Toward a personalized approach to psychotherapy outcome and the study of therapeutic change.

Cuijpers highlights that, in spite of major progress in mental health research, there are still many important unanswered questions regarding psychotherapies. He emphasizes the significance of looking beyond symptomatic reduction and studying a range of treatment outcomes. He suggests (and we agree) that symptom reduction does not necessarily reflect many crucial and sustainable aspects of therapeutic change. One of the reasons why change in symptoms is the most widely studied outcome is that researchers conducting rando mized controlled trials (RCTs) are required to define their primary outcome a priori. Defining multiple primary outcomes results in an increase of the number of individuals to be included in a study to satisfy statistical power requirements. Thus, selecting a broader more representative range of outcomes becomes expensive, impractical and strategically problematic within the current major funding mechanisms. Additionally, reports of con flicting findings when similar research questions are examined using different measures make it difficult to determine which measures are to be prioritized conceptually and psychometrically. It is indeed crucial to conceptualize and measure outcomes from the patient’s perspective. Even patients who experience reductions in symptoms and meet remission criteria may still struggle in major domains such as navigating relationships, regulating emotions, maintaining consistent employment, and coping with stress. Other aspects of outcome, such as patients’ capacity to cope with stressors and to use strategies learned in therapy in the face of adversity, should also be evaluated. Another understudied outcome is patients’ gained subjective sense of freedom – one’s ability to confront and resolve conflicting demands that arise from perceptions of the outer and inner worlds and make “choices” that are not determined by unconscious forces. A patient-centered approach suggests that the treatment course should be guided by patients’ specific needs, preferences, and perspectives on their own therapeutic change. Many medical specialties are now shifting towards a “precision medicine” model – tailoring treatment to the individual patient. In psychotherapy, this model requires a comprehensive assessment of the individual patient’s functioning across multiple domains in order to develop a personalized treatment plan. Some progress has been made in the development of computerized algorithms, with preliminary evidence for efficacy of matching patients with the optimal treatment package. However, implementing these algorithms requires the availability of skilled therapists who can deliver the selected “optimal” complex treatment modality. Treatment packages involve extensive clinical training and supervision, which limits their feasibility and applicability, especially for large populations of patients who reside in areas with limited access to experienced mental health professionals. Thus, in addition to focusing on matching patients with treatment packages, researchers could focus on matching specific treatment components with specific patients’ needs. One of the big unanswered questions is whether therapy should focus on the patients’ strengths or remedy their deficits. For example, do patients who struggle with interpersonal relationships benefit more from treatments focusing on social and interpersonal skills? Similarly, will patients who struggle with avoidance or apathy benefit more from exposure to rewarding and meaningful activities? Alternatively, a personalized approach may focus on reinforcing existing strengths and resources. For example, patients who are naturally aware of their thought processes may benefit from focusing on distorted cognitions (even if they do not receive a full manualized protocol of cognitive behavioural therapy). On the other hand, patients who have a strong social support system and connections with helpful significant others may benefit from behavior al activation focusing on social and interpersonal engagement. These are important research issues that have rarely been addressed. One of the challenges in studying the benefits of particular treatment components (or mechanisms of change) is that researchers rarely include in their studies components that are not part of their declared treatment approach (although there are some exceptions). This creates a gap between the relatively clean studies on treatment components associated with change and a clinical practice where most therapists flexibly integrate techniques from various approaches. Studies reflecting clinical practice could facilitate our understanding of which particular components of treatment are beneficial to patients with specific clinical presentations. Another crucial challenge raised by Cuijpers is the high rates of non-response to treatment. Whereas meta-analyses provide valuable information regarding the utility.