed as an introduction to a series of papers on Attachment and Psychotherapy.

The maintenance of psychotherapy skill acquisition: a two-year follow-up.

A two-year follow-up study investigated changes in interview behaviour of 11 therapists who had previously been trained in the conversational model of psychotherapy by a combined videotaped microteaching and supervision package. Results generally showed the acquired skills had been well maintained. However, there was a large increase in the giving of information and explanation, a behaviour explicitly discouraged within the conversational model. In addition, the response to verbal cues, a positive model behaviour, decreased over the follow-up period.

Stress and puerperal psychosis.

Eighty-eight in-patients admitted to a psychiatric mother-and-baby unit and 80 randomly selected recently delivered women in the general population were interviewed using the LEDS. Only five of 33 patients (15%) with puerperal psychosis had provoking agents, which is less than the figure for women in the community (36%). Provoking agents were present in only 8 of 25 patients with post-natal depression, but they were present in seven of nine patients with pre-natal depression and eight of nine women in the community with pre-natal depression.

The clinical picture of the depressed form of puerperal psychosis.

The clinical features of 104 patients admitted to a mother and baby unit over a 5-year period with RDC diagnoses of depression or schizoaffective depression were studied by self-ratings, measurements of non-verbal behaviour from standardised videotaped interviews, and observer ratings based on multiple information sources. The hypothesis was tested that they included a large subset which represented the depressed form of a bipolar puerperal psychosis. It was deduced that these illnesses would start early in the puerperium, and would have some specific clinical features. A comparison of patients with onset of depression within 2 weeks of delivery with those with onset during pregnancy or much later in the postnatal period showed a number of significant differences. A discriminant function analysis using serial reclassification of atypical patients refined the early-onset group by the exclusion of about one third of the patients who had an atypical clinical picture; the patients who remained, who are considered to represent the depressed form of puerperal psychosis, showed less anger, less self-rated emotion and more animation than the other depressed patients.

The clarification and assessment of a method of psychotherapy.

The 'conversational model' of psychotherapy was investigated with a view to discovering which behaviours distinguish psychotherapists trained in this method from others, of equal clinical experience. A rating scheme designed to capture the theoretical aspects of the model, and 30 predictions were made concerning behaviours which were expected to distinguish the psychotherapists. Five psychotherapists were matched to five psychiatrists who had not been trained in this method; each doctor took on four patients for therapy, and each patient was seen on five occasions. All interviews were recorded, and excerpts from the recordings rated. Only ten of the 30 predictions were upheld. In ten further predictions, the psychotherapists displayed the appropriate behaviours, but the behaviours were not peculiar to the model, since eclectic psychiatrists also displayed them. Six model behaviours were not practised frequently by the psychotherapists, and four 'non-model' behaviours were equally common in either group. The research formed the basis for the preparation of materials to teach psychotherapeutic skills in a more efficient way.

Evaluating the teaching of a method of psychotherapy.

A teaching package was produced to help trainees in psychiatry learn the techniques specific to a 'conversational model' of psychotherapy, prior to group supervision. This consisted of a booklet and three videotapes. The third tape used a micro-counselling approach to illustrate each key skill and was viewed together with a teacher. After this, trainees met in groups of three with a psychotherapist for eight weekly sessions. To evaluate this teaching, 12 trainees were asked to interview simulated patients before and after they used the package and after supervision. These interviews were recorded on videotape and rated. There were significant improvements on most of the key skills as a result of this training, and nine of the 12 trainees improved considerably. There was a strong negative correlation between improvement scores and a biological orientation to psychiatry. It is concluded that the teaching package is an economic but effective way of helping trainees learn the basics of a method of psychotherapy before they are given supervision.