The Relationship between Dropout and Outcome in Naturalistic Cognitive Behavior Therapy
Garret G. Zieve, Jacqueline B. Persons, & Lisa Ann D. Yu
This paper is in press in Behavior Therapy.
Abstract: Dropout from psychotherapy is frequent and limits the benefits patients can receive from treatment. The study of factors associated with dropout has the potential to yield strategies to reduce it. This study analyzed data from a large sample of adults (N = 1092) receiving naturalistic cognitive behavioral therapy (CBT) to test the hypotheses that dropouts, as compared to completers, had (1) higher symptom severity at treatment termination, (2) a slower rate of symptom change during treatment, and (3) a higher odds that the therapist rated treatment as ending for reasons related to poor outcome. Results showed that although dropouts ended treatment with higher symptom severity than completers, dropouts and completers did not differ in their rate of symptom change during treatment, suggesting that dropouts had higher symptom severity at termination because they received fewer sessions of treatment, not because their symptoms changed at a slower rate. Dropout was also associated with a higher odds of having a therapist-rated termination reason indicating a poor outcome, suggesting that dropout is more likely if patients are dissatisfied with some aspect of the therapy outcome or process. These findings suggest that strategies for monitoring and enhancing patient satisfaction with the process and outcome of treatment may help patients stay in treatment longer and end treatment with fewer symptoms than if they had dropped out.
Early Severity Predicts Remission of Cognitive Behavior Therapy for Depression
Jacqueline B. Persons & Cannon Thomas
This project is a very exciting one that was initiated by Cannon Thomas and relies on data from a database of anonymous patient progress monitoring data collecting during routine care. The database was collected by Jackie Persons and Cannon Thomas and others (especially our long-time research assistant Cory Pallatto Hughan) during Jackie’s years at the San Francisco Bay Area Center for Cognitive Therapy. This project has its origins in Cannon’s clinical observation and data produced by other investigators showing that most depressed patients who receive cognitive therapy show a marked reduction in symptoms very early in the treatment and that early response predicts outcome. Our study takes up two questions. First, is it early response that predicts outcome, or is it that the patient who has shown an early response is quite a bit less severely symptomatic after that early response, and so early severity predicts outcome. We also examine whether the effect is true in both naturalistic routine clinical care and in treatment provided in research studies. Our paper, which we have presented at several conferences and submitted for publication, shows that symptom severity at week 4 of CBT predicts remission from depression. Our data show that when patients have Beck Depression Inventory scores in the severe range after 4 weeks of treatment (that is, in session 5), they are very unlikely to show a complete remission of their depression at the end of treatment. The clinical implication of this finding is that when patients remain severely depressed early in treatment it is essential to move quickly and aggressively to make changes in the treatment plan in order to increase the patient’s chances of a good treatment outcome.
The Congruence Study
Alexandra Jensen, Connie Fee, Anthony L. Miles, Victoria L. Beckner, Daniela Owen, & Jacqueline B. Persons
The congruence study flows out of a previous study that failed. A large group of us collected a lot of data to test the hypothesis that the degree of a patient’s engagement in and use of the feedback form that we use in therapy at the Oakland CBT Center, the CBT & Science Center, the San Francisco Bay Area Center for Cognitive Therapy, and the San Francisco Group for Evidence-Based Psychotherapy, predicts symptom change. Results were negative.
One of our research assistants, Alexandra Jensen, as she worked on the data, became interested in the question of whether congruence between what the patient reported was important to remember in the session and the content of the homework assignment might be important. She and Dr. Persons worked out the idea that congruence between these two things might predict homework compliance. Homework compliance is an important topic because it predicts outcome of psychotherapy, and this finding is especially strong for CBT for depression. As a result, this study has the very elegant quality that it contributes to science and also has direct clinical applicability. Allie Jensen did an outstanding job of moving this study forward, learning to use R and do multilevel modeling to analyze the data, and working with our research assistant Connie Fee to prepare this paper for presentation at the Association for Behavioral and Cognitive Therapies in San Diego in November 2017. The poster Allie produced was gorgeous, and she and Connie did a great job of presenting it at the conference, as this photo illustrates! Allie and Connie and Jackie are now working to write up this project for submission to a peer-reviewed journal.
Study of Skills Learning in CBT with Amy Sanchez, M.A.
Although there is a lot of evidence that CBT is quite effective in treating mood and anxiety disorders, surprisingly little is known about exactly how it achieves its benefits. One hypothesis is that in CBT patients learn skills to change behaviors and thoughts and manage their emotions, and by practicing the skills repeatedly, the person learns skills that help them reduce symptoms of anxiety and depression and achieve their other treatment goals. Other hypotheses include that the therapy helps by increasing a person’s confidence about having skills that he or she can call on when needed, or by changing schemas, or the beliefs that underpin and guide a person’s perceptions of his or her experience.
The beautiful thing about this research question is that it is a question that is of importance both to psychotherapy researchers and to the clinician who is working with patients every day. We all want to know where to focus our energy to provide the most help to our patients. (And of course, the answer might be different for different patients!) Jackie is beginning to collect data to test these hypotheses by designing the progress note she uses in her clinical work and the feedback form she uses in therapy to collect information about skills teaching in the session by the therapist, and about the patient’s skills practice and confidence. Dr. Persons is collecting those data in the course of her clinical work, and asking her patients for permission to place the data in an anonymous database that can be used for later research on skills learning and CBT.