Blog

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.

October 2013

Patient Preference for Psychological vs Pharmacologic Treatment of Mental Disorders

McHugh, K.R., Whitton, S.W., Peckham, A.D., Welge, J.A., & Otto, M.W. (2013). Patient preference for psychological vs pharmacological treatment of psychiatric disorders: A meta-analytic review. Journal of Clinical Psychiatry, 74, 595-602.

For the most part psychotherapy and pharmacological interventions have equivalent positive effects on depression in the short term, and psychotherapy has better outcomes in the long term (see my May, 2013 blog). There is also evidence that the effects of medications for depression are overestimated (also in the May 2013 blog). Despite all of this evidence, psychotherapy use has remained the same or declined slightly over the past 10 years (currently at about 3.4% of the population), whereas medication use for depression has doubled to over 10% of the population. At the same time, guidelines for evidenced based practice emphasize incorporating patient preferences when there is an absence of evidence-based decision rules for treatment selection. Providing patients with their preferred treatment is associated with better treatment uptake and outcomes (see June, 2013 blog). McHugh and colleagues conducted a meta analysis to review the literature on patient preferences for psychological versus pharmacological interventions for mental health disorders among adults. They included studies with treatment and non-treatment seeking samples of patients with a variety of disorders. (A quick note about meta-analysis. Meta analysis is a way of statistically combining the effect sizes from a number of studies into a common metric so that an average effect size can be calculated. Meta analysis is now the standard by which studies are reviewed. Meta analysis results are much more reliable than any single study and so represent the best way to inform clinical practice from research findings). McHugh and colleagues identified 34 studies representing over 90,000 participants. Most studies were of depressive disorders and anxiety disorders. When given a preference, 75% of participants preferred psychotherapy over medication to treat their mental health problem. In treatment seeking samples, the percentage was lower at 69%, but still significantly in favour of psychotherapy. Younger people and women were more likely to prefer psychotherapy, though the findings still showed a preference for psychotherapy among older people and men. The availability of combining psychotherapy and medication did not affect the results, so that even when given the option of both psychotherapy and medication people still preferred psychotherapy alone.

Practice Implications:

In all subsamples, participants were 3 times more likely to prefer psychotherapy to medication for their mental disorder. Patient preference for treatment is a core component of evidence based mental health practice that improves outcome and reduces drop outs. Without evidence for superiority for one treatment over another, patients should be given their preference, and on average patients overwhelmingly prefer psychotherapy. To optimize outcomes in clinical settings, providers should consider patient preferences, including their preference for psychotherapy over medication.

Author email: kmchugh@mclean.harvard.edu
Does Medicalization of Psychological Problems Reduce Stigma?

Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33, 782-794.

Psychotherapists may wonder how best to explain a psychological problem to their clients and their family members. Will their explanation help to reduce stigma and increase hope? Laypeople, clinicians, and researchers increasingly understand psychological problems in biomedical terms. Further, some anti-stigma campaigns describe mental health problems, including depression, as biological, medical illnesses. Reducing stigma is important to improve uptake of therapy, reduce an internalized sense of defectiveness, and increase hope and self esteem. Some argue that understanding psychological problems as biologically based will combat stigma by reducing blame and punitive treatment. Kvaale and colleagues asked whether there is a cost to medicalization of psychological problems by unwittingly promoting the stereotype that those with a mental illness have a deep seated, fixed, and defining essence. Proponents of medicalization hope that such an approach will reduce blame for a mental illness, and will result in less desire for social distance from the mentally ill. However, medicalization might also result in: an increased belief that those with psychological problems are dangerous; and greater pessimism and hopelessness about the prognosis (i.e., a belief that the problem can not be improved). A meta-analysis by Kvaale and colleagues looked at experimental studies of student and community based samples in which explanations for a psychological problem was manipulated to include biomedical explanations versus psychological explanations or no explanations. The meta-analysis aimed to examine the causal effects of biogenetic explanations for psychological problems on: blame, perceived dangerousness, social distance, and prognostic pessimism. Regarding blame, the authors reviewed 14 studies that included 2326 participants and found that biogenetic explanations were associated with a decreased tendency to blame individuals with psychological problems. Regarding perceived dangerousness, the authors reviewed 10 studies with 1207 participants, and found that biogenetic explanations were associated with an increase in perceiving those with psychological problems as dangerous. However this result is tentative because publication bias may have resulted in an over estimation of the association (see my May 2013 blog on publication bias [“Are the Effects of Psychotherapy for Depression Overestimated?”]). Regarding social distance, the authors reviewed 16 studies with 2692 participants, but found no relationship between biogenetic explanations and reduced social distance. Regarding prognostic pessimism, the authors reviewed 16 studies with 3469 participants, and found that biogenetic explanations were associated with greater pessimism about the prognosis of a psychological problem.

Practice Implications

The meta analysis by Kvaale and colleagues found that biomedical explanations for psychological problems typically decrease blame, but increase prognostic pessimism and perceptions of dangerousness, although the latter conclusion is somewhat tentative. The findings lead one to be skeptical of the view that stigma will be reduced by promoting an understanding of psychological problems as biogenetic diseases. Kvaale and colleagues suggest that the affected individual, family members and mental health professionals could be more pessimistic about change because of a biomedical explanation, thus impeding the patient’s recovery process. Psychotherapists should share information about the biogenetic factors of psychological problems. However, this must be done with caution. Kvaale and colleagues conclude that explanations that invoke biomedical factors may reduce blame but also may have unintended side-effects. Biogenetic explanations should not be promoted at the expense of psychosocial explanations, which may have more optimistic implications.

Author email: e.kvaale@student.unimelb.edu.au

August 2013

Does Focus on Retelling Trauma Increase Drop-out From Treatments For Posttraumatic Stress Disorder (PTSD)

Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81, 394–404.

There are now a number of psychotherapies that the Society of Clinical Psychology list as effective psychotherapies available for posttraumatic stress disorder (PTSD). Approaches include prolonged exposure (PE), and cognitive processing therapy (CPT) among others (click here for examples). Therapies for PTSD also vary in how much they focus on retelling the trauma. Some treatments like trauma-focused CBT place a higher level of focus on retelling the trauma event, whereas Present Centred Therapy (PCT), which was originally conceived as a control condition, largely avoids the trauma. Patients may begin a treatment and find some aspect of it distressing resulting in discontinuation. There is ongoing debate regarding the belief that exposure-based treatments, which require the patient to retell traumatic events in detail to his or her therapist, are especially unacceptable or poorly tolerated by patients. Drop out rate is a common metric used to assess tolerability of a treatment. In the April 2013 blog I reported on a meta analysis that found that the average drop out rate in randomized controlled trials of adult psychotherapy was 19.7%. However drop out rates for PTSD in the community can be as high as 56%. Imel and colleagues conducted a meta analysis of drop out rates in randomized controlled trials of treatments for PTSD. They also assessed if drop out rates differed by the amount the therapy focused on retelling the trauma. In the meta analysis, 42 studies were included representing 1,850 patients; 17 of the studies directly compared two or more treatments. The aggregated drop out rates across all studies was 18.28%, which is not different from the rate in randomized trials of adult psychotherapy in general, but is much lower than reported in regular clinical practice. Group treatment was associated with a 12% increase in drop outs compared to individual treatment. In general, an increase in trauma focus was not associated with greater drop out rates. However, when trauma focused treatments were directly compared to PCT (a trauma avoidant intervention) in the same study, trauma-specific treatments were associated with a twofold increase in the odds of dropping out.

Practice Implications

Many have been concerned that exposure-based therapies can lead to symptom exacerbation and result in dropout. The findings of Imel and colleagues’ meta analysis suggest that dropout rates are not significantly different among active treatments. However, PCT may be an exception to this general pattern of no differences among active treatments. Perhaps PCT should be considered a first line treatment for those who do not prefer a trauma focused treatment. In addition, providing treatment for PTSD in groups was associated with greater drop out rates possibly due to shame related to public disclosure of the trauma. The authors suggest mimicking research trial procedures in community practice in order to reduce drop out rates, such as: providing therapist training, support, and supervision; careful patient screening; regular assessment of patient progress; and ongoing contact with assistants that may promote session attendance.

Author email: zac.imel@utah.edu

July 2013

Practice Implications of Therapeutic Alliance Research

Horvath, A.O., Fluckiger, C., Del Re, A.C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16.

The psychotherapy alliance is probably the most researched concept in psychotherapy. A PsychInfo search of terms including the word “alliance” will turn up over 7000 hits. Although the concept of alliance has been around at least since the 1950s, the commonly acceptable pan-theoretical definition that is currently used was proposed by Bordin in the 1970s. This definition emphasizes the conscious aspects of the collaboration between therapist and client, and involves three elements: agreement on goals, agreement on tasks, and the bond between client and therapist. What is important in terms of developing the alliance is the therapist’s ability to step back from his or her own agenda and emphasize, prioritize, and negotiate the collaborative relationship. This allows for the selection of an intervention that is congruent with client expectations, which then will foster a high level of mutuality. Horvath and colleagues conducted a large meta analysis of alliance - outcome research from the years 1991 to 2009 that included 190 independent studies and over 14,000 participants. The overall relationship between alliance and outcome was statistically significant and moderate in size. This was a highly reliable effect. The results were consistent regardless of which measure was used, who rated the alliance (client, therapist, independent rater), or what type of treatment was studied (i.e., CBT, IPT, Psychodynamic, etc). Similar results were found in separate published meta analyses of child and adolescent psychotherapy and of family and couple therapy, though the effect is larger in couple therapy.

Practice Implications

The quality of the alliance is an index of the level of mutual and collaborative commitment to therapy by the therapist and client. Its distinguishing feature is the focus on therapy as a collaborative enterprise. Establishing a good alliance prevents clients from dropping out, and the sense of collaboration creates a context to introduce new ways of addressing the client’s concerns. In the early phases of therapy, tailoring the methods of therapy (tasks) to suit the specific client’s needs, expectations, and capacities is important in building the alliance. Misjudging the client’s experience of the alliance (i.e., believing that it is in good shape when the client does not share this perception) could render therapeutic interventions less effective. Horvath and colleagues suggest active monitoring the clients’ alliance throughout treatment. Therapists’ nondefensive responses to client negativity or hostility are critical for maintaining a good alliance. Research indicates that therapists who are good at building a strong alliance tend to have better alliances with most of their clients. However, the reverse is also true – some therapists consistently struggle to establish and maintain a good alliance with their clients. The strength of the alliance often fluctuates when therapists’ challenge clients to deal with difficult issues, when misunderstandings arise, and when transference occurs and/or is highlighted. Resolution of these normal variations is associated with good treatment outcomes. The next blog entry discusses research on alliance ruptures and repairs.

Author email: horvath@sfu.ca
Repairing Therapeutic Alliance Ruptures

Safran, J.D., Muran, J.C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80-87.

One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance predicts outcome across a range of different treatments, and that a weakened alliance is correlated with dropping out of psychotherapy. Jeremy Safran and his colleagues have characterized a “second generation” of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur. A rupture in the therapeutic alliance is defined as a tension or breakdown in the collaborative relationship between patient and therapist. These could include: disagreement on goals of therapy, disagreements on the tasks of therapy, or strains in the patient - therapist bond. Ruptures may vary in intensity from relatively minor tensions, of which one or both of the participants may be only vaguely aware, to major breakdowns in collaboration, understanding, or communication. Similar concepts include: empathic failure, therapeutic impasse, and misunderstanding event. For example, a therapist returned from holidays to a session with a patient with whom she previously had a good alliance. The patient appeared more sullen, and quieter than usual in this session. The patient rated the alliance lower following the session, and the therapist felt the same. In the next session the therapist asked about the change in the patient and explored reasons for the change. It emerged that the patient’s old feelings of loss and abandonment re-surfaced with the therapist’s absence, and the patient felt resentment when the therapist returned. Examining this pattern resolved the rupture and led to continued gains by the patient especially regarding the relational theme of abandonment. In a small meta analysis by Safran and colleagues, 3 studies representing 148 patients were reviewed. The relationship between rupture-repair episodes and treatment outcomes was significant, though modest. In a subsequent meta analysis of 8 studies representing 376 patients, the relationship between an intervention to repair alliance ruptures and positive outcomes was significant and large.

Practice Implications

A therapist’s non-defensive response to a client’s negative feelings about the therapy is critical to repairing a rupture. Safran and colleagues suggest 6 strategies for therapists to deal with alliance ruptures. (1) Repeating the therapeutic rationale can help to repair a strained alliance. (2) Changing tasks or goals can make the therapy and its objectives more meaningful to the patient. (3) Clarifying misunderstandings at a surface level by acknowledging how the patient might feel misunderstood or criticized by the therapist. (4) Exploring relational themes associated with the rupture, could help the therapist and patient understand the patient’s relational themes and reactions. (5) Linking the alliance rupture to common patterns in the patient’s life, as in the example provided above, allows the patient to change the pattern in the therapeutic relationship. (6) Providing a new relational experience such that the therapist’s non-defensive response and willingness to repair the rupture may be a new and positive experience for the patient leading to a better alliance and laying the groundwork for further change.

Author email: safranj@newschool.edu

June 2013

Client Preferences for Psychotherapy

Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013, March 11). Further examination of the psychotherapy preference effect: A meta-regression analysis. Journal of Psychotherapy Integration. Advance online publication. doi: 10.1037/a0031423

Client preferences consist of preferences regarding the type of treatment offered (e.g., preference for psychotherapy or medication, preference for a behavioral approach to treatment or an insight oriented one), desires for a certain type of therapist or provider (e.g., preference for an older therapist, a female provider, or a therapist who has a nurturing personality style), and preferences about what roles and behaviors will take place in session (e.g., preference for the therapist to take a listening role or an advice giving role). In a previously published meta analysis Swift and colleagues (2011) reviewed data from 35 studies that compared preference-matched and non-matched clients. A small but significant preference outcome effect was found, indicating that preference-matched clients show greater improvements over the course of therapy, and that clients whose preferences were not matched were almost twice as likely to discontinue treatment prematurely. In this follow up meta regression study, Swift and colleagues assessed whether preference accommodation is more or less important for types of disorders, types of treatments, or different demographics like sex or age. (Meta regression involves accumulating data from across many studies to assess predictors [e.g., sex, age, diagnosis, treatment type, etc.] of the preference effect). For example, some research has indicated that men prefer therapists with more feminine traits and that men prefer pharmacological interventions. But does accommodating these preferences affect outcomes and drop out rates? Is matching preferences essential for younger clients? Is matching preferences more important for women or ethnic minorities? The authors analysed data from 33 studies representing 6,058 clients to address some of these questions. The only variable that predicted the influence that preferences have on rates of premature termination was the length of the intervention. That is, it may be more important to accommodate client preferences for briefer therapies. Perhaps, as clients continue in therapy for longer durations, other variables such as the therapeutic alliance play a bigger role in determining whether or not one drops out prematurely. It is also possible that as treatment continues, clients may experience a shift in preferences to more closely match the treatment conditions that they were given. Once this shift in preferences has occurred, preferences are no longer mismatched, and the risk of dropping out may be diminished.

Practice Implications

This study provides evidence that incorporating client preferences may be important for all types of clients. Generally, when client preferences are accommodated, clients show greater improvements while in treatment and are less likely to discontinue the intervention prematurely. As much as is practical, practitioners might collaboratively work with clients to identify what preferences they hold for treatment, and to discuss those preferences in the context of what is the most effective treatment that is available. This is particularly important for psychotherapies of shorter duration..

Author email: joshua.keith.swift@gmail.com

This month...

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October 2013

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August 2013

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July 2013

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June 2013

Practice Implications

Psychotherapy Practice Research Network (PPRNet)