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Deterioration in Psychotherapy: A Summary of Research by Jorgen Flor

Summary of a study by Jorgen Flor on negative outcomes in psychotherapy.

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Deterioration in Psychotherapy: A Summary of Research by Jorgen Flor

  1. 1. Summary This qualitative study explores 10 Norwegian psychologists thoughts about patients' deterioration in psychotherapy. Data are analyzed using systematic text condensation, and discussed in the light of existing research literature. The results show a lack of common terminology, little knowledge and great variation in how informants understand patients' deterioration. Psychologists underestimate the occurrence of deterioration in their own practice, they experience to a small extent a culture where these issues can be discussed and several reports that theme is uncomfortable. Informants have gotten little or no teaching, guidance or training on the topic, although they express a desire for this. The study shows how little awareness of patients' deterioration in education and research propagates to the practical professional practices. This study is not appropriate to say something about the findings is representative of psychologists in general. Further research should collect data on negative outcomes from both patients and therapists using quantitative methods Conclusion The purpose of this work has been to explore how psychologists think about negative outcome, and contribute to a better basis for quantitative work with the same questions. This study shows that quantitative surveys has methodological challenges with respect to validity. One can not assume that negative outcome is interpreted equally. This underpins the assessments that were made in advance and which led to the choice of method and formulation of research questions. Informants in this study have difficulties both to define and identify patients' deterioration. Although everyone recognizes that deterioration may occur, their explanations as to why, how and when this occurs is incongruent. A main finding is therefore a lack of common terminology about negative outcome. This may be because none of the psychologists have received adequate instruction or guidance about patients' deterioration, neither during education, through continuing education nor in the workplace in general. The consequence is that their responses emerges as educated guesses withouth basis in evidence-based knowledge. They speculate that patients' deterioration often are temporary, that it is due therapists mistakes or that there is a marginal phenomenon in his own practice. Such arbitrary and haphazard understanding is reinforced by the absence of a culture at the workplace where these questions are subject to systematic thematization. Their workplace seem to lack a psychological safe environment that enables this thematization. The difficulties of adopting a self-critical attitude to their own practice is enhanced by personal discomfort and negative feelings relating to patient deterioration. Little knowledge of negative outcomes, considerable variation in how to measure treatment outcomes, lack of culture in the workplace to address these questions and a personal discomfort related to their role creates a major obstacle to thematises patients' deterioration. This study can counteract this tendency by creating more awareness of the negative outcome in psychotherapy.
  2. 2. Some excerpts fromthe discussion Measuring the effect of psychological interventions is essential When the psychologists state that few or none of their patients has deteriorated, they build this on our own clinical judgment assessments. No displays of data, statistics or other sources. These judgments are influenced by a range of cognitive fallacies, complicating efforts to identify, explain and deal with patients' deterioration. When therapists interpret the therapy process, they should avoid relying entirely on their own clinical judgment. A precise conceptual framework is a prerequisite to talksoberly about worsening This study reveals great variety and lack of precision in how psychologists describe patients' deterioration. If one is to be able to talk about negative outcomes, we need a recognizable and understandable terminology for it. This study indicates that such a conceptual framework is not in place by the informants. (…) Concepts such as "harmful therapy" and "harmful therapists" implies that the therapist blame for patients' deterioration. Such discussion can stand in the way of a sober understanding of negative outcomes, inhibit survey of patients' deterioration and affect therapist's assessment of their own skills. Treatment-induced deterioration until the opposite is proven? However, there is an important difference between having the responsibility to detect and deal with negative outcomes, and getting blamed for it happening. The results of this study suggest that many psychologists may experience the latter, and that this can come at the expense of work with the first. Both the therapist and the therapist system is part of the must-have-responsibility for the measures necessary for the negative outcomes to be identified. Therapists should also have that basically that any deterioration caused processing, and look for evidence to the contrary. Thus the therapy or therapist "guilty" until proven otherwise. From transient to persistent deterioration - the therapist's responsibility eitherway? The difficulties in defining what negative outcomes are frequently associated with the assumption that patients become worse before they get better. The term deterioration is equally hazy when used to describe temporary deterioration as it is when used to characterize lasting deterioration. The question of when a determination that a patient has deteriorated becomes even harder. This vagueness associated with a symptom exacerbation can probably be solved by means of a clearer conceptual framework about negative outcome. It absolutely overriding premise is that if the patient becomes worse during therapy, the therapist must clarify why. Some clinical implications One of the main conclusions of this study is that a good knowledge on negative outcome is necessary for clinicians to identify patients' deterioration. Today, this seems to be scarce, and one should therefore ensure that future psychologists are taught about negative outcomes. In addition, one should update todays clinicians using courses and guidance. This study indicates that experience of psychological security is too poor for more jobs. It is of serious concern that psychologists report discomfort, shame, guilt and negative feelings
  3. 3. related to this topic. In light of this, one should consider doing surveys specificially aimed at psychologists' experience of doing "Wrong" to their patients. A good working environment is a prerequisite to talk about the difficult questions related to negative outcome.