Internet Editor’s Note: Ms. Alice Coyne and colleagues recently published an article titled “Therapist Responsivity to Patients’ Early Treatment Beliefs and Psychotherapy Process” in Psychotherapy.
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Although using an empirically supported treatment package to treat specific mental health problems may represent a good starting point, there is growing recognition that evidence-based practice (EBP) involves more than the uniform application of such standardized interventions. One of the main research findings driving this perspective is that global therapist adherence to a specific treatment is unrelated to patient outcomes (Webb, DeRubeis, & Barber, 2010). Thus, to be effective with any given patient, therapists will inevitably face decisions about when to stick with a protocol or when it may be best to go “off script.” Unfortunately, another widely acknowledged problem is that treatment manuals rarely include practical, evidence-based guidelines for what to do when treatment is not progressing as planned. This gap is especially problematic given compelling evidence that simply continuing with the prescribed treatment strategies in the face of disruptive therapy process can be harmful (Castonguay, Boswell, Constantino, Goldfried, & Hill, 2010).
Expanding the Evidence Base
In response to such findings, many researchers and clinicians have increasingly focused on evidence-based personalization strategies, including in the very early stages of therapy (e.g., treatment selection and planning). One broad approach to such evidence-informed decision making is known as context-responsive psychotherapy integration (CRPI; Constantino, Boswell, Bernecker, & Castonguay, 2013). CRPI is a pantheoretical and transdiagnostic framework that utilizes an if-then approach to clinical decision points. Specifically, in CRPI, common factors are viewed as frequently encountered clinical scenarios (including if markers of relevant patient characteristics and/or emerging therapy processes) to which therapists need to be responsive by using modular, evidence-based, and pointed then strategies.
One relevant class of common factors are patients’ treatment-related beliefs. Arguably the most widely studied of these beliefs is a patient’s outcome expectation (OE), or prediction about the extent to which a given course of treatment will be helpful (Devilly & Borkovec, 2000). A recent meta-analysis found that greater early therapy OE was associated with more positive treatment outcomes (Constantino, Vîslă, Coyne, & Boswell, 2018). Another relevant belief is a patient’s perception of treatment credibility, or how personally logical and suitable a given approach seems (Devilly & Borkovec, 2000). Similar to OE, a recent meta-analysis found that greater early patient-perceived treatment credibility was associated with more improvement (Constantino, Coyne, Boswell, Iles, & Vîslă, 2018).
Given that patients’ treatment-related beliefs can exist prior to and/or very early after the first contact with a provider, and that they wax and wane across a given course of therapy, they may represent salient evidence-informed if markers both for very early treatment decision making (i.e., initial context-responsiveness) and for momentary responsiveness throughout. Put another way, because therapists are constantly called upon to make decisions during treatment, it can be useful to draw on research (when possible) to make such decisions. And, we see attending to patients’ treatment-related beliefs as just one approach to this process.
Using Patients’ Treatment Beliefs to Select a Treatment
One of the earliest decision points therapists face is treatment selection. To maximize the likelihood of an effective patient-treatment match, therapists would be wise to attend to patient beliefs at this stage. To do so, therapists can use the initial interview to elicit information about:
- Patients’ previous therapy experiences, if applicable, including the aspects of any past treatments that patients found helpful or unhelpful (and their perspectives on the reasons why).
- Details about patients’ past relationships with previous therapists, if applicable, and expectations or preferences about the current therapist and therapy relationship.
- Patients’ past successful and unsuccessful attempts to cope with their problems.
- Patients’ beliefs about the etiology and maintenance of their presenting problem(s).
Such information can then be used, for example, to select a treatment with putative change mechanisms that fit with a patient’s personalized beliefs about the etiology and maintenance of their presenting problem(s). Or, information about treatment or coping strategies that a patient has found to be ineffective in the past could be used to rule out approaches that prioritize similar strategies. In CRPI language, such information would be used to make an evidence-informed decision about which “home” orientation has a maximal fit with a patient’s own understanding of, language around, and beliefs about their current issues. Ideally, this type of treatment selection process would increase or maintain patients’ initial positive OE and treatment/therapist credibility perceptions, which evidence indicates should facilitate better ultimate outcomes.
Cultivating Positive Treatment Beliefs
After using patients’ OE and credibility perceptions to select a personally suitable empirically supported treatment, therapists will soon face another decision point regarding how best to tailor the treatment rationale and plan to fit even more closely with what the patient finds credible and hope-inspiring (i.e., putting an idiographic spin on a nomothetic set of interventions). For example, therapists may wish to:
- Use empirically supported treatment-focused expectancy persuasion tactics such as describing a given treatment as evidence-based, broad in focus (e.g., one that targets emotions, cognitions, and behaviors), and prestigious. Therapists can also use some technical jargon and provide vignettes of past successful cases (see Constantino, Vîslă, et al., 2018).
- Tailor the treatment rationale to fit closely with a patient’s beliefs about pathology and change (see Constantino, Vîslă, et al., 2018; Constantino, Coyne, et al., 2018).
- Personalize the treatment rationale and plan to fit with patients’ unique strengths and current state of mind (see Constantino, Vîslă, et al., 2018; Constantino, Coyne, et al., 2018).
Using such strategies has been shown to increase patient OE and credibility beliefs, which may, as noted, increase the ultimate likelihood that treatment will be successful. For some patients, early attention to such beliefs may be a vital step in ensuring that treatment gets off on the right foot (Coyne, Muir, & Constantino, 2019; DeFife & Hilsenroth, 2011).
Responding to Negative or Waning Treatment Beliefs
Even after selecting a treatment that matches a patient’s expectations and credibility beliefs, therapists should be alert for more belief-relevant decision points as shifts in patient OE and credibility perceptions might occur throughout treatment. When positive, such shifts may represent markers (i.e., the if) that treatment is “on track” and the most appropriate therapist response (i.e., the then) would be to continue implementing the theory-consistent strategies that a patient has found credible and helpful. When negative, such shifts may represent markers that treatment is “off track” and the most appropriate therapist response would be to depart (either temporarily or permanently) from the selected treatment.
In the latter scenario, a first step to evidence-informed decision-making would be to notice and attend to markers of waning treatment beliefs. Such markers may be direct (e.g., a patient verbally expressing lowered hope regarding the likely effectiveness of treatment, a lower score on an OE or credibility measure) or indirect (e.g., lowered treatment engagement, withdrawal, resistance). After detecting such markers, therapists may next wish to determine the origins of a patient’s waning treatment-related beliefs. Eliciting such information is important given that the type of evidence-based departure that is called for can differ based on the context. For example, when a patient’s waning OE and/or credibility perception occurs in the context of a treatment that has been effective thus far, the best response could involve attempts to directly cultivate more positive OE and credibility perceptions regarding the original treatment. For example, therapists may wish to try:
- Reminding patients of past successes and highlighting early improvement, which has been linked to increased credibility perceptions (Mooney, Connolly Gibbons, Gallop, Mack, & Crits-Christoph, 2014).
- Taking a warm and supportive stance when working with low patient OE and credibility beliefs (Constantino et al., 2007) and treading lightly by being careful not to outpace a patient’s beliefs by conveying a greater degree of optimism regarding treatment than a patient is willing to accept (Ahmed & Westra, 2008).
- Personalizing OE and credibility enhancing statements to fit with patients’ unique experiences and strengths (see Constantino, Vîslă, et al., 2018; Constantino, Coyne, et al., 2018). For example, therapists could remind patients of strategies that have worked for them in the past, even when patients were feeling temporarily hopeless.
At other times, waning OE or credibility perceptions may have to do with a more serious mismatch between the selected treatment and a patient’s belief system. In such cases, rather than touting the virtues of a treatment that has not been working for a patient, the most effective response strategies could include modifying the aspects of the selected treatment that a patient does not find credible or effective, or even using more radical measures such as permanently departing from the original approach (Constantino, Coyne, et al., 2018; Constantino, Vîslă, et al., 2018). For example, if the diminished OE or credibility perception stems from the use of a particular treatment strategy (e.g., the completion of automatic thought records), therapists can adapt that component so that a given patient finds it more credible/suitable (e.g., completing thought records together in-session rather than as between-session homework) or replace that component with another strategy that fits with a patient’s personal beliefs (e.g., using acceptance-based strategies to address negative thoughts for a patient who does not buy into the idea of directly altering cognitions). Alternatively, if a patient’s diminished OE and credibility perception appear related to the treatment in its entirety, a therapist may wish to depart from the original treatment and move to an approach that better fits with the patient’s belief system (Coyne et al., 2019).
In sum, we believe that responding to patients’ treatment-related beliefs represents one example of evidence-informed decision-making that may guide therapists in treatment personalization attempts. The use of such evidence-based decision-making should help to maximize the likelihood that a particular treatment course will be effective for a given patient. The aforementioned strategies represent just a few examples of this perspective, and interested readers can get more information about this approach from the following publically available resources:
- For a clinical example of how one therapist attempted to use the CRPI framework to cultivate more positive treatment beliefs and to flexibly respond to waning treatment beliefs, please see Coyne et al. (2019), which is presently featured on the Society for the Advancement of Psychotherapy (APA Division 29) website.
- A video-recorded interview with Dr. Michael Constantino, an expert on patient OE, as part of the Society for the Advancement of Psychotherapy’s “Teaching and Learning Evidence-Based Relationships” initiative.
- A video-recorded interview with Dr. James Boswell, an expert on treatment credibility, as part of the Society for the Advancement of Psychotherapy’s “Teaching and Learning Evidence-Based Relationships” initiative.
Cite This Article
Coyne, A. E., Muir, H. J., & Constantino, M. (2019, June). Responsivity to patients’ early treatment beliefs as a form of evidence-based decision making. [Web article]. Retrieved from https://societyforpsychotherapy.org/responsivity-to-patients-early-treatment-beliefs-as-a-form-of-evidence-based-decision-making
Ahmed, M., & Westra, H.A. (2008, September). Impact of counselor warmth on attitudes toward seeking mental health services. Paper presented at the meeting of the North American Chapter of the Society for Psychotherapy Research, New Haven, CT.
Castonguay, L. G., Boswell, J. F., Constantino, M. J., Goldfried, M. R., & Hill, C. E. (2010). Training implications of harmful effects of psychological treatments. American Psychologist, 65, 34-49. doi:10.1037/a0017330
Constantino, M. J., Boswell, J. F., Bernecker, S. L., & Castonguay, L. G. (2013). Context-responsive integration as a framework for unified psychotherapy and clinical science: Conceptual and empirical considerations. Journal of Unified Psychotherapy and Clinical Science, 2, 1-20.
Constantino, M. J., Coyne, A. E., Boswell, J. F., Iles, B., & Vîslă, A. (2018). A meta-analysis of the association between patients’ early perception of treatment credibility and their posttreatment outcomes. Psychotherapy, 55, 486–495.
Constantino, M. J., Manber, R., Ong, J., Kuo, T. F., Huang, J., & Arnow, B.A. (2007). Patient expectations and the therapeutic alliance as predictors of outcome in group CBT for insomnia. Behavioral Sleep Medicine, 5, 210-228. doi:10.1080/15402000701263932
Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55, 473-485.
Coyne, A.E., Muir, H. J., & Constantino, M. J. (2019). Therapist responsivity to patients’ early treatment beliefs and psychotherapy process. Psychotherapy, 56, 11-15. http://dx.doi.org/10.1037/pst0000200
DeFife, J. A., & Hilsenroth, M. J. (2011). Starting off on the right foot: Common factor elements in early psychotherapy process. Journal of Psychotherapy Integration, 21, 172–191. http://dx.doi.org/10.1037/a0023889
Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, 73-86. doi:10.1016/S0005-7916(00)00012-4
Mooney, T. K., Connolly Gibbons, M. C., Gallop, R., Mack, R. A., & Crits-Christoph, P. (2014). Psychotherapy credibility ratings: Patient predictors of credibility and the relation of credibility to therapy outcome. Psychotherapy Research, 24, 565-577. doi:10.1080/10503307.2013.847988
Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 200-211. doi:10.1037/a0018912