When meta-analysis continues to mislead: A reply to Østergård and Hougaard (2020).

Reply to comments on an article by Duncan and Sparks (see record 2018-10637-001). Østergård and Hougaard (2020) reiterate the flawed conclusions of their meta-analysis of the Partners for Change Outcome Management System (PCOMS) and obfuscate the main point of our critique (Duncan & Sparks, 2020). Despite the lauded statistics and selection criteria, the inclusion of six significantly confounded investigations resulted in a misleading overattribution of meaning to studies of questionable methodology that warranted exclusion. Further, their hypothesis that social desirability leads to inflated effect sizes on the Outcome Rating Scale (ORS) is insufficient. It is not supported by studies finding comparable results to the ORS on independent outcome measures or investigations reporting that change on measures of life functioning, like the ORS, precedes that depicted on symptom scales. While more research is needed, the totality of credible research supports the efficacy of PCOMS. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

When meta-analysis misleads: A critical case study of a meta-analysis of client feedback.

Consumers of psychotherapy outcome literature consider meta-analysis the gold standard for assessing the efficacy of interventions across disparate studies. Many assume that findings are valid, especially when published in journals with research credentials. Uncritical acceptance, however, can result in real-world consequences, including whether interventions attain evidence-based status or become marginalized or are considered for implementation in public service arenas. This article examines one meta-analysis, "The Effect of Using the Partners for Change Outcome Management System as Feedback Tool in Psychotherapy-A Systematic Review and Meta-Analysis" (Østergård, Randa, & Hougaard, 2018). The findings are at odds with both the empirical record of routine outcome management as well as professional taskforce recommendations and thus provide an ideal exemplar of the risks of uncritically accepting the conclusions of a meta-analysis. Using guidelines from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011) and a qualitative case study methodology, this article examines Østergård et al.'s (2018) study selection, quality of evidence, and appropriateness of interpretation, emphasizing the link between flawed method and the ultimate validity of its conclusions. The method illustrated in this case study can be used to assess the legitimacy of meta-analytic findings to inform practice, funding, and policy decisions as well as how rhetoric minimizes flaws and bolsters believability. Our analysis revealed that half of the selected studies of the meta-analysis contained significant limitations, including inadequate dose of treatment and/or adherence problems, thereby calling into question its conclusions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Partners for Change Outcome Management System: A Both/And System for Collaborative Practice.

Systematic client feedback (SCF) is increasingly employed in mental health services worldwide. While research supports its efficacy over treatment as usual, clinicians, especially those who highly value relational practices, may be concerned that routine data collection detracts from clinical process. This article describes one SCF system, the Partners for Change Outcome Management System (PCOMS), along a normative (standardized measurement) to communicative (conversational) continuum, highlighting PCOMS' origins in everyday clinical practice. The authors contend that PCOMS represents "both/and," providing a valid signal of client progress while facilitating communicative process particularly prized by family therapists steeped in relational traditions. The article discusses application of PCOMS in systemic practice and describes how it actualizes time-honored family therapy approaches. The importance of giving voice to individualized client experience is emphasized.

"Mental Health" Power and Its Effects: A Commentary on Battling Against Inter-Faith Relations in Israel.

Hakak (2016) provides an opportunity to examine how mental health and therapy systems in the United States operate to maintain current social and political structures. This commentary suggests that practitioners, including family therapists, participate in and support practices that do not serve the interests of marginalized social groups, despite our best intentions. Discourse theory offers a lens through which such practices become visible and thus open to revision.

The Norway Couple Project: Lessons Learned.

Couple therapists in routine practice may find it difficult to apply findings from an increasingly expanding and complex body of couple therapy research. Meanwhile, concerns have been raised that competency in evidence-based treatments is insufficient to inform many practice decisions or ensure positive treatment outcomes (American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist, 2006, 271). This article aims to narrow the research/practice gap in couple therapy. Results from a large, randomized naturalistic couple trial (Anker, Duncan, & Sparks, Journal of Consulting and Clinical Psychology, 2009, 693) and four companion studies are translated into specific guidelines for routine, eclectic practice. Client feedback, the therapeutic alliance, couple goals assessment, and therapist experience in couple therapy provide a research-informed template for improving couple therapy outcomes.

Outside the Black Box: Re-assessing Pediatric Antidepressant Prescription.

OBJECTIVE: The purpose of this review is to assess whether evidence supports a favorable risk/benefit profile for pediatric antidepressant use and reconsideration of the black box. METHOD: The review examines studies post-black box purporting to show declines in pediatric antidepressant use and rising youth suicide, summarizes evidence for efficacy and safety of pediatric antidepressants, and discusses irregularities in recent meta-analyses of fluoxetine for youth. RESULTS: Pediatric antidepressant prescription did not significantly decline post-black box and youth suicide has risen only in recent years. Recent meta-analyses fail to undermine evidence that antidepressants are associated with increased risk of suicidality in youth. CONCLUSIONS: First line prescription of antidepressants for youth is not advisable. The black box and international warnings on pediatric use of antidepressants are warranted. Wider availability of psychosocial options for depressed youth is recommended.

OBJECTIF: Cette revue a pour but d'évaluer si les données probantes soutiennent un profil risques-avantages favorable à l'utilisation d'antidépresseurs pédiatriques, et de réexaminer la boîte noire. MÉTHODE: La revue examine les études postérieures à la boîte noire censées démontrer l'utilisation décroissante d'antidépresseurs pédiatriques et la montée du suicide chez les adolescents, résume les données probantes sur l'efficacité et l'innocuité des antidépresseurs pédiatriques, et présente les irrégularités des récentes méta-analyses de la fluoxétine pour adolescents. RÉSULTATS: La prescription d'antidépresseurs pédiatriques n'a pas connu de baisse significative postérieurement à la boîte noire, et le suicide chez les adolescents n'a augmenté que dans les dernières années. Les méta-analyses récentes n'infirment pas les données probantes de l'association des antidépresseurs à un risque accru de suicidabilité chez les adolescents. CONCLUSIONS: La prescription en première intention d'antidépresseurs à des adolescents n'est pas à conseiller. La boîte noire et les mises en garde internationales sur l'utilisation pédiatrique d'antidépresseurs sont justifiées. Une offre plus variée d'options psychosociales pour les adolescents déprimés est recommandée.

Teaching accountability: using client feedback to train effective family therapists.

The AAMFT Task Force on Core Competencies (Nelson et al., 2007) proposed that marriage and family therapy (MFT) educators teach and provide evidence of trainee competence beyond coursework and accrued clinical hours. This article describes the integration of a systematic client feedback protocol into an MFT-accredited program's curricula to address the call for outcome-based learning. Outcome management (OM) provides a framework for teaching and assessing trainee effectiveness. Continuous incorporation of client feedback embodies collaborative, strengths-based, integrative, and diversity-centered program values. Students learn a system for being accountable to clients, the profession, and service communities.

The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample.

OBJECTIVE: The purpose of this study was to explore the relationship between the alliance and outcome in couple therapy and examine whether the alliance predicted outcomes over and above early change. The authors also investigated partner influence and gender and sought to identify couple alliance patterns that predicted couple outcomes. METHOD: The authors examined the alliances and outcomes at posttreatment and follow-up of 250 couples seeking treatment for marital distress in a naturalistic setting. The Session Rating Scale was used to measure the alliance; the Outcome Rating Scale and Locke Wallace Marital Adjustment Scale were used to measure outcomes. Couples were White, Euro-Scandinavian, and heterosexual, with a mean age of 38.5 years and average number of years together of 11.8. On a subsample (n = 118) that included couples with 4 or more sessions, the authors investigated the relationship between the alliance and outcome controlling for early change, and patterns of alliance development were delineated. RESULTS: In the full sample, first-session alliances were not predictive of outcomes, but last-session alliances were predictive for both individuals and their partners. In the subsample, third-session alliances predicted outcome significantly above early change (d = 0.25) that exceeded the reliable change index. Couple alliances that started over the mean and increased were associated with significantly more couples achieving reliable or clinically significant change. Gender influences were mixed. CONCLUSIONS: Given the current findings suggesting a potential alliance impact over and above symptom relief as well as the importance of ascending alliance scores, continuous assessment of the alliance appears warranted.

Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting.

Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers. A research paradigm called patient-focused research--a method of enhancing outcome via continuous progress feedback--holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy. The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy. Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback. Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived.

The ethics and science of medicating children.

Prescriptions for psychiatric drugs to children and adolescents have skyrocketed in the past 10 years. This article presents evidence that the superior effectiveness of stimulants and antidepressants is largely a presumption based on an empirical house of cards, driven by an industry that has no conscience about the implications of its ever growing, and disturbingly younger, list of consumers. Recognizing that most mental health professionals do not have the time, and sometimes feel ill-equipped to explore the controversy regarding pharmacological treatment of children, this article discusses the four fatal flaws of drug studies to enable critical examination of research addressing the drugging of children. The four flaws are illustrated by the Emslie studies of Prozac and children, which offer not only a strident example of marketing masquerading as science, but also, given the recent FDA approval of Prozac for children, a brutal reminder of the danger inherent in not knowing how to distinguish science from science fiction. The authors argue that an ethical path requires the challenge of the automatic medical response to medicate children, with an accompanying demand for untainted science and balanced information to inform critical decisions by child caretakers.

Taking a stand: an adolescent girl's resistance to medication.

Therapists and clients encounter pressure to seek medication for adolescent depression and dangerous behaviors. A review of current research indicates that medical practitioners prescribe antidepressants for adolescents despite questionable efficacy, side effects, and frequent refusal. Adolescent girls' expressions of distress expose them to systems that promote medication prescription. A critical look at medical, gender, and adolescent discourses sheds light on drug prescription as standard practice and highlights its impact on adolescent girls' agency, voice, and community connection. Resistance to medication is reconsidered as an act of personal and political choice. Amy, a 16-year-old girl, and her therapist describe strategies for managing depression without medication.