8.4 Service delivery and evaluation in psychotherapy

Choosing, explaining and combining psychotherapies

Assessment and suitability

• Assessment begins with a careful history of the presenting problem and a formulation, before any technique, psychoeducation or treatment is chosen.

• The suitability factors are psychological mindedness, ego strength, motivation, tolerance of anxiety and frustration, and capacity for a therapeutic relationship.

• Measured intelligence is a weak guide to suitability, because therapies are adapted for people of lower ability.

• Psychological mindedness is the capacity to understand one's difficulties in psychological terms, reflecting on links between thoughts, feelings and behaviour.

• Psychological mindedness with capacity for a working alliance most favours brief psychodynamic therapy.

• Chronic, entrenched maladaptive patterns are a relative contraindication to brief, time-limited therapy, because they need longer treatment to change.

• An acute psychotic state, in which reality testing has failed, is a reason not to start exploratory psychotherapy.

• If a patient makes an ambiguous disclosure of possible harm to a dependent, clarify it with them first, then decide whether safeguarding action is needed.

Matching therapy to the presentation

Tap to enlarge

• CBT is used across mood, anxiety, eating, psychotic, substance use and physical symptom conditions, but not for malingering, which a talking therapy cannot change.

• Interpersonal psychotherapy is a time-limited treatment for depression, chosen when the presentation centres on grief, role disputes, role transitions (such as retirement) or interpersonal deficits.

• A comprehensive dialectical behaviour therapy programme (individual therapy, group skills training, phone coaching) is considered for women with borderline personality disorder when reducing recurrent self-harm is the priority.

• Anorexia-focused family therapy is the first-line psychological treatment for children and young people with anorexia nervosa.

• In anorexia-focused family therapy, parents take charge of eating first, and control is handed back as weight recovers.

• Eye movement desensitisation and reprocessing (Shapiro) pairs recall of the traumatic memory with bilateral eye movements.

• NICE recommends eye movement desensitisation and reprocessing as a trauma-focused therapy for adults with post-traumatic stress disorder presenting more than three months after non-combat trauma.

• Behaviour therapy, built on learning theory, suits challenging behaviour kept going by reinforcement, including in a child with intellectual disability or limited language.

• Behaviour therapy starts with a functional analysis, then changes the antecedents and consequences of the behaviour, often through carers.

• Motivational interviewing suits ambivalence about change: it reflects both sides and develops discrepancy between behaviour and goals.

• The four principles of motivational interviewing are expressing empathy, developing discrepancy, rolling with resistance and supporting self-efficacy.

Support, counselling and crisis work

• Refer on when the technique, intensity or risk management needed goes beyond your competence, as with trauma-focused treatment or specialist personality disorder care.

Behavioural techniques

• Systematic desensitisation pairs relaxation with graded exposure up a hierarchy, based on Wolpe's reciprocal inhibition; it is a conditioning technique within behaviour therapy.

• Flooding exposes the person to the most feared situation at full intensity, with escape prevented until anxiety falls through habituation and extinction.

Flooding starts at the top of the hierarchy, whereas graded exposure and systematic desensitisation climb it step by step.

Defining features of named therapies

• Cognitive analytic therapy (Ryle) describes relating as reciprocal role procedures and names repeating patterns such as dilemmas and snags.

• Cognitive analytic therapy maps these in a sequential diagram with a reformulation letter, and closes with goodbye letters.

• Mentalisation-based treatment (Bateman and Fonagy) comes from attachment theory and holds that mentalising, reading behaviour through mental states, collapses under emotional arousal in borderline personality disorder.

• The hallmark of mentalisation-based treatment is the not-knowing stance.

• The pre-mentalising modes are psychic equivalence (inner experience taken as outer reality), pretend mode and teleological mode.

• The four dialectical behaviour therapy skills modules are mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.

• Distress tolerance means getting through a crisis by distraction, self-soothing and radical acceptance.

• Radical acceptance is fully accepting a painful reality; holding it in balance with change strategies is the dialectic.

• Milan systemic family therapy uses hypothesising, circular questioning and an observing team behind a one-way screen, reading the symptom as part of a pattern the family maintains.

• Universality, finding that others share problems once thought unique, is one of Yalom's group therapeutic factors, with instillation of hope, altruism, catharsis, cohesiveness and interpersonal learning.

• Socratic questioning, or collaborative guided discovery, is the signature method of cognitive therapy in the Beck tradition.

Tap to enlarge

Socratic questioning differs from rational emotive behaviour therapy, which directly disputes irrational demands.

Explaining and making a referral

• Explain the model, jointly agreed goals, the format, the length (six to twenty sessions or open-ended weekly work) and the patient's tasks between sessions.

• Explain what goes back to the referrer, what risk triggers disclosure, and that benefit is realistic, not a cure.

• Warn that exploratory and exposure work can feel worse before it feels better, and that a first failure does not make the case hopeless.

• The referral states an explicit question, the urgency, the risk, and a summary of history, medication and previous attempts.

• Consent is an active step, not assumed from silence, under the Mental Capacity Act 2005 in England and Wales.

• State who holds clinical responsibility during the wait and whom the patient contacts in a crisis.

Combining psychotherapy with medication

• The benzodiazepine evidence is clearer in theory and animals than in human trials, so do not present it as inevitable treatment failure.

• A patient who credits improvement solely to the drug or solely to the therapy may stop the other too early.

Psychoeducation, alliance and harm

• Psychoeducation is planned, collaborative teaching that explains the condition, supports self-management and produces a shared relapse prevention plan.

• In psychosis and bipolar disorder, structured family psychoeducation covers early warning signs and can lower high expressed emotion without blaming relatives.

• The alliance combines a trusting bond with agreed goals and tasks; monitor it and repair ruptures.

• Use a trained mental health interpreter rather than relatives, who may inhibit disclosure.

• About 5 to 10% of patients deteriorate during therapy in trials; harms include dependency, strained relationships, and distress or dissociation in poorly paced work.

• If avoidance or self-harm increases, reassess the formulation and plan with the therapist rather than continuing or discharging automatically.

Effectiveness of psychotherapy

Efficacy, effectiveness and efficiency

• Deterioration affects about 5 to 10% of people in psychotherapy, and a mean improvement can hide them.

• Statistical significance does not establish clinical importance, which is judged against the minimal clinically important difference, the smallest change patients recognise as meaningful.

Trial design

Patients and therapists know the assigned treatment, so expectancy is hard to separate from the treatment effect.

• A waiting list controls only for time, and a demoralising wait can inflate the therapy's apparent benefit.

• Treatment as usual varies across services, so trials should describe it.

What predicts outcome

• The therapeutic (working) alliance is the most consistently replicated predictor of outcome, in psychodynamic therapy as in other therapies.

• Patient demographics and therapist characteristics have no consistent link to outcome.

• In the National Institute of Mental Health depression collaborative trial, the patient's contribution to the alliance, not the therapist's, was significantly linked to outcome in both psychotherapies and in the drug and placebo arms.

• Allegiance, investigators' commitment to a therapy, can create apparent differences between therapies through therapist experience, comparator quality or outcome choice.

Borderline personality disorder

The first four were built for the disorder; acceptance and commitment therapy was not.

Other groups

• Cognitive therapy and interpersonal psychotherapy for major depressive disorder give similar acute improvement and retention with or without a comorbid personality disorder, mostly cluster C.

• Distress in informal carers of people with mental illness falls most with manualised programmes lasting at least eight weeks that need active carer participation.

Routine outcome monitoring

• Routine outcome monitoring uses validated measures repeatedly and can reveal deterioration that clinical impression misses, especially when progress is off track.