Until this review, there had only been one review into which clinician behaviours contribute to alliance formation with young clients, and this was based on only four studies. So, it was high time a larger systematic review was performed.
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This new study differed from the previous one by: 1) including more severe cases (lower positive affect and more self-reported disability); and 2) assessing whether PAT impacts reward sensitivity via a range of measures. It’s in this second department that the study really “goes to too much trouble” in the best possible way. In addition to several self-report scales, the study used physiological and behavioural task measures of reward processing, which require some description to appreciate.
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In this study, therapist effects explained approximately 4% variance in client outcomes. Interestingly, although within-therapist differences between sessions in intervention skill competence predicted client improvement, average differences between therapists did not. In other words, the variation in each clinician’s performance from session to session or client to client made a difference to how much clients in their care improved, but in this study at least, no therapists achieved consistently better aggregated outcomes than other therapists. Observer ratings of session difficulty also predicted whether clients improved, as did the interaction between treatment difficulty and intervention competence. This means that clients who were harder to treat achieved greater symptom reduction when therapists executed intervention skills better. Again, microskill competence did not predict client improvement.
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Hoppen, Kip and Morina (2023) performed a meta-analysis of 160 randomised controlled trials involving 10,566 adult clients whose primary problem was PTSD. It excluded small trials (N < 20) and trials targeting comorbid PTSD and substance use disorders or traumatic brain injury. It also excluded trials where PTSD diagnosis was established by self-report (questionnaires) rather than by semi-structured interview schedules. The search was current on November 29th, 2022. Treatment frequency was examined both dichotomously as “standard” (less frequent than 1.5 sessions/week) and “intense” (1.5 sessions/week or more frequently) and continuously, although the pattern of results was the same regardless of how frequency was measured. Drop out was measured as the number of participants randomised minus the number completing post-treatment assessment.
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The results were impressive. There was a time x interaction effect for depressive symptoms (as measured by the BDI-II), whereby both groups reduced depression symptoms from pre- to post-treatment but only the ImRS group achieved further reductions in depression from post-treatment to 2-month follow-up. To reinforce the significance of this finding, the average pre-treatment BDI-II score for both groups was in the severe range; by post-treatment (and follow-up), the ImRS group mean scores were in the mild range while the mean scores for the cognitive restructuring group were in the moderate Range. These are impressive results for 3 sessions!
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Regarding the comparison of ST (combined IGST and PGST) v TAU, ST produced greater reductions in BPD severity, evident by the 1.5-year mark. When comparing types of ST, IGST produced greater reductions in BPD severity than PGST, evident by the 2.5-year mark. When comparing IGST with TAU, IGST was significantly more effective in reducing BPD severity by the 1-year mark. By contrast, PGST was not significantly different from TAU. Regarding retention, PGST did not improve on TAU (72%, 73% respectively at end of first year, 62%, 64% at end of second year). IGST retained a greater proportion of participants (82% at 12 months, 74% at 24 months).
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Batastini and colleagues (2020) conducted the most comprehensive and rigorous meta-analysis of studies comparing video-conferencing to in-person delivery of mental health services on mental health outcomes.
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