Suzy

Suzy is a 42-year-old woman who has been suffering from depressive symptoms for at least six months. Most of the time she is feeling grumpy, irritable, and down. Normally, Suzy was never this quickly startled or negative, and people close to her almost do not recognize her anymore. Suzy has become isolated. After a huge fight with her oldest daughter, Suzy decides to see the general practitioner who referred her to a psychologist. The psychologist tells Suzy that her symptoms could be classified as a depressive disorder and that her divorce one year earlier had possibly been a trigger for the start of her episode. The doctor advises Suzy to participate in an interpersonal psychotherapy group for patients with depressive disorders.

A couple of weeks later, Suzy starts in an interpersonal psychotherapy group with seven other patients with depressive symptoms. Although each group member has a different story, Suzy can relate and recognize their suffering. There are also two clinicians who do their best to provide effective treatment and give each group member time to talk about their situation. Unfortunately, five sessions into the therapy, Suzy is still not feeling better. In fact, she is feeling worse and has no idea how to talk about this in the group. She is ashamed, blames herself, and feels more isolated than ever.

We Want to Help Patients

Although group psychotherapy has been shown to be effective in the treatment of a variety of psychiatric symptoms, and it generally results in outcomes comparable to individual psychotherapy, not all patients benefit from treatment (Burlingame, Strauss & Joyce, 2013). Similar to individual therapy, in group psychotherapy, 5-15% of the patients will have worsened by the end of treatment (Schuman, Slone, Reese & Duncan, 2014; Slone, Reese, Mathews-Duvall & Kodet, 2015).

Suzy is feeling worse during group therapy, but despite their good intentions, her clinicians fail to notice the deterioration. This is not uncommon. It has been found that clinicians in general, tend to be quite poor at predicting negative treatment outcomes and have a tendency to miss negative changes during treatment (Hannan et al., 2005; Hatfield, McCullough, Plucinski, & Krieger, 2010; Chapman et al., 2012; Walfish, McAlister, O’Donnell, & Lambert, 2012).

We Also Need Some Help: Progress Feedback

Providing clinicians with information about their patients’ progress has been proposed as a possible solution (e.g. Bickman, 2008). Progress feedback entails that the clinician and their patients receive information about the patients’ progress on a questionnaire. The patient’s score is compared with earlier results on the questionnaire or, in case of more advanced systems, with an expected recovery trajectory. When the patient is not improving enough, both the clinician and the patient receive a signal, and some systems even give treatment suggestions with the use of a clinical support tool (CST) (Lambert, 2017).

That sounds great for Suzy and her clinicians. If Suzy’s progress had been monitored, then she and her clinicians would have known that the therapy was not going well, and they could talk about possible causes and solutions. Unfortunately, the use of progress feedback methods is currently not standard practice in group treatment.

Progress Feedback: What Do We Know?

The effects of progress feedback in psychotherapy have mainly been studied in individual psychotherapy and it seems that feedback is especially effective when patients are not progressing during treatment, like Suzy (Lambert, Whipple & Kleinstäuber, 2018). Progress feedback is even more effective when clinicians receive additional treatment suggestions in case of deterioration, such as “your patient is unhappy about the working alliance, help him to express his negative feelings about this, accept responsibility for your contribution to the interaction and seek for solutions.”

Until now, the effectiveness of progress feedback in group psychotherapy has been assessed in eight controlled studies (Burlingame et al., 2018; Byrne, Hooke, Newnham & Page, 2012; Davidsen et al., 2017; Davies et al. 2008; Koementas-de Vos, Nugter, Engelsbel & De Jong, 2018; Newnham, Hooke & Page, 2010; Schuman, Slone, Reese & Duncan, 2014; Slone, Reese, Mathews-Duvall & Kodet, 2015). In most studies it is found that progress feedback on well-being or general symptoms is helpful for patients in group treatment in terms of improving treatment outcome and/or number of followed sessions. In contrast to individual psychotherapy, there is no general finding that progress feedback is especially effective for patients who are not doing well. All patients are likely to benefit. Solely providing feedback on group climate instead of treatment progress seems to have a negative effect on treatment outcome (Davies et al., 2008). On the other hand, when extra information on working alliance, goals, and approach is provided alongside with treatment progress it can be more effective than progress feedback alone (Slone, Reese, Mathews-Duvall & Kodet, 2015).

Progress Feedback in Group Psychotherapy: A Case Example

In our study (Koementas-de Vos, Nugter, Engelsbel & De Jong, 2018) we developed a progress feedback method where patients fill out a standardized questionnaire on general symptoms, the Outcome Questionnaire 45 (OQ-45; Lambert et al., 2004), before each group therapy session. At the start of the group session clinicians receive a general graph of the trajectories for all patients, see Figure 1 for an example.

Figure 1

Figure 1 reflects Suzy’s functioning at the fifth group therapy session. Suzy’s scores on the OQ-45 have increased since the third session, which means that her symptoms are getting worse. Her clinicians are also alerted by the risk items that Suzy has thoughts about ending her life. At the same time, Suzy receives a graph on her treatment progress as well and is informed that she is not doing well. Both clinicians and Suzy receive the suggestion to discuss the deterioration.

The results of our study show that providing progress feedback does not have an effect on the severity of symptoms at the end of treatment, but patients end their treatment in significant fewer sessions in comparison with group treatment as usual. In other words, the feedback method seems to make the group psychotherapy more efficient.

In the case of Suzy, at the start of the following group session her clinicians talk about the worsening of symptoms with Suzy. It is a big relief for Suzy. She tells the group that she is feeling alone and she is convinced that nobody cares. She experiences the concern of  her clinicians and the group members are well-willing in thinking about possible solutions for the experienced loneliness. Suzy formulates a new treatment goal: I want to get in touch with my sister again. The following sessions Suzy works on her goal and she sees her sister more frequently. She even asks her sister for help. After a few more sessions the progress feedback graph reveals a decrease of symptoms: Suzy is feeling better.

Group Psychotherapy and Progress Feedback: The Future

Research on monitoring treatment progress and feeding progress back to clinicians and patients in group psychotherapy is still at an early stage. Currently, we know that progress feedback in group treatment can be effective, but it is unclear what elements of progress feedback in group psychotherapy seems to be effective and why they are effective. For example, we do not know if extra treatment suggestions for clinicians are more effective than progress feedback alone.

Furthermore, most progress feedback research is data-driven and underlying theories are hardly mentioned. There are feedback theories that could help in the search for effective progress feedback, like the Feedback Intervention Theory (FIT) of Klüger and DeNisi (1996) and the Contextual Feedback Intervention Theory (CFIT) of Riemer and Biekman (in: Sapyta, Riemer & Biekman, 2005). These theories describe the importance of goal-directed feedback interventions: if the feedback information is too far related from the stated goal, then the feedback will have no effects or even adverse effects.

Research on underlying mechanisms of effective progress feedback in group psychotherapy is highly needed. Hopefully, with more research on how to provide effective feedback in a group setting, we can prevent more patients like Suzy from deteriorating during therapy and obtain better outcomes for a larger number of patients.

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Marjolein M. W. Koementas-de Vos, M.Sc.

Marjolein M. W. Koementas-de Vos is an external PhD candidate. Her research entails the use of progress feedback in group psychotherapy. Alongside the research project she works as a clinical psychologist and psychotherapist at GGZ Noord-Holland-Noord, a mental health care institute in The Netherlands. She is also trainer, supervisor and teacher for psychologists in training for mental health psychologist and specialist.