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The Outcomes of Case Formulation and Alliance Focused Supervision of Psychotherapy

This study examines the impact of clinical supervision on client working alliance and symptom reduction in the treatment of major depression. The results show significant improvements in working alliance, symptom reduction, treatment retention, and evaluation. The study suggests that even a single pretreatment supervision session can have a positive effect on therapy outcomes.

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The Outcomes of Case Formulation and Alliance Focused Supervision of Psychotherapy

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  1. TheCROP Intervention Study SPR, Buenos Aires, July 2019 The outcomes of case formulation and alliance focused pre-treatment supervision of psychotherapy: A pragmatic randomized controlled study. Jan Nielsen, Birgit Bork Mathiesen, Susanne Lunn, Line Rettig Lauritzen & Stig Poulsen, University of Copenhagen, Denmark.

  2. The CROP Study Common Factors, Responsiveness and Outcome in Psychotherapy

  3. The CROP StudyUniversity of Copenhagen Birgit Bork Mathiesen Stig PoulsenSusanne Lunn Jan Nielsen Line Rettig Lauritzen

  4. The Intervention Study Structure of the presentation • Introduction • The context • The study • The pilot phase: Our experiences so far • Discussion and perspectives

  5. The Intervention Study 1. Introduction Supervision research

  6. Is supervision the answer to Enhanced outcome for clients Therapist training needs Reducing drop out Less detoriated treatment Quality control Therapists assesssment of own skills and efforts Knowledge of clients satisfaction …

  7. The clinical supervision paradox Clinical supervision has traditionally been: Considered an important part of professional training; Being rated highly by trainees and practitioners: (Orlinsky& Rønnestad, 2005)

  8. DPCCQPerceived Sources of Influence on Career Development (Orlinsky & Rønnestad, 2005, p. 137 / tab. 9.1.)

  9. DPCCQPerceived Sources of Influence on Career Development (Orlinsky & Rønnestad, 2005, p. 155 / tab. 10.4)

  10. The clinical supervision paradox Clinical supervision … - cont. The process of clinical supervision has been extensively studied; Less is known about the impact of supervision on psychotherapy practice and client symptom outcome. Conclusion: We lack evidence that supervision improves clients’ outcomes (Bambling, & King, 2000; Watkins, 2011).

  11. Psychotherapy and supervision Client Therapist/Supervisee Supervisor

  12. Practice Supervision Therapeutic Transmission System TTS Supervisory Transmissison System STS Client Therapist- -Supervisee Supervisor Psychotherapy research Supervision research

  13. OutcomePractice Training Supervisory Transmissison System Therapeutic Transmission System Client Therapist-Supervisee Supervisor Outcome ?

  14. Our inspiration Psychotherapy Research, May 2006; 16(3): 317-331

  15. BamblingFocus and design The study evaluated the impact of clinical supervision on client working alliance and symptom reduction in the brief treatment of major depression. The authors randomly assigned 127 clients with a diagnosis of major depression to 127 supervised or unsupervised therapists to receive eight sessions of problems-solving treatment. Standard measures of therapeutic alliance [WAI]and symptom change [BDI] were used as dependent variables.

  16. BamblingPre-treatment: alliance + case formulation During therapy, supervised therapists received eight supervision sessions. Before beginning treatment, supervised therapists received one supervision session for brief training in the working alliance supervision approach and in specific characteristics of each case.

  17. BamblingResults The study showed a significant effect for both supervision conditions on • working alliance from the first session of therapy; • symptom reduction; • treatment retention, and • evaluation.

  18. BamblingConclusion It was not possible to separate the effects of supervision from the single pretreatment session. WAI-scores were markedly higher for supervised therapists allready by the end of session 1 and continued through the following sessions, with no further significant widening of the gab. The effect found for session 1 alliances scores means it is not possible to adequately serapate supervision effect and the pretreament session.

  19. The effect of pretreatment on WAI? A (supervision) WAI B (no supervision) Pre session 1 2 3 4 5 6 78 WAI

  20. BamblingPerspectives The most interesting and unexpected finding of this research was that the (pre-)supervision had an effect from the first session of therapy. (Bambling, 2009 / TSAS-manual) Simply being aware of the alliance model seems to give therapists an advantage over their colleagues in the control condition. (Bambling, 2009 / TSAS-manual)

  21. BamblingFuture research – our focus Question: Does pretreatment supervision make a superior starting point for working alliance and will ongoing supervision maintain the high WAI-scores? To clariry this: Could a single pretreatment supervision session alone be sufficient to produce the effects reported in this study?

  22. The Intervention Study 2. Context The CROP study

  23. The Intervention Study The scientific and empirical base The CROP study is an observational study of therapy processes carried out in the naturalistic setting of the Danish practice sector. It will generate data on the quality and effectiveness of psychological treatment provided by psychologists in the Danish practice sector.

  24. The Intervention Study The scientific and empirical base – cont. Self-report data from the participating psychologists and their clients will be collected through an automated and secure online database before, during and after therapy (see Poulsen et al. 2018). The overall purpose of the CROP study is to expand scientific knowledge about therapist responsiveness in psychotherapy, i.e. the way in which therapists adapt their treatment to client needs and preferences.

  25. The Intervention Study Linking therapy and supervision research CROP’s intervention study is a pragmatic randomized controlled study of a brief pre-treatment supervision focusing on case formulation and working alliance in order to examine the impact of this intervention on therapist responsiveness and client rated symptom outcome. Client Therapist Supervisee Supervisor

  26. The Intervention Study Pretreatment intervention – or supervision? According to the design in the Bambling study, it was not possible to distinguish between the effect of the pretreatment intervention and the supervision that followed later on. This distinction is the main focus of this RCT-study, and the Bambling intervention study has not been replicated to date.

  27. The Intervention Study 3. The study Aim, sample, design and interventions

  28. The Intervention Study Aim Through randomization a group of psychologist is selected to a brief pre-treatment training session focusing on case formulation and working alliance; To examine the impact of this intervention on therapist responsiveness and client rated symptom outcome; With this intervention, we hypothesize that the therapists will be more responsive to their clients, and building a stronger working alliance.

  29. The Intervention Study Sample Therapists are recruited in collaboration with the Section of Self-Employed Psychologists organized under the Danish Psychological Association. Therapists who want to participate in the pre-treatment supervision do not intend to receive other sorts of supervision on the therapy with the specific client.

  30. The Intervention Study Sample Clients are recruited through the therapists. Written informed consent is obtained from clients after the purpose and procedures of the CROP study has been explained both verbally and through the provision of a written information sheet.

  31. The Intervention Study Study design A group of the participating (CROP-)psychologists will be randomized into two groups where they either will or will not receive a pre-therapy supervision intervention by a third party (our data manager).

  32. The Intervention Study Design The CROP study Naturalistic study of psychologist and clients Condition 1:Condition 2: Psychologists without Psychologists with planned supervision planned supervision The Intervention Study: Randomization

  33. The Intervention Study Design – cont. Conditions meet (no planned supervision) Randomization First interview with a new client First interview with a new client The intervention meeting First psychotherapy session … First psychotherapy session … Effect: WAI, SCL, IIP

  34. The Intervention Study The intervention The pre-treatment session consists of • supervisors instructing therapists in case formulation and early alliance management principles, and • supervisors and therapists discuss characteristics of a specific case with an emphasis on how to enhance the quality of their case formulations and applying alliance management principles. Supervisors and therapists have access to client assessment information from the therapists’ intake interview.

  35. The Intervention Study Caseformulation According to Kendjelic& Eells (2007): • improves treatment outcome, • correlates with greater accuracy of therapist interpretations, • enhances treatment in difficult and complex cases, • helps maintain treatment gains at 6 months, • improves treatment of depression with comorbid disorders, and • aids in identifying when to deviate from a standard treatment protocol.

  36. The Intervention Study Case formulation A generic psychotherapy case formulation includes: 1. Symptoms and problems; 2. Precipitating stressors; 3. Predisposing events and conditions; 4. An inferred explanatory mechanism accounting for the above mentioned components; 5. The implications of the case formulation for the therapy planned and the working alliance.

  37. The Intervention Study Alliance foci A brief pre-treatment supervision on working alliance comprising: • Bond, task and goals, • Work stage alliance, and • Rupture management, improved the therapeutic relationship from the very first therapy session in Bambling et al.’s study (2006). This indicates that a short pre-treatment intervention could be as effective as proper supervision.

  38. The Intervention Study The Three-Stage model of Alliance Supervision (TSAS)

  39. The Intervention Study Structure of the intervention meeting (2 hours) Part I Presentation: 2 psychologist + 2 ‘supervisors’ Introduction to the rationale: Caseformulation + alliance (‘supervisors’) Part II Principles for case formulation (‘supervisors’) Individual reflection on own case material from 1. interview (psychologists) Discussion of individual case formulations (common)

  40. The Intervention Study Structure of the intervention meeting – cont. Part III Principles for alliance management (‘supervisors’) Individual reflection on alliance based on the case formulation (psychologists) Discussion of expected direction and quality of alliance (common) Part IV Summary of the meeting, questions and conclusion.

  41. The Intervention Study Pretreatment vs. supervision The intervention is directed towards the planned psychotherapy, and thus more future-oriented, based on ‘forward reasoning’ rather than ‘backward reasoning’. It is informed by the therapist´s initial knowledge and impression of the client, condensed into a caseformation. The case formulation forms the base for the following alliance assessment, included potential ruptures.

  42. The Intervention Study Pretreatment vs. supervision – cont. The idea is to discuss potential scenarios based on the intake information on the client (Bambling, personal comm). It is a practical discussion of the intake session to demonstrate both understanding and some ideas on how to apply the approach. It is about practicing the model and not on trying to predict the comming sessions.

  43. The Intervention Study Data analysis Will compare the two conditions in relation to the following dependent variables: • client-rated working alliance (WAI), • client symptom scores (SCL: measurement at intake, during and after end of treatment), and • interpersonal functioning (IIP).

  44. The Intervention Study Time line The main CROP pilot study, comprising 10 psychologists and 20 clients, will begin in January, 2019. First phase of the main study (CROP) will run from autumn 2019 with a total intake of 100 psychologists with 1000 clients.

  45. The Intervention Study Time line – cont. The pilot phase of the The Intervention Study was also planned to begin Januar 2019, but due to technical problems with the randomization, it is postponed until August 2019.

  46. The Intervention Study 4. The pilot phase Our experiences so far

  47. The Intervention Study Sampling: The Pilot Phase

  48. The Intervention Study Consequences No intervention meeting so far  No preliminary data / examples / experiences  But …….

  49. The Intervention Study One ‘pilot’ meeting with 2 CROP-colleagues The manual seems to function  The two ‘pilots’ worked well with their cases  Valuable feedback / response on content, procedure and material  Minor changes to the manual followed this meeting !

  50. The Intervention Study Reorganization The randomization procedure has now been reorganized, and our data manager has promised than from August 6th all psychologist will be randomised properly !

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