Complex individual pathways or standard tracks? A data‐based discussion on the trajectories of change in psychotherapy

Abstract

Objective: Current approaches of routine outcome monitoring (session-by-session measures) expect that trajectories of change should move on a standard track. Patients moving out of standard tracks are assumed to be at risk of deterioration. From a nonlinear dynamic systems perspective, there is not any assumption regarding a supposed standard track a patient should follow. Individual trajectories should be more complex than averaged tracks, highly individual, and characterised by pattern transitions. Method: We tested if high-frequency (daily) trajectories of change are moving on standard tracks, if there are different complexity levels of high-versus low-frequency time series, if 'not on track' dynamics will be correlated with poor outcome and if complexity peaks representing the critical instabilities of a process will be correlated with the outcome. The patients included in the data analysis (N = 88) used the Therapy Process Questionnaire (TPQ) for daily self-assessments and the ICD-10based Symptom Rating (ISR) for outcome evaluation. Results: High-frequency trajectories are not running on standard tracks and are not necessarily correlated with poor outcome. Locally increased complexity may be associated with good outcome. Conclusion: It may be useful to move beyond the concept of standard tracks and expected treatment outcomes. Routine feedback procedures should use the information that is given by the nonlinear dynamics of multiple change criteria. K E Y W O R D S dynamic complexity, nonlinear dynamic systems, on track versus. not on track, processoutcome research, psychotherapy feedback This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

A complex systems approach to the study of change in psychotherapy

“…An important design consideration when collecting time-series data is selecting the time interval (sampling rate) most sensitive for detecting change in the variables of interest [ 5 , 66 ]. Some variables change slowly (e.g., over weeks, months, years) and others more quickly (e.g., in seconds, minutes, hours) [ 24 , 31 , 67 – 70 ].…”

Complexity in psychological self-ratings: implications for research and practice

“…In a recent study by Rubel et al [88], process-outcome relations in psychotherapy could not be reliably predicted on the basis of processoutcome relations from patients with highly similar pretreatment characteristics. A finding which may be explained by the presence of a butterfly effect (i.e., individual trajectories diverge over time; see also [61,62]).…”

“…• Frequent process monitoring is essential to track the change process • Few measurements may give a misleading impression of the clinical change processes standard tracks [61]. On the individual level, clinical change processes are highly irregular and fluctuating, as comes apparent when enough measurements are taken.…”

“…Short-term prediction is possible, but prediction becomes highly unreliable after a few days. A clinical example is provided by Tschacher et al [35], who found that the evolution of schizophrenia symptoms for many patients in their study sample was predictable only in the short term, but not in the long term (see also [34,61,62]).…”

Depression – ein komplexes dynamisches System

“…Benutzt werden hierfür standardisierte Prozessfragebögen wie der Therapie-Prozessbogen (TPB, Schiepek et al, 2019) oder aber personalisierte Fragebögen, die auf der Basis einer umfassenden Fallkonzeption gemeinsam mit den Patient*innen erstellt werden. Erkennbar ist in jedem Fall, dass Therapieprozesse keinem Standardverlauf folgen, sondern hoch komplex und individuell verlaufen (Schiepek et al, 2020).…”