The effectiveness of psychotherapy delivered in routine service settings

Understanding the extent to which psychological therapy is effective, and under which conditions, is important for the provision of mental health treatment. Historically, there has been a large weighting for evidence generated from research methodologies that possess high internal validity (e.g., randomised-controlled trials). Unfortunately, treatments evaluated with these methodologies, usually conducted in University settings, often fail to represent various aspects of routine care settings and treatments which they are purposefully intended for (e.g., lower levels of client heterogeneity and risk, fixed treatment lengths, manualised treatments). Due to this distinction (i.e., efficacy vs. effectiveness), it is subsequently important to establish the extent to which treatments remain effective when delivered within routine care. Since the turn of the century there has been a marked increase in the amount of evidence from routine care settings regarding the effectiveness of psychological therapy. The first chapter of this thesis was a comprehensive review of this body of literature, focusing on one-to-one, face-to-face psychological treatments within naturalistic settings. 252 studies were identified, comprising a total of 298 different therapy samples. These samples were analysed quantitatively using meta-analysis. The findings demonstrated that psychological therapy produces marked improvements (i.e., large effect-sizes) across each self-reported outcome domain explored (depression, anxiety, general distress). Effect-sizes tended to be larger under certain conditions: (i) studies conducted in the UK/North America, (ii) studies which only include patients who complete treatment, and (iii) studies with low risk of bias. This was the largest review of routine practice studies concerning psychological therapy which has been conducted to date. The second chapter of this thesis was an evaluation of how patients respond to psychological treatment from a UK tertiary care psychological therapy service. Evidence arising from these settings is highly scarce. Such treatments are intended to be across longer periods and for more distressed/complex presentations than treatments delivered in other care settings (primary and/or secondary care). The current study found that while tertiary care therapy is effective, the amount of change is smaller than available benchmarks. Rates of improvement were suppressed by a sub-set of patients who appeared to not respond to treatment. The three forms of psychological therapy offered were not significantly different in effectiveness. Patient rate of improvement (positive growth) reduced with each session. There was limited evidence to support continuing treatment beyond 100 sessions. Taken together, the chapters presented provide further evidence that psychological therapy is effective across a wide range of routine care settings. Similar to prior findings, there was limited support for long-form psychological treatments. Support was shown for the potential utility of routine outcome measures as a tool to determine when a patient is no longer benefiting from treatment. The evidence considered in these chapters predominantly concerns self-report outcome measures. Further research is needed to determine consistency of findings through other measures of effectiveness (e.g., clinician-rated change, health-care cost/utilisation, reduction in harm events). Further research is needed which focuses upon how improvements made during therapy are maintained beyond treatment ending.