Closing the Gap for Children with OCD: A Staged-Care Model of Cognitive Behavioural Therapy with Exposure and Response Prevention.

Childhood obsessive-compulsive disorder (OCD) is among the most prevalent and disabling mental health conditions affecting children and adolescents. Although the distress and burden associated with childhood OCD are well documented and empirically supported treatments are available, there remains an unacceptable "treatment gap" and "quality gap" in the provision of services for youth suffering from OCD. The treatment gap represents the large number of children who never receive mental health services for OCD, while the quality gap refers to the children and young people who do access services, but do not receive evidence-based, cognitive behavioural therapy with exposure and response prevention (CBT-ERP). We propose a novel staged-care model of CBT-ERP that aims to improve the treatment access to high-quality CBT-ERP, as well as enhance the treatment outcomes for youth. In staged care, patients receive hierarchically arranged service packages that vary according to the intensity, duration, and mix of treatment options, with provision of care from prevention, early intervention, through to first and second-line treatments. Based on a comprehensive review of the literature on treatment outcomes and predictors of treatments response, we propose a preliminary staging algorithm to determine the level of clinical care, informed by three key determinants: severity of illness, comorbidity, and prior treatment history. The proposed clinical staging model for paediatric OCD prioritises high-quality care for children at all stages and levels of illness, utilising empirically supported CBT-ERP, across multiple modalities, combined with evidence-informed, clinical decision-making heuristics. While informed by evidence, the proposed staging model requires empirical validation before it is ready for prime time.

Modeling individualized trajectories of symptom change to improve feedback procedures in psychotherapy.

OBJECTIVE: Psychotherapy feedback compares an individual's treatment progress to the averaged progress of all clients to determine whether their progress is sufficient. However, this can invoke the ecological fallacy if the average trajectory combines heterogenous trajectories with clinically meaningful differences. The current study, instead, explored individualized trajectories of change in psychotherapy and examined the feasibility of using these individualized models to predict clients' future trajectories. METHOD: The Outcome Questionnaire-45 was completed at each session of psychotherapy by 398 adults (16-83 years; Mage = 36.01 years) attending two Australian psychology training clinics. Up to seven Bayesian, polynomial curve-linear regression models were fit and compared for each client. For a hold-out sample (N = 50), models were fit sequentially for each client in five-session increments and used to generate tailored predictions of expected progress at the next five sessions. RESULTS: Constant (no change) and linear (steady change) were the most common shapes of change; only 3% of clients experienced negatively accelerating improvement, as per the expected treatment response curve used in current feedback procedures. Three exemplars demonstrated how individualized modeling and predictions could be utilized in clinical practice to provide richer, more nuanced feedback to psychotherapists about client progress and likely prognosis. CONCLUSIONS: This study was the first to model individualized trajectories of symptom change across psychotherapy and in doing so, uncovered substantial heterogeneity in client trajectories. This means that averaged trajectories are likely to be misleading. Individualized modeling could complement current feedback procedures. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Does feedback improve psychotherapy outcomes compared to treatment-as-usual for adults and youth?

Objective: Client-informed outcome feedback has consistently been shown to enhance psychotherapy outcomes for adults, particularly for clients at risk of treatment failure. However, there is a paucity of studies examining feedback in youth psychotherapy. Specifically, there is no research examining the feedback effect of the Youth-Outcome Questionnaire [Burlingame, G. M., Wells, M. G., & Lambert, M. J. (1996). The youth outcome questionnaire. Stevenson, MD: American Professional Credentialing Services.], despite the dominance of the adult version of the measure (Outcome Questionnaire-45 [Lambert, M. J., & Burlingame, G. M. (1996). Outcome questionnaire 45.2. Wilmington, DE: American Professional Credentialing Services.]) in adult feedback studies. Method: The effectiveness results for adult (N = 398) and youth clients (N = 397) attending psychotherapy at two psychology training clinics are presented and benchmarked against treatment-as-usual (for adults and youth) and feedback (for adults). Results: Psychotherapy with a feedback-informed approach was more effective than treatment-as-usual benchmarks, with 50% of adults and 64% of youth significantly improving after psychotherapy. Rates of adult improvement were similar to feedback-informed benchmarks, although the current sample had a higher rate of deterioration. There are no previously identified feedback-informed benchmarks for the Y-OQ, making this sample the first benchmark for future studies. Conclusions: Results support the benefits of feedback at enhancing psychotherapy outcomes for adults, and replicate this finding in a youth sample. Results also replicate that trainee psychotherapists can be as effective as licenced psychotherapists.