Putting the psychotherapy spotlight back on the self-reflecting actors who make it work.

Abstract

World Psychiatry 18:3 October 2019 group-level rates of non-response, it is difficult to translate this information into meaningful clinical recommendations for individual patients. An important developing area of research is early detection of risk for non-response. Conventionally, nonresponse studies are conducted after the trial has closed and patients are no longer receiving treatment; i.e. treatment failure is studied retrospectively. We propose that efforts should be focused on detecting non-response or deterioration early on, after the first several sessions. Then, a stepwise treatment approach could be used in order to intervene (e.g., augment specific treatment components or shifting towards a different treatment focus). Data from RCTs are valuable as they provide opportunities to test various treatment components and outcomes over time within distinct controlled treatments. However, as funding for psychotherapy research rapidly declines in the US and around the world, researchers are faced with a significant crisis. Some are shifting towards naturalistic studies through the development of practice research networks. Such networks are based on the premise that research thrives on true continuous communication between stakeholders and collaboration between clinicians in the community and researchers in academia. Studies developed are informed and guided by clinicians’ observations and input, and findings are integrated in clinical settings. These studies also promote greater diversity and representation of individuals from minority groups, who often do not have access to academic medical centers where RCTs are conducted. We anticipate that, in the future, more of our data will emerge from such studies. Overall, future research should include combinations of rigorous method ologies and personalized approaches to psychotherapy. Studies should identify non-responders early on and develop protocols to address risk of non-response or deterioration before the trial ends. These studies should be done in collaboration between clinicians, researchers, policy makers and patients. Outcomes should include not only symptomatic changes but also a range of intermediate outcomes/mechanisms that may go beyond the researcher’s theoretical orientation. Such collaboration can expand our understanding of the complex and nuanced aspects of “therapeutic change” and move us closer towards answering the question: “what makes psychotherapy work?” .