BIGSPD talk: CCAT - PowerPoint PPT Presentation

1 / 33
About This Presentation
Title:

BIGSPD talk: CCAT

Description:

Mental Health Foundation for funding the study ... Sensitive to therapist errors & iatrogenic' deterioration (Shearin & Linehan, 1993) ... – PowerPoint PPT presentation

Number of Views:78
Avg rating:3.0/5.0
Slides: 34
Provided by: gle104
Category:
Tags: bigspd | ccat | iatrogenic | talk

less

Transcript and Presenter's Notes

Title: BIGSPD talk: CCAT


1

2
Therapist competence and therapy outcome in the
cognitive-analytic therapy of severe complex
mental health problems
  • Glenys Parry Dawn Bennett
  • University of Sheffield
  • School of Health Related Research
  • and Sheffield Care Trust
  • Sheffield Health Social Research Consortium
    Conference
  • 9th November 2006

3
Acknowledgments
  • Mental Health Foundation for funding the study
  • Mark Evans and Sarah Littlejohn for help in
    developing the CCAT.
  • Therapists and members of consensus panels Gill
    Aitken, Brigitta Bende, Gill Bloxham, Kate
    Cahill, Phil Clayton, Sarah Cluley, Louise
    Cooke, David Crossley, Mark Evans, Kate
    Freshwater, Deborah Gamsu, Yvonne Harris, Anna
    Jellema, Sarah Littlejohn, Carol Lomax, Judy
    Merchant, Sue Pethen, Debby Pickvance, Rachel
    Pollard, and Lawrence Welch.

4
Why study competence?
  • A significant source of variance in outcomes.
  • Service users think therapist errors are
    important (Castillo, 2003)
  • Major challenge for training courses and brand
    name therapies if no relationship between
    specific (technical) competence outcome

5
Why study competence?
  • We lack an understanding of how to foster
    competence and reduce therapist errors.
  • Re. implementing NICE guidelines, vital part of
    transferability of randomised trials results.
  • Studies of competence will have direct
    implications for design delivery of both
    therapist training and psychological therapy
    services

6
Therapist competence
  • Different from adherence (i.e. sticking to the
    manual) this has been linked to poorer outcomes
  • Not only what was done but how well
  • Differing concepts of competence
  • in a therapist (i.e. a competent therapist)
  • performance (process variable)
  • quality of an interaction (context-dependent)

7
Challenges for research
  • Different patterns of outcomes for different
    therapists (Luborsky et al 1986)
  • Most therapists have mixed outcomes only
    minority generally better or poorer results
    (Huppert et al 2001)
  • Relationship between training (or experience) and
    client outcomes is weak (Stein Lambert 1995)
  • This may reflect methodological difficulties,
    e.g. differential attrition case mix

8
Challenges for research
  • Earlier, we found evidence that therapist skill
    in resolving alliance threats may have an impact
    on outcome in people with more severe complex
    problems (personality disorder) (Bennett, Parry
    Ryle, 2006)
  • Repeated or unredeemed errors have been linked to
    drop-out or deterioration

9
Severe complex problems
  • We predict relationship between competence and
    outcome stronger for people with severe complex
    mental health problems including personality
    disorder
  • Tend not to improve spontaneously in the short
    term (Stone, 1993)
  • Sensitive to therapist errors iatrogenic
    deterioration (Shearin Linehan, 1993)
  • More difficulty in therapeutic alliance
    (Waldinger Gunderson, 1984 )
  • More likely that maintenance of good working
    relationship (hence good outcome) requires
    therapist skill.

10
Aims of this study
  • For a sample of patients with severe complex
    mental health problems who received cognitive
    analytic therapy
  • To investigate the relationship between levels of
    experience and therapist competence (null
    hypothesis there will be no relationship)
  • To investigate the relationship between therapist
    competence and therapy outcome (null hypothesis
    there will be no relationship)

11
Sample
  • Patients with severe complex problems seen for
    CAT in routine services using naturalistic data
  • N112 patients in total (not all available for
    all analyses)
  • All patients had minimum of two year history of
    symptoms and service use
  • Methodological limitation descriptive not
    purposive sampling retrospective assignment of
    Axis II borderline personality disorder Axis I
    depression
  • n25 therapists
  • Full range of levels of training and experience
    from novice to expert

12
Measures CCAT
  • Measure of competence in CAT unit of assessment
    is whole session (Bennett Parry, 2004)
  • Empirically developed from NCVQ/UKCP competence
    framework for cognitive and humanistic therapies
  • 64 items of observable competencies grouped into
    10 domains each with overall score (0-4 Likert
    scale) total score 0-40.
  • Distinction between
  • early late sessions
  • technique specific non-specific competence

13
CCAT continued
  • Interactional view of competence takes account of
    task difficulty
  • Three reasons for an item of competence not being
    observed
  • Inappropriate in that session
  • Difficult to perform
  • Missing could should have happened but didnt
  • Acceptable reliability
  • Inter-rater agreement fair (Cohens Kappa
    0.63-0.67)
  • Item consistency (Cronbachs alpha 0.96, 0.98)

14
CCAT measure
  • 1. Phase-specific tasks
  • a) early engagement, induction remoralisation
  • b) review and evaluation of process and outcome
  • 2. Using theory to inform practice
  • 3. CAT-specific tools and techniques
  • 4. Establishing and maintaining the external
    framework
  • 5. Common factors basic supportive good practice
  • 6. Respect, collaboration mutuality
  • 7. Assimilation of warded-off, problematic states
    and emotions
  • 8. Making links and hypotheses
  • 9. Identifying and managing threats to the
    therapeutic alliance
  • 10.Being aware of and managing ones own
    reactions and emotions

15
Level of experience
  • Four levels of therapist experience
  • Novice (n5) new to CAT and to psychological
    therapy (e.g. DClinPsych or MRCPsych trainee)
  • Intermediate (n8) some experience of CAT and of
    psychological therapies (e.g. counsellor after
    one year of supervised experience)
  • Experienced (n7) gt2 years psychological
    therapist at CAT practitioner level
  • Trainer (n5) gt10 years psychological therapist
    ACAT accredited supervisor trainer in CAT

16
Assessment of outcome
  • Subgroup of patients for whom both pre- and post-
    therapy measures were available
  • CORE
  • BDI
  • SCL-90R
  • Therapy outcome assigned to one of three levels
    (n77 sessions)
  • Good (n37) statistically reliable improvement
    to a clinically significant criterion (Jacobson,
    1988)
  • Moderate (n27) statistically reliable
    improvement
  • Poor (n13) either no change or deterioration

17
Method
  • Three rater pairs established reliability on 27
    sessions
  • Further sessions rated by single judge
  • Each therapy session rated on CCAT
  • CCAT ratings blind to outcome of therapy
  • Two separate issues
  • Do therapy sessions of experienced therapists
    show higher CCAT scores?
  • Do therapy sessions from good outcome cases have
    higher CCAT scores?

18
Results competence experience
  • 3-way ANOVA therapist x case x experience showed
    no main effect of therapist
  • But significant main effect of experience
    (F7.66, plt.001)
  • Significance of linear trend tested by 1-way
    ANOVA with between-groups sum of squares
    partitioned into linear and non-linear variance
  • Significant relationship of experience with CAT
    competence (plt.0001)

19
CCAT scores across four levels of therapist
experience
20
What does it mean?
  • Therapy competence is related to experience in
    this sample
  • However
  • Not a longitudinal study least talented novices
    may later stop practising CAT
  • Variance reduces with experience levels
  • Some novices are demonstrating competence with
    little training and experience

21
CCAT scores across four levels of therapist
experience
22
What does it mean?
  • Therapy competence is related to experience in
    this sample
  • However
  • Not a longitudinal study least talented novices
    may later stop practising CAT
  • Variance reduces with experience levels
  • Some novices are demonstrating competence with
    little training and experience
  • Evident ceiling effect between intermediate and
    trainer level therapists

23
CCAT scores across four levels of therapist
experience
24
Results competence outcome
  • Significantly higher level of CAT competence
    demonstrated by therapists in sessions from CAT
    therapies with good outcomes compared with
    sessions from therapies with poor outcomes
  • Bonferroni post-hoc test showed that all the
    means of all three groups are significantly
    different from each other.

25
CCAT score for three outcome groups
26
What does this mean?
  • For this sample, very low levels of CAT
    competence were associated with poor outcomes

27
CCAT score for three outcome groups
28
What does this mean?
  • For this sample, very low levels of CAT
    competence were associated with poor outcomes
  • None of the good outcome therapies had poor
    levels of competence

29
CCAT score for three outcome groups
30
What does this mean?
  • For this sample, very low levels of CAT
    competence were associated with poor outcomes
  • None of the good outcome therapies had poor
    levels of competence
  • BUT it is possible to show moderate levels of
    competence and still have a poor outcome

31
CCAT score for three outcome groups
32
Conclusions
  • Reject the null hypotheses Positive findings of
    orderly relationships
  • Experienced therapists are more competent
  • More competent therapists get better outcomes
  • BUT methodological limitations of practice-based
    evidence
  • heterogeneous sample retrospective diagnosis
  • confound between experience and training
  • different measures of outcome
  • Replication part of current randomised
    controlled trial of CAT, CBT CMHT in helping
    people with borderline personality disorder

33
Write a Comment
User Comments (0)
About PowerShow.com