The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Adapting Therapy to Each Client: Becoming an Evidence-Based Therapist I
Norcross, J.C. & Wampold, B.E. (2018). A new therapy for each patient: Evidence‐based relationships and responsiveness. Journal of Clinical Psychology, Online First, DOI: 10.1002/jclp.22678
Over the next several months, I will review in this blog results of a number of meta-analyses conducted recently on patient factors and relationship factors in psychotherapy. These factors provide evidence-based guidance to psychotherapists on how best to relate to and adapt to clients so that psychotherapy is more effective. This introductory article by Norcross and Wampold is an overview of the nine meta analyses related to transdiagnostic client factors to which therapists can adapt their interpersonal stances and treatment. The goal is to enhance treatment effectiveness by therapists tailoring therapy to individual client characteristics that are related to outcomes. Decades of research indicate that client transdiagnostic characteristics have more influence on outcomes than the particular treatment method, and likely more influence than the particular client diagnosis. The research indicates that giving the identical treatment to every client without adaptation to client characteristics is not an effective approach to providing psychotherapy. These meta analyses of client factors indicate that therapists should select different interventions and relational stances according to the client and the context. What are these client characteristics and therapist adaptations that are reliably related to outcomes? The client factors most strongly related to outcomes include therapist adaptations to: client culture/race/ethnicity (99 studies, g = .50); client preferences for type of therapy (51 studies, g = .28), client religion/spirituality (97 studies, g = .13 to .43), client stage of change (76 studies, g = .41), client reactance/resistance level (13 studies, g = .78), client coping style (32 studies, g = .53), and client attachment style (32 studies, g = .35). Over the next months, I will be reviewing in more detail these meta analyses of client factors and the practice implications of each so that therapists can use this evidence-base to help them to adapt to particular client characteristics.
Practitioners will find that fitting the therapy to clients’ culture, stage of change, religion/spirituality, reactance/resistance, coping style, and attachment style will improve treatment outcomes. Doing so will have a greater impact on outcomes than the particular type of therapy provided or adapting treatment to the particular client diagnosis. The results of this large body of evidence suggests that therapists should no longer ask: “what is my theoretical orientation” but rather they should ask: “what relationship, adaptation, and approach will be most effective with this particular client”.
Psychotherapy for Eating Disorders
Grenon, R., Carlucci, S., Brugnera, A., Schwartze, D., … Tasca, G. A. (2018). Psychotherapy for eating disorders: A meta-analysis of direct comparisons, Psychotherapy Research, DOI: 10.1080/10503307.2018.1489162
Eating disorders can cause a great deal of physical and mental impairment because of the severity of the symptoms and because of comorbid conditions like depression, anxiety, substance use, and others. Anorexia nervosa (AN) occurs in about 0.5% of the population, bulimia nervosa (BN) occurs in about 1.5% of the population, and binge-eating disorder (BED) occurs in about 3.5% of the population. Treatment guidelines include both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as front line interventions for BN and BED. However, results from previous meta analyses of psychological treatments for eating disorders were confounded by not focusing exclusively on randomized controlled trials, mixing studies of adult and adolescent samples, combining an array of outcomes rather than separately reporting primary (eating disorder symptoms) and secondary (interpersonal problems, depression) outcomes, and not distinguishing between bona fide psychotherapies (like CBT, IPT, psychodynamic therapy, and others) from non-bona fide treatments (like self help, behavioral weight loss supportive counseling). Grenon and colleagues conducted a meta analysis of psychotherapies for eating disorders to examine if: psychotherapy is effective compared to a wait list, if bona fide psychotherapy and non-bona fide treatment differ in outcomes, and if one type of psychotherapy (i.e., CBT) was more effective than other bona fide psychotherapies (like IPT, behavior therapy, psychodynamic therapy, dialectical behavior therapy). Their meta analysis included 35 randomized controlled trials of direct comparisons. Psychotherapy was significantly more effective than a wait-list control at post treatment, so that 53.89% of patients were abstinent of symptoms after psychotherapy compared to only 8.92% who were abstinent in the wait-list group. Bona fide psychotherapies (51% abstinent) were significantly more effective than non-bona fide treatments (40% abstinent) at post treatment, and dropout in bona fide psychotherapies (17.5%) was significantly lower than in non-bona fide treatment (29.1%). Further, the difference between CBT and other bona fide psychotherapies was not significant.
Psychotherapy for eating disorders are effective for patients with BN or BED. There were too few studies of those with AN to come to any conclusions about their treatment. Patients with BN or BED are best treated with a bona fide psychotherapy that involves face to face psychological therapy like CBT, IPT, psychodynamic therapy, dialectical behavior therapy, or behavior therapy. Non-bona fide treatments like self help, behavioral weight loss, and supportive counseling should only be used as an adjunct to bona fide psychotherapy for eating disorders.
Association Between Insight and Outcome of Psychotherapy
Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847
For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.
The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.
Author email: Simone.Jennissen@med.uni-heidelberg.de
Is Psychotherapy Effective? Revisited.
Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.
Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.
Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.
How Reliable is the Association Between Therapeutic Alliance and Patient Outcomes?
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000172
The therapeutic alliance is one of the most researched concepts in psychotherapy. The alliance, also called the working alliance or therapeutic alliance, consists of the collaborative agreement between patient and therapist on the tasks (what to do) and goals (what to achieve) of their therapeutic work together. Alliance also includes the relational or emotional bond between therapist and patient. It is different from therapist empathy, transference, countertransference, the real relationship and other concepts related to the therapeutic relationship. Researchers and clinicians have known for years about the importance of developing and maintaining an alliance to achieving patient outcomes. The growing research in this area now allows one to see how stable this finding is. Fluckiger and colleagues conducted a meta analysis of 306 studies with over 30,000 patients that assessed the alliance-outcome relationship. The research occurred in naturalistic settings (during regular clinical practice) and in randomized controlled trials. The overall effect size based on 295 independent comparisons was r = .278 (95% CI: .256, .299), indicating a statistically significant medium-sized association accounting for about 8% of treatment outcomes. To put this in perspective, this effect is as large as or larger than the effects of many common medical interventions. The type of therapy made no difference to this finding - the alliance was just as important to CBT as it was to psychodynamic, interpersonal, and emotionally focused therapies. The alliance-outcome correlation was somewhat smaller, though still significant among those with substance-use disorders, but otherwise was consistent for all other disorders tested (depression, anxiety, PTSD, borderline personality disorder). The alliance measure used, who rated the alliance, when it was assessed, and the outcome that was measured tended to have a small or no impact on the results. The alliance-outcome relationship was just as important to everyday clinical practice as it was in randomized controlled trials.
The alliance-outcome association is highly reliable or stable across a number of therapies, diagnoses, measurements, and study designs. This very large body of research suggests that therapists should: (1) build and maintain an emotional bond, and agreement on tasks and goals with patients throughout therapy; (2) develop the alliance early by focusing on agreement on treatment and goals; (3) address ruptures in the alliance early and immediately; and (4) assess the strength and quality of the alliance regularly throughout treatment from the patient’s perspective using a well-known brief alliance measure.
Are E-Health Interventions Useful for Weight Loss?
Podina, I. R., & Fodor, L. A. (2018). Critical review and meta-analysis of multicomponent behavioral e-health interventions for weight loss. Health Psychology, 37(6), 501-515.
Over 35% of Americans are overweight or obese, and this poses significant health-related challenges. Obesity likely contributes to heart disease, Type II diabetes, and some forms of cancer. Also, obesity is often co-morbid with mental health conditions including depression and binge-eating disorder. Practice guidelines list multicomponent behavioural interventions as state of the art treatment for weight loss. These include dietary counselling, increased physical activity, and behavioural methods to support behaviour change. However, such interventions often require direct in-person contact with a health or mental health professional, which can be expensive and create a barrier to accessing treatment for some. An option to increase access is to deliver the multicomponent behavioural intervention by internet or by another electronic format such as DVD. In this meta analysis, Podina and Fodor reviewed 47 randomized controlled studies representing over 1500 participants in which e-health interventions for weight loss in overweight or obese individuals were tested against in-person treatment or a control condition (no treatment or treatment as usual). E-health interventions were more effective than control conditions for weight loss outcomes at post-treatment, g = 0.34 (95% CI [0.24 to 0.44]). Similar results were found at follow-up. However, e-health interventions were significantly less effective than active in-person treatments, g = -0.31 (95% CI [-0.43 to -0.20]) for weight loss in overweight or obese individuals.
E-health interventions (mostly internet delivered treatment) of multicomponent behavioral treatment for weight loss was more effective than no treatment or treatment as usual. However, e-health was significantly less effective than traditional face to face behavioral interventions to help people reduce their body weight. The authors raised concerns about the use of e-health interventions for weight loss as the first line treatment as the effects were small and the approach was less effective than in-person interventions.