Sustaining Change from Psychotherapy: A Mixed Method Study

Background and Purpose: A large body of research supports the effectiveness of psychotherapy for a number of established approaches (e.g. cognitive behavioral, psychodynamic, and disorder-specific). Perhaps surprisingly, mental health research lacks follow-up studies.  Far less is known about (1) the extent to which gains from psychotherapy are maintained, and about (2) how clients make and maintain theese changes, that is, about how they participate in their own recoveries. Kazdin of Yale (2009) has noted this and has called for research into "the most pressing question (of) how therapy leads to change." 

Method:  This study used a quant-Qual mixed method sequential design to ask both questions. 168 former clients who had ended psychotherapy in the preceding 12 – 18 months at an outpatient mental health clinic were mailed both a follow-up Outcome Questionnaire (OQ-45.2) to complete and an invitation to return to the clinic for a qualitative interview. The interview questions were created by a focus group of clinic therapists and asked about: what did and didn’t help in psychotherapy, advice they would have for their therapist in working with future clients, and about how they continue to maintain the changes they made. Wampold & Imel’s (2015) contextual model was used as a conceptual framework throughout the study.   

Forty-two former clients returned an OQ-45.2. These were scored and compared to each client’s pretest (baseline) and posttest (end of treatment) scores.  Fifteen former clients participated in interviews describing their experiences of psychotherapy. Seven researchers coded the interviews for emerging qualitative themes. These themes were then shared with clinic staff as a form of a reliability check.  Statistical analyses were used to explore the degree to which clients made and maintained progress using an empirical measure: the OQ-45.2, (using a longitudinal, within subjects design).  These included paired sample t-tests, effect sizes, attention to clinically significant change, and sub-group analyses. 

 Results: The findings of the quantitative strand demonstrated change from pretest to posttest, posttest to follow-up, and from pretest to follow-up with an overall effect size of d = .5.  Qualitative themes emerged within three primary categories used to describe the findings. These included questions asking about: (1) what drove or facilitated change, (2) what participants do to maintain change post-therapy, and (3) what was and was not helpful in their therapy experience. Primary themes included the importance for these former clients of structure, the monitoring of progress, some “real relationship,” and of receiving feedback. Participants attributed change to variables such as an enlarged perspective.

Conclusions & Implications:  The findings are consistent with a recent qualitative meta-analysis (Levitt, et al., 2016). Practice implications include the importance of both monitoring client progress and of termination as a distinct phase of therapeutic relationships. Policy implications include attention to the importance of economic and other macro-level variables in supporting or discouraging mental health. Former clients who reported continuing symptomology often identified issues such as unemployment and economic stress as important extra-therapeutic factors. These findings in many ways support a larger literature that speaks to social determinants of health.