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Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (2016). Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials. Psychotherapy, 53(1), 90-104.

There is growing research support for the efficacy of short-term psychodynamic psychotherapies to treat common mental health problems. A subtype of short-term psychodynamic psychotherapies is called experiential-dynamic therapy (EDT), which goes by a number of different names such as Fosha’s accelerated experiential-dynamic psychotherapy, and McCullough’s affect phobia therapy. A fundamental assumption of EDT is that conditions like depression, anxiety and personality disorders are by-products of an individual’s attempts to regulate strong emotions associated with adverse experiences in attachment relationships during childhood. When the attachment system and associated affects are re-awakened in current relationships, the individual may engage in maladaptive coping that leads to difficulties in relationships. While EDTs may focus on helping patients to understand how their attachment difficulties lead to inhibitory affects and maladaptive defenses, the treatment favors interventions that facilitate direct experience of underlying emotions in the here and now of the therapy. In this meta-analysis, Lilliengren and colleagues reviewed 28 studies with 1,782 adult patients who had a mood, anxiety, personality, or mixed disorder. Compared to inactive controls, EDT showed a moderate and significant effect at post-treatment (range: d = .39 to .65) and at follow-up assessments (range: d = .26 to .62), with largest effects for depression and anxiety. When researchers compared EDT to cognitive-behavioral therapy (CBT) in five studies, there were no significant effects at post-treatment (d = .02, 95% CI: -.24, .28) or follow-up (d = .07, 95% CI: -.22, .36). The average quality of EDT studies was good. In fact, studies with larger samples, that used blind randomization and assessments, and appropriate statistical tests showed larger effects for EDT. Drop-out rates for EDT (16.3%) were similar to other treatments.

Practice Implications

Experiential-dynamic therapy (EDT), which is a variant of short-term psychodynamic psychotherapy, was more effective than no-treatment and just as effective as evidence-based treatments like CBT. The findings are similar to those reported in many comparative outcome studies in which any bona-fide psychotherapy is effective for many disorders. The average quality of the EDT studies was quite good, suggesting that the findings were reliable and valid, and perhaps underestimating the true effects of EDT.

Author email: peter.lilliengren@psychology.su.se

Reich, C.M. & Berman, J.S. (2018). Are psychotherapies with more dropouts less effective? Psychotherapy Research. Online first publication.

The client dropout rate in clinical studies is about 20%, and almost double that in regular clinical practice. A dropout is a unilateral decision on the part of the patient to discontinue treatment after the first session. This is often viewed as a treatment failure, but it is possible that some patients feel better enough to not continue with therapy, and others may have practical constraints like transportation or childcare difficulties. In three meta analyses, Reich and Berman ask: (1) do those who drop out experience more distress than completers to begin with?, (2) do completers have better outcomes than drop outs?, and (3) do less effective treatments also have more drop outs? In general, the studies included different types of psychotherapy but most were CBT (~75%), most therapists had a masters or doctoral degree (~33%) but many studies also included student therapists (~25%), client problems included depression (~17%), anxiety (25%), or other disorders, and most studies were randomized controlled trials (~61%). To answer the first question the authors conducted a meta analysis of 76 studies. Clients who dropped out of therapy were in more distress prior to beginning treatment than individuals who completed the treatment (d= − 0.14, 95% CI [− 0.08, − 0.20], p < .001). The effect was small but significant. Younger and male clients tended to be in more distress at pre-treatment. To answer the second question, the authors conducted a meta analysis of 43 studies. Clients who dropped out of therapy were significantly more distressed following therapy than individuals who completed treatment (d = .0.56, 95% CI [.0.37, 0.70] p < .001). This was a moderately large and significant effect. To answer the third question, the authors completed a meta regression of data in 34 studies. Overall, treatments with more drop outs also had completers with worse outcomes at post treatment, β = -.37, SE = 0.17, p < .05. Also, when treatments were shorter in length, greater overall dropout was associated with even worse outcomes for treatment completers, β = − 1.28, SE = 0.35, p < .001.

Practice Implications

These meta analyses support the notion that on average those who drop out do so because they do not find the treatment to be helpful. Patients who drop out tend to be more distressed to begin with, and are more likely to be young and male. An intriguing finding was that those treatments with more drop outs also tended to be less effective for those who completed the therapy. In other words, effective treatments also tended to maintain more patients. Previously, writers suggested clinically useful methods to reduce premature termination from psychotherapy. These include: providing patients with information about duration of therapy and how change occurs, educating patients about therapist and patient roles, taking into account patient preferences when deciding on treatment methods and therapist stances, strengthening early hope, fostering the therapeutic alliance, and assessing and discussing treatment progress on an ongoing basis.

So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A., & McCrone, P. (2013). Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry, 13, 113. 

Depression is a major cause of disability in the world, and so efforts to improve access to its treatment have been ongoing for several decades. In particular, many researchers and clinicians propose cognitive behavioural therapy (CBT) as an effective treatment with a good evidence-base. There have been many clinical trials showing the efficacy of CBT. In recent years, there have also been attempts to computerize CBT (CCBT) as a self help intervention in order to increase its accessibility for those with depression, and perhaps also to improve its cost effectiveness. In fact, the Increasing Accessibility to Psychotherapy (IAPT) program in the UK provides CCBT as the most common first treatment for depression. However there remain questions about the longer term effectiveness of CCBT to reduce symptoms of depression, its potentially high patient dropout rate (a negative outcome), and its effects on quality of life of those burdened by depression. In this meta analysis, the largest of its kind, So and colleagues assess these issues with regard to CCBT. They reviewed 14 direct comparison randomized controlled trials that provided 16 comparisons of CCBT versus a control condition (wait list or treatment as usual) for adults with depression. At post-treatment, CCBT was more effective than controls in reducing depression −0.48 [95% CI −0.63 to −0.33]. However, at follow up (up to 6 months), the effects of CCBT disappeared −0.05 [95% CI −0.19 to 0.09]. Also improvement in functioning and quality of life were not significantly different between CCBT and control conditions, −0.05 [95% CI −0.31 to 0.22]. The rate of drop out from CCBT (32%) was almost double that of control conditions (17%), RR = 1.68 [95% CI 1.31 to 2.16]. There was also evidence of publication bias (i.e., a tendency for some researchers not to publish non-significant findings), so that the positive post-treatment results in favour of CCBT might be inflated.

Practice Implications

Although CCBT may be touted as a way to increase access to treatment for depression, this meta analysis indicates some concerns about the widespread implementation of CCBT. The effects of CCBT appear to be limited to a short-term reduction of depressive symptoms that may not be sustained in the longer run. There was no appreciable impact of CCBT on quality of life relative to controls, and so CCBT may have a limited impact on the burden of depression. Most troubling was a high drop out rate of 32%. Drop out from CCBT in the IAPT program in the UK is about 50%, and this may be indicative of the actual drop out rate in real world practice.

Swift, J.K., Greenberg, R.P., Tompkins, K.A., & Parkin, S.R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54, 47-57.

Treatment refusal occurs when a patient is offered an intervention but then fails to begin it. In treatment studies, this may occur when a patient initially agrees to participate in a trial but then discontinues immediately after finding out what intervention they will receive. In a clinic setting, a patient might call a mental health professional to schedule an initial appointment but not show up. This causes problems for the patient who is not receiving treatment, and for the professional who has an unfilled therapy hour. Premature termination, on the other hand occurs when a patient begins treatment but ends unilaterally against the provider’s recommendations and prior to recovery. Again, these patients typically do not improve and they do not receive an adequate dose of the treatment. Barriers to accepting or completing psychotherapy might include the cost, and the time and effort involved to engage in the therapeutic process. Barriers to accepting or completing pharmacotherapy might also include cost, unpleasant side effects, and fewer contacts with a non-judgemental listening professional. The aim of Swift and colleagues’ meta-analysis was to compare rates of treatment refusal and premature termination between psychotherapy and pharmacotherapy. The meta-analysis included 186 studies, 57 of which (with 6,693 participants) reported data on treatment refusal. A significant number of patients (8.2%; 95% CI: 7.0, 9.6%) failed to start treatment after they were told what treatment they would receive. Participants were 1.76 times more likely (95% CI: 1.27, 2.45) to refuse treatment if they were offered pharmacotherapy compared to psychotherapy. The average premature termination rate from treatment was 21.9% (95% CI: 20.6%, 23.3%). Patients assigned to pharmacotherapy were 1.2 times more likely (95% CI: 1.03, 1.41) than those who were assigned to psychotherapy to discontinue treatment prematurely.

Practice Implications

Participants were almost 2 times more likely to refuse treatment if they were offered pharmacotherapy compared to psychotherapy, especially for social anxiety disorder, depression, and panic disorder. Similarly, premature termination was higher for pharmacotherapy compared to psychotherapy, especially for eating disorders and depressive disorders. Previous research indicated that patients are 3 times more likely to prefer psychotherapy over medications for mental disorders. Research indicates that mental health professionals should work to incorporate patient preferences, values, and beliefs when making treatment decisions in order to reduce premature termination and treatment refusal.

Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015, August 24). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of Consulting and Clinical Psychology. Advance online publication.

“Dropping out” refers to clients who discontinue therapy prematurely and against professional advice. In contrast, “refusing” refers to clients who do not start a therapy that is made available to them. Together, both dropping out and refusing are referred to as “attrition” from therapy. Attrition is a problem for clinicians because of loss of revenue and time, and a problem for clients because their mental health needs remain unmet. In a previous meta analysis that included 669 studies, Swift and Greenberg (2012) reported that the average drop out rate across all therapies was 19.7%. In this meta analysis, Fernandez and colleagues looked specifically at drop outs and refusers in cognitive behavioral therapy (CBT). The authors reviewed 115 studies that reported drop outs, 36 of which also reported on the number of participants who refused treatment before starting. The average percent of patients who refused CBT prior to starting treatment was 15.9%, and the average percent of patients who dropped out after starting CBT was 26.2%. So the total average attrition rate was 42.1%. Compared to any other disorder, patients with depression were significantly more likely to refuse CBT (21.6%) or to drop out (36.4%). It is possible that depressed patients have a harder time summoning the energy to participate in therapy, and experience lower hope, greater social withdrawal, and lower motivation once they initiate CBT. For those receiving e-therapies (e.g., internet, phone, and CD-based treatments), pre-treatment refusal rates were 10% to 15% higher than individual or group CBT, and drop outs from e-therapies were 10% higher compared to individual or group CBT. Those offered e-therapy might be ambivalent about its utility, the therapeutic alliance might be limited, and they might have a lower sense of engagement in the therapeutic process. Finally, a greater number of planned therapy sessions was related to lower attrition rates. Perhaps the promise of more sessions raised clients’ hopes of achieving better outcomes.

Practice Implications

These findings suggest that engaging and encouraging clients to participate in the therapy may have to start even before therapy begins. This may involve enhancing readiness by means of motivational interviewing, for example. Clients who are depressed are particularly likely to refuse treatment or drop out, and so clinicians must pay particular attention to the level of motivation and engagement of depressed clients. Although e-therapies are promising in that they may allow a therapist or agency to reach more people including those who live in remote areas, the attrition rate of e-therapies may be unacceptably high. Attrition may lead to demoralization and lowered expectations for treatment among these patients, which may negatively impact future treatment. Perhaps e-therapies should not be considered as a first-line treatment for those who can easily access individual or group therapy. Alternatively, the high attrition rates of e-therapies may be reduced by supplementing the intervention with some in-person therapy sessions to enhance engagement and a therapeutic alliance.

Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193-207.

In one of my first PPRNet Blogs I reported on a meta analysis by Swift and Greenberg (2012) in which they found that almost 1 in 5 patients in clinical trials dropped out of therapy. There were no differences between therapeutic orientations in the drop out rates. However, the authors did report that those with eating disorders (23.9%) and personality disorders (25.6%) dropped out at a higher rate than other disorders. Premature termination from therapy is an important problem in that those who drop out are less satisfied and have poorer outcomes than treatment completers. In this follow up to their meta analysis, Swift and Greenberg ask the interesting question of whether premature termination differs across therapy orientations for any of the specific disorders. They compared the drop out rates of different treatment approaches for each of 12 separate disorders.  The studies defined drop out in various ways, including: unilateral termination, not attending a set number of sessions, not achieving clinically significant change, etc. Treatment orientations, included: behavior therapy, cognitive–behavioral therapies, dialectical behavior therapy (DBT), psychodynamic psychotherapies, solution-focused therapy, interpersonal psychotherapy, humanistic/existential/supportive psychotherapies, and integrative approaches. Primary diagnoses included: depression, eating disorders, borderline personality disorder, other personality disorder, somatoform disorder, bereavement, obsessive compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), psychotic disorders, and social phobia. The authors conducted 12 meta analyses, one for each disorder to compare the therapy approaches. Overall, they included 587 studies. There were no differences in drop out rates among therapy approaches for 9 of the 12 disorders. For depression, integrative therapy had significantly lower drop out rates than other approaches (10.9% vs 19.2%), and for PTSD integrative therapy also had the lowest drop out rate compared to other treatments (8.8% vs 21.0%). Also, for PTSD, exposure based interventions had the highest drop out rates (up to 28.5%). For eating disorders, DBT had the lowest drop out rates compared to other approaches (5.9% vs 24.2%), but this was largely explained by older patient samples and shorter duration of treatment in DBT.

Practice Implications

There were no differences between treatments in drop out rates for 9 of 12 disorders. Swift and Greenberg argued that for these disorders, other factors (e.g., therapeutic alliance, client expectations) rather than specific techniques were enough to keep clients in therapy. For depression and PTSD, integrative treatments resulted in the lowest drop out rates. This suggests that therapists might consider incorporating techniques from other orientations that increase the acceptability of therapy for their clients with depression and PTSD. Use of exposure based interventions for PTSD may require a significant amount of work to prepare clients in order to reduce higher drop out rates.