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Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk

Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy, 10(6), 361-373.

Much of psychotherapy research has focused on searching for effective psychotherapies rather than focusing on effective psychotherapists. Research on psychotherapies generally assumes that therapists are equally effective or relatively less important to patient outcomes than the interventions themselves. Therapists in clinical trials are trained to follow a manual in an attempt to reduce the therapists’ impact on patient outcomes, and to focus the study on the specific ingredients of the therapy itself. However, research indicates that the degree to which a therapist follows a manual has little bearing on patient outcomes, and that therapists do differ in terms of their patients’ outcomes. In one large study, between 33% and 65% of therapists was ineffective or harmful. Okiishi and colleagues asked if it is possible to identify highly effective therapists (“super-shrinks”) and highly ineffective therapists (“pseudo-shrinks”) based on their patients’ outcomes. The therapists were 56 men and women who treated 1779 clients in a university counselling centre. Each therapist saw at least 15 clients, so that there was a good sampling of therapists’ outcomes across a variety of clients. Therapists had a range of experience, training, and theoretical orientations. Clients were adults who had moderate to severe problems with anxiety, depression, or adjustment. Outcomes were measured after every session, and the average number of sessions was 5.16 (SD = 7.20). On average clients improved so that their level of distress significantly declined. Therapist characteristics (sex, experience, training background, theoretical orientation) did not predict patient outcomes. However, client change varied significantly, so that some clients improved at a faster rate than others, some did not change, and some got worse. There were no differences between therapists in their clients’ level of distress, so therapists had equivalent caseloads in terms of client initial distress. However, therapists significantly differed from each other in terms of their clients’ outcomes. For example, the top 3 therapists consistently had clients who got better (super-shrinks), and the bottom 3 therapists consistently had clients who got worse (pseudo-shrinks).

Practice Implications

One would hope that a loved one would get to see a “super-shrink” therapist, since these therapists seem to consistently have clients who do well in therapy. But what about the average or “pseudo-shrink” therapist– what can be done to elevate their skills and their patients’ outcomes? We’ve discussed in this blog several things therapists can do to improve their outcomes, including: using progress monitoring in their practice, receiving training focused on deliberate practice, and seeking out specific continuing education around developing, maintaining, and repairing the therapeutic alliance.

Boswell, J. F., Constantino, M. J., Oswald, J. M., Bugatti, M., Goodwin, B., & Yucel, R. (2018). Mental health care consumers’ relative valuing of clinician performance information. Journal of Consulting and Clinical Psychology, 86(4), 301-308.

Research has shown that some therapists are more effective than others both in terms of their overall effectiveness and in terms of their effectiveness with specific patient problems. Further, despite advances in medicine on this topic, there is little or no information provided to patients about a therapist’s track record on overall effectiveness. In any case, little is known about what patients value in psychotherapists and how much they are willing to give up in order to get what they value. For example, do patients prefer therapists who are highly effective for most problems, and would they be willing to tolerate a poorer therapeutic relationship in order to work with such a highly effective therapist? In this study, Boswell and colleagues employed a relative valuing procedure often used in economics to assess the relative value to patients of different therapist characteristics and performance. Patients were asked how much they were willing to give up on one therapist characteristic (therapist’s overall effectiveness with clients [i.e., overall track record]) in order to receive more of some other characteristic (therapist specific effectiveness in a problem domain, a better therapeutic alliance, lower cost of therapy). The study included 403 patients treated in mental health clinics in the U.S. Patient characteristics were typical of those seen in such clinics – predominantly they had problems with depression or anxiety, were 41 years old on average, mostly women (68.5%), and receiving individual psychotherapy (89.3%). In general, patients highly valued a therapist with a track record of general overall effectiveness. However, patients were willing to give up more of their therapists overall effectiveness if the therapist had a track record of successfully treating their specific problem (e.g., therapist A has lower general efficacy but has demonstrated greater specific efficacy for depression). Patients were also willing to sacrifice therapist general effectiveness in order to pay less for therapy (vs paying a higher fee for a more effective therapist), and in order to work with a provider with whom they would have a better therapeutic alliance (vs a lower alliance with a more generally effective therapist). Surprisingly, patients placed a lower value on factors like therapist gender and race. Younger patients put greater value on therapist performance data (i.e., their track record data), suggesting a generational effect in which younger clients tend to prefer to make decisions based on available data.

Practice Implications

Patients were willing to give up some therapist general effectiveness in order to work with someone who has a track record of being effective for their specific problem, who costs less, and with whom they could have a better therapeutic alliance. Fortunately, therapist general efficacy and domain specific efficacy tend to be highly correlated, and so patients may not have to choose between these. The findings also suggest that patients may be willing to see a therapist who is less generally effective if it meant they could have a good relational experience with the therapist. Research indicates that therapists are able to improve their outcomes and therapeutic alliances with additional training and deliberate practice.

Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted events and side effects in cognitive behavior therapy. Cognitive Therapy and Research, 42(3), 219-229.

Unwanted events are negative consequences for clients that may or may not be related to treatment (i.e., events outside of therapy or inside of therapy that may negatively affect clients).  These might include: occupational problems, stigmatization, strains in personal relationships, changes in the social network, patients feeling overwhelmed, undermined self-efficacy, deterioration of symptoms, emergence of new symptoms, suicidality, and others. Side effects refer to negative reactions in clients directly related to appropriately delivered therapy. Research estimates that between 5% and 20% of patients report side effects of psychotherapy. One could argue that side effects may be inevitable even in well-delivered therapy, and therapists who are aware of the potential for side effects may be better equipped to help clients to manage. In this study, Schermuly-Haupt, interviewed 100 psychotherapists who provided CBT in outpatient clinics in Germany about side effects among their clients. All therapists were supervised as part of their work and so the authors assumed the therapy was appropriately delivered. Therapists had on average 5 years of experience and were trained to provide CBT. The interview asked therapists about their most recent treatment case in which the client attended at least 10 sessions. Clients typically had major depression, an anxiety disorder, or a personality disorder, and had attended 28 sessions of therapy on average. During the interview, therapists identified if an unwanted event occurred for a client from a standardized list, and then rated the duration and severity of the effects. They also rated the degree to which the unwanted event was directly related to therapy (i.e., a side effect). Prior to the interview, only 26% of therapists reported their client experienced side effects. However, the interview process found that almost all clients experienced an unwanted event (98%) that may or may have been related to therapy, and 43% experienced at least one side effect that was at least somewhat related to treatment. The most frequent side effects were: “negative wellbeing/distress” (27% of clients), “deterioration of symptoms” (9% of clients) and “strains in family relations” (6% of clients). Of the therapists, 46% rated the side effects as at least moderately severe, and 8.8% of side effects were rated as persistent (lasting more than a month).

Practice Implications

Unwanted events outside of therapy are very common among our clients, but so are side effects from appropriately delivered treatment. Psychotherapy is not always harmless, and it may be best to acknowledge and prepare both clients and therapists for side effects. These may represent ruptures in the alliance that can be managed through alliance-focused therapy, for example. That is, side effects may be caused a mismatch between the goals of a therapist and client, or a disagreement on how to proceed in therapy given what a client needs at the time. Goals and tasks of therapy may need to be renegotiated following the experience of a side effect.

Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: Evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17, 215. DOI 10.1186/s12888-017-1370-7

Over a decade ago the United Kingdom (UK) invested large sums of public dollars to fund the Increasing Access to Psychotherapy (IAPT) program. In IAPT, most patients receive cognitive behavioral therapy (CBT) as first-line treatment for depression or anxiety, and may receive generic counseling as second line treatment. One of the admirable aspects of IAPT is that the program consistently assesses outcomes, makes its data available for analyses, and publishes yearly reports on their outcomes. In this very large study, Pybis and colleagues assess whether CBT and generic counseling have different outcomes for patients with depression or anxiety. Over 33,000 patients who received treatment at one of 103 sites were in the study. Most patients (about 23,000) receiving CBT, and the others (about 10,000) receiving generic counseling. Two-thirds of the patients were female, most (84%) were white British, and the mean age was 41 (SD = 13.86). CBT focused on changing negative thoughts and behaviors in order to improve depressive symptoms. Generic counselling was harder to define, though the authors described these therapists as practicing in an integrative manner by bringing skills from training in different forms of psychotherapy. Generic counseling therapists did not focus on giving advice or opinions, but rather on helping clients understand themselves better. Pre- to post-treatment effect sizes for CBT (0.94 [0.92, 0.95]) and generic counseling (0.95 [0.92, 0.98]) were equivalent for depression outcomes. In CBT 50.4% of patients reliably improved, whereas 49.6% reliably improved if they received generic counseling. The average number of sessions attended by patients in the two treatments (CBT = 8.9 [6.34]; counseling = 7.5 [5.54]) were also equivalent. However, there were significant site effects. That is, a moderate and significant amount of patient outcomes (15%) could be accounted for by the site at which they received treatment (i.e., some sites or clinics had better outcomes than others).

Practice Implications

Generic counseling as provided in the IAPT in the UK was as effective as structured CBT for reducing symptoms of depression. However, almost half of patients did not improve in either treatment. Generic counseling was likely a label used to describe integrative psychotherapy that followed principles from a variety of psychotherapies that were based on psychological principles. There were much larger site/clinic effects than treatment modality effects, so that clients in some clinics had better than clients who received treatment in other clinics. This is consistent with research on therapist effects that show that some therapists are more effective than others, regardless of their orientation. This research suggests that training therapists to be more effective by improving their facilitative interpersonal skills may yield better outcomes for clients.

Vasiliadis, H-M., Dezetter, A., Latimer, A., Drapeau, M., & Lesage, A. (2017). Assessing costs and benefits of insuring psychological services as part of Medicare for depression in Canada. Psychiatric Services in Advance.

About 20% of the population have a mental disorder like depression during their lifetime, and depression is associated with a number of negative health outcomes like mortality, health system costs, and low quality of life. Most patients prefer psychotherapy over medications, but there are significant barriers to accessing psychotherapy, with cost as the biggest barrier. Recently in the United Kingdom, a cost-benefit analysis was used to argue that the development of the Improving Access to Psychological Therapies (IAPT) program would pay for itself in five years. The IAPT is a system of reimbursing psychological therapies through the publicly funded National Health Service in the UK. Similar models are in place in France and Australia. Vasiliadis and colleagues also conducted an economic study in Canada to evaluate the cost-effectiveness of providing psychological services as part of Canada`s Medicare system. They did so by using economic modeling of incidences of depression among patients over a 40-year period, and assessing the relative costs and outcomes of increasing publicly funded access to psychotherapy compared with the status quo. They used known incidence rates for depression in the adult population (2.9%), and estimated health service use from the Canadian Community Health Survey (CHS), and estimated costs (hospitalizations, GP visits, specialist visits, seeing a psychologist or counsellor, antidepressant prescriptions) from provincial health billing manuals. They also used the existing research literature to estimate the average effects of psychotherapy for depression on various outcomes (quality of life, suicide and attempts, health service use, etc.). Adequate mental health services for depression was defined as either 8 sessions of psychotherapy or use of antidepressants. They found that 36.7% of Canadians with depression did not use mental health services, and only 67.4% of those who did access treatment received adequate care. In the economic models that were tested, increasing access to care resulted in a projected decrease in depression, suicidality, health system and societal costs. Increasing access would cost an additional $123 million per year, but savings to society in terms of reduced health system costs and increased productivity was $246 million per year. In other words, for every $1 spent by Medicare on psychotherapy, Canada would recoup $2 in reduced costs and increased productivity.

Practice Implications

The findings of this Canadian study echo those of similar economic studies done in the UK, France, and Australia. Increasing access to psychotherapy for depression through Medicare is more effective and less costly than the status quo. In fact this Canadian study may underestimate potential gains because it did not account for the increased use of the health system by depressed people with chronic medical conditions. Currently, public expenditures for mental health and addictions in Canada account for only 7.2% of the total health budget. An increase of 0.07% of the total health budget to cover psychological services would result in health care cost savings, improved mental health, reductions in disability, and increased productivity among Canadians.