A new mixed-methods study published in the Journal of Counseling Psychology examined what a “good outcome” meant for patients who underwent cognitive-behavioral therapy (CBT) and psychodynamic therapy for major depression.
Through in-depth interviews with patients, the researchers found that patients understood recovery and improvement as an ongoing process, with new questions and difficulties arising over time. Psychotherapy patients also reflected that a “good outcome” includes feeling empowered and having fewer internal conflicts, more positive relationships, and less negative ones. These findings provide a more nuanced and patient-centered alternative to the symptom-based outcomes measures regularly used in randomized clinical trials (RCTs) to determine the effectiveness of therapy or medication for depression.
“Our findings suggest that a symptom-based distinction may not always be meaningful in light of patients’ experiences, and consequently, a continuum based on outcome would still not do justice to the variety of experiences that do yield varying clinical implications,” De Smet and colleagues from Ghent University, write.
“In that sense, a good outcome in psychotherapy for depression seems to require a multidimensional understanding, in line with the complex and diverse experiences of depression itself.”
Research on the outcomes and effectiveness of psychotherapy has found evidence that a broad range of approaches can reduce depressive symptoms, including psychodynamic therapy and CBT. These trials have deemed effective treatments that show a significant reduction of symptoms and symptom severity.
However, the focus on symptom reduction has been criticized for overly medicalizing patient experiences of therapy and for minimizing the importance of other changes that contribute to the quality of life. Moreover, the usefulness of RCTs for therapy has been challenged as they have deficient ecological validity –in other words, therapy within clinical trials (which is heavily manualized and controlled) looks different from the kind of therapy provided in everyday settings.
The purpose of this latest study was to understand how people who had “good outcomes” in CBT or psychodynamic therapy for depression, in terms of symptom reduction measures, understood their own improvement and recovery. These patients had “good outcomes” when their depressive symptoms were measured using the Beck Depression Inventory-II (BDI-2) before and after therapy. The researchers identified those who were recovered or improved using the Jacobson and Truax method for outcome classification. Those who fell into these categories were then interviewed about how they experienced their experience.
The results from the interviews highlighted that patients within both categories (recovered and improved) and who were in both types of therapy (psychodynamic and CBT) had similar experiences of “good outcomes.” The researchers captured their results in three major themes: empowerment, personal balance, and ongoing struggle.
Ongoing Struggle: After the end of therapy, patients described experiencing a more consistent mood and feeling less distress. At the same time, however, they expected that their struggles would continue over time and stated that they still needed to learn and grow.
Patients who recovered reported feeling as though some concerns had not yet been addressed. Improved patients were more likely to talk about ups and downs during the end of therapy, some mentioning experiencing relapses after improvements.
Patients from both groups talked about being hopeful that the psychotherapeutic experience provided relief and that they could either continue to learn and grow after therapy, or that they could return to therapy (especially improved patients).
Feeling Empowered: Both recovered and improved patients described a newfound self-confidence, increased self-esteem, and a sense of personal growth. They also described being mindful of and respecting their boundaries and taking care of their needs.
Empowerment was also experienced through feeling more in control of negative thoughts, and better able to understand emotions, helping them feel more capable of facing future distress and difficult situations.
Personal Balance: When describing personal balance, patients talked about experiencing more interpersonal harmony, which often meant that they had fewer negative relationships or interactions while fostering better ones. They also described feeling closer to significant others. Also, patients who were categorized as improved were more likely to express a separation from people who they identified as intrusive or overbearing.
Patients also mentioned having increased insight into their symptoms. Recovered patients were more likely to identify problematic aspects of their lives that might have led to their symptoms and described actively work to change them. On the other hand, improved patients who mentioned insight were more likely to repeat insight brought up by the therapist rather than themselves.
The design and results of this study have implications for the research on psychotherapy outcomes. The study highlights how patients benefit from therapy beyond the reduction of symptoms and that patients value therapy for the various ways in which they experience change. The results also highlight the discrepancy between what patients identify as meaningful and what traditional research studies measure to determine the effectiveness of an intervention.
De Smet, M.M., Meganck, R., De Geest, R., Norman, U.A., Truijens, F. & Desmet, M. (2020). What “Good Outcome” Means to Patients: Understanding Recovery and Improvement in Psychotherapy for Major Depression From a Mixed-Methods Perspective. Journal of Counseling Psychology, 67(1), 25-39 (Link)