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Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Baldwin, S. & Imel, Z.E. (2013). Therapist effects. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 258-297). New York: Wiley.

Does it matter that some therapists are more effective than others? Can less effective therapists be trained to improve their outcomes and relationship quality with patients?  These are important questions not only for our patients’ well-being but also for the long term survival of psychotherapy as a health enterprise. If we do not measure outcomes and help therapists who are less effective, stakeholders (i.e., clients, families, agencies, insurance companies) may stop paying for the services. In the September 2013 blog I discussed a large study that showed that a few therapists were reliably harmful and some therapists were reliably helpful to their patients. That study also reported that most therapists were effective in 5 of 12 problem domains for which their patients sought help. What these findings and the Handbook chapter by Baldwin and Imel (2013) show is that there are significant between-therapist effects (i.e., therapists differed from each other on patient outcomes) and within-therapist effects (i.e., therapist outcomes within their own caseload differed based on the patients’ problems). Baldwin and Imel (2013) reported on their meta analysis in which between-therapist differences accounted for 5% of the outcome variance. That seems small, but it’s not. One study, for example, estimated that for each 100 patients that would be treated, the worst therapist compared to the best therapist would have 6 more patients who deteriorated. I would prefer my loved ones to be seen by the best therapist, even if the difference between best and worst is only 5%. Nevertheless, 95% of the variance in outcomes is within the therapist’s caseload. That is, the patient, other contextual variables, and the therapist-patient relationship are by far the biggest contributors to outcome. As Baldwin and Imel point out, not only are some therapists are more effective for some patients and not others, but also some therapists are better at developing a therapeutic relationship with some patients than with others. Baldwin and Imel reported that, on average, 9% of the variance in the quality of the therapeutic alliance is associated with the therapist – that’s a clinically meaningful effect.

Practice Implications

As Baldwin and Imel (2013) state, ignoring therapist accountability is detrimental to patients and to the mental health field in general. If stakeholders do not see evidence of positive outcomes, then they will withdraw funding, and patients will have even less access to services. Therapists differ in their outcomes, and outcomes also differ within each therapist’s caseload. If a primary goal is to improve therapist performance and patient outcomes, then therapists need to measure outcomes and therapeutic relationship quality. This knowledge about performance with specific patients can help therapists seek continuing education and training to improve outcomes and therapeutic alliances with specific patients for whom the therapist is less effective. This may require continuous outcome monitoring and real-time feedback to therapists regarding their patients’ outcomes (see my September 2013 blog in identifying clients who might deteriorate).

Bell, E. C., Marcus, D. K., & Goodlad, J. K. (2013). Are the parts as good as the whole? A meta-analysis of component treatment studies. Journal of Consulting and Clinical Psychology, 81, 722-736.

Component studies (i.e., dismantling treatments or adding to existing treatments) may provide a method for identifying whether specific active ingredients in psychotherapy contribute to client outcomes. In a dismantling design, at least one element of the treatment is removed and the full treatment is compared to this dismantled version. In additive designs, an additional component is added to an existing treatment to examine whether the addition improves client outcomes. If the dismantled or added component is an active ingredient, then the condition with fewer components should yield less improvement. Among other things, results from dismantling or additive design studies can help clinicians make decisions about which components of treatments to add or remove with some clients who are not responding. For example, Jacobson and colleagues (1996) conducted a dismantling study of cognitive-behavioral therapy (CBT) for depression. They compared: (1) the full package of CBT, (2) behavioral activation (BA) plus CBT modification of automatic thoughts, and (3) BA alone. This study failed to find differences among the three treatment conditions. These findings were interpreted to indicate that BA was as effective as CBT, and there followed an increased interest in behavioral treatments for depression. However, relying on a single study to influence practice is risky because single studies are often statistically underpowered and their results are not as reliable as the collective body of research. One way to evaluate the collective research is by meta analysis, which allows one to assess an overall effect size in the available literature (see my November, 2013 blog on why clinicians should rely on meta analyses). In their meta analysis, Bell and colleagues (2013) collected 66 component studies from 1980 to 2010. For the dismantling studies, there were no significant differences between the full treatments and the dismantled treatments. For the additive studies, the treatment with the added component yielded a small but significant effect at treatment completion and at follow-up. These effects were only found for the specific problems that were targeted by the treatment. Effects were smaller and non-non-significant for other outcomes such as quality of life.

Practice Implications

Psychotherapists are sometimes faced with a decision about whether to supplement current treatments with an added component, or whether to remove a component that may not be helping. Adding components to existing treatments leads to modestly improved outcomes at least with regard to targeted symptoms. Removing components appears not to have an impact on outcomes. The findings of Bell and colleagues’ (2013) meta analysis suggest that specific components or active ingredients of current treatments’ have a significant but small effect on outcomes. Some writers, such as Wampold, have argued that the small effects of specific components highlight the greater importance of common factors in psychotherapy (i.e., therapeutic alliance, client expectations, therapist empathy, etc.). This may be especially the case when it comes to improving a patient’s quality of life.

Author email: david.marcus@wsu.edu

Munder, T., Brütsch, O., Leonhart, R., Gerger, H., & Barth, J. (2013). Researcher allegiance in psychotherapy outcome research: An overview of reviews. Clinical Psychology Review, 33, 501-511.

Although evidence for the efficacy of psychotherapy is largely uncontested, there remains debate about whether one type of treatment is more effective than another. This debate continues despite a recent American Psychological Association (APA) resolution on the equivalent efficacy of most systematic psychotherapy approaches. There are many aspects to this debate (e.g., some treatments are more researched than others and so appear to be better; symptom focused measurements are more sensitive to change and so may favour one treatment over another; some treatments are more amenable to manualization and short term application; etc.). One element of the debate that has received a lot of attention is researcher allegiance. Researcher allegiance refers to researchers preferring one treatment approach over another, and this preference may bias comparative outcome trials in favour of the preferred therapy. Researcher allegiance is measured by assessing primary researchers’ publication history or by their self-declared preference for a particular therapy approach. There exist 30 meta analyses that assessed researcher allegiance since the 1980s. These meta analyses focused on different therapy types, client populations (adults, children), and research designs (randomized trials, naturalistic effectiveness studies). However, some meta analyses have reported contradictory results for the researcher allegiance effect. This could be due to the different foci of the meta analyses (i.e., different treatment approaches, patient populations, age groups, etc.), and also possibly due the allegiance of those conducting the meta analyses. Munder and colleagues (2013) conducted a mega analysis of these meta analyses. As the name implies, a mega analysis aggregates the findings of available meta analyses. Munder and colleagues found a significant moderate effect of researcher allegiance. Researcher allegiance was consistent across patient populations, age groups, outcome measures, type of study design, and year of publication.

Practice Implications

As the APA resolution indicates, psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles. Evidence-based practice in psychotherapy is "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences". The results of this mega analysis undermine the claim of some comparative outcome studies that suggest that one evidence-based psychotherapy is more effective than another.

Author email: tmunder@uni-kassel.de

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

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

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