Mindfulness’ Reduction of Depression is not Related to Patient Engagement, Therapist Adherence or Interpersonal Skills
By John M. de Castro, Ph.D.
“Mindfulness training helps improve a patient’s engagement with their health, particularly in patients with chronic pain. It fosters a sense of bodily engagement and improves an individual’s ability to promote their health and well-being outside of the clinical setting.” – Caroline Meade
Psychotherapy is an interpersonal transaction. Its effectiveness in treating the ills of the client is to some extent dependent upon the chemistry between the therapist and the client, termed the therapeutic alliance. Research has demonstrated that there is a positive relationship with moderate effect sizes between treatment outcomes and the depth of the therapeutic alliance. The personality and characteristics of the therapist are essential ingredients in forming a therapeutic alliance. Research has shown that effective therapists are able to express themselves well. They are astute at sensing what other people are thinking and feeling. In relating to their clients, they show warmth and acceptance, empathy, and a focus on others, not themselves.
There are also other factors that may be important for successful therapy. The client’s engagement in the process may be as important as the therapists. In addition, the therapist’s adherence to the therapeutic program or interpersonal skills may also be important ingredients in producing successful therapeutic outcomes. There is little known, however, of the role of these characteristics in the effectiveness of treatment for mental health issues such as depression.
In today’s Research News article “Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement. Clinical psychology & psychotherapy.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585745/), Snippe and colleagues recruited adults with diabetes and comorbid depression and randomly assigned them to receive either Mindfulness-Based Cognitive Therapy (MBCT), Cognitive Behavioral Therapy, or to a wait-list. Treatments occurred in 8 weekly 45-60-minute sessions. MBCT was specifically developed to treat depression and involves mindfulness training, containing sitting, walking and body scan meditations, and cognitive therapy that is designed to alter how the patient relates to the thought processes that often underlie and exacerbate psychological symptoms, particularly depression.
The patients were measured before and after treatment for depression. “Therapists received a structured treatment manual including specific instructions on exercises, inquiry, and homework assignments per session.” All treatment sessions were video recorded. The recordings were viewed and coded by 2 blinded evaluators who rated the sessions according to the therapists’ adherence to the manual, therapists’ interpersonal skills, and client engagement in the sessions.
They found that although depression levels were significantly reduced by both treatments, the degree of improvement was not related to either the therapists’ adherence to the manual, therapists’ interpersonal skills, or to the clients’ engagement in the sessions. They found that the clients’ engagement in the sessions was positively associated with the therapists’ adherence to the manual. They also found that non-adherence to the manual occurred with verbose clients, when no symptoms were present, and with the clients’ life events during the week.
The results are interesting and reveal, as has previously been reported, that Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavioral Therapy (CBT) are both effective in reducing depression. It is interesting that the degree of effectiveness was not related to therapists’ adherence to the manual, therapists’ interpersonal skills, or to the clients’ engagement in the sessions. It remains for future research to identify the factors responsible for differing therapeutic outcomes.
So, mindfulness’ reduction of depression is not related to patient engagement, therapist adherence or interpersonal skills.
“When you are looking at primary care, this is the single most important thing. Can your intervention help enhance people’s capacity for self-management and health behavior change, especially among those who struggle most with self-regulation? Because at the heart of accountable care and patient-centered care is people being able to self-manage their own illness.” – Zev Schuman-Olivier
CMCS – Center for Mindfulness and Contemplative Studies
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Snippe, E., Schroevers, M. J., Tovote, K. A., Sanderman, R., Emmelkamp, P., & Fleer, J. (2019). Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement. Clinical psychology & psychotherapy, 26(1), 84–93. doi:10.1002/cpp.2332
Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence–outcome association. The current study aims to examine whether therapists’ interpersonal behaviours and patients’ active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness‐based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater’s explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory‐II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients’ active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists’ interpersonal skills, and patients’ active engagement did not predict posttreatment depressive symptom reduction. Patients’ active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient’s in‐session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.
Key Practitioner Message
- Therapist adherence was not associated with posttreatment depressive symptom improvement after CBT and MBCT
- Patient engagement was positively associated with therapist adherence to CBT and MBCT
- A broad variety of patient‐related reasons for therapist nonadherence were observed, of which some may not result in poorer treatment outcomes and may rather reflect therapist flexibility.