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.
This month...
…I blog about content from the updated edition of the Handbook of Psychotherapy and Behavior Change, published in 2021: how much psychotherapy is necessary, dropping out, and outcome monitoring.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
March 2021
Adding Psychodynamic Therapy to Antidepressant Medications
Depression is the single largest contributor to disability worldwide. There are a number of established treatments for depression including antidepressant medications and psychotherapies. One of the psychological treatments that is evidence-based is short-term psychodynamic psychotherapy (STPP). There is evidence in the general psychotherapy research literature that combining psychotherapy with antidepressant medications is more efficacious than providing medications alone. However, no meta-analysis has looked specifically at adding STPP to antidepressant medication. In this meta-analysis Driessen and colleagues analysed data from 7 studies that compare STPP plus medications versus antidepressant medications alone, or that compare STPP plus medications versus supportive therapy plus medications. Although the number of studies was small, the unique aspect of this meta-analysis is that Driessen and colleagues were able to get all of the individual level data from each study, so they were able to analyse data from 482 participants. Typical meta analyses only look at study level data (effects reported from the study as a whole) and not individual level data (effects for each individual who participant in each study). So, the results from Driessen and colleagues’ study provides a more precise and specific analysis of the findings. Combined treatment of STPP and antidepressant medications was significantly more efficacious than antidepressants with and without supportive therapy at post-treatment, but the effects were small (d = 0.26, SE = 0.01, p = .01). At follow up, combined treatment of STPP and antidepressant medications was again more efficacious than antidepressant medications and supportive therapy, but the effects were moderately large (d = 0.50, SE = 0.10). Other findings also suggested that STPP’s specific interventions provided significant added benefit over and above the non-specific effects of supportive therapy. The findings were consistent whether or not analyses were done on studies with complete versus incomplete data, controlling for baseline depression scores, and use or not of a treatment manual. Overall, the quality of the studies was good, and the findings were stable across studies.
Practice Implications
People with depression and their clinicians might expect better outcomes in terms of depressive symptoms if they combine STPP and antidepressant medications, rather than receiving medications alone. The benefits might be related to the specific interventions of STPP, which suggests that therapists may need specific training and supervision in order to make the most of STPP’s effectiveness.
December 2020
Psychotherapy for Those Who Do Not Respond to Treatment
Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.
Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).
Practice Implications
The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.
How Useful Are Smartphone Apps for Mental Health?
Weisel, K.K., Fuhrmann, L.M., Berking, M., Baumeister, H., Cuijpers, P., & Ebert, D.D. (2019). Stand alone smartphone apps for mental health: A systematic review and meta-analysis. NPJ Digital Medicine, 2, 118. https://doi.org/10.1038/s41746-019-0188-8
Mental health and lifestyle apps are very popular. There are more than 318,000 health related mobile apps on the market, 490 of which are specifically about mental health. Most of the apps do not provide information about their effectiveness, and only 11% appear valid on the face of it. Apps are potentially useful to increase access to mental health treatments since smartphones are ubiquitous in the population. However, past reports show that the drop-out rates of unguided internet interventions for mental health are very high, only 17% of clients actually complete all the modules, the average client only completes about 16% to 25% of modules, and any positive effects often disappeared when assessed in the longer term. In this meta-analysis, Weisel and colleagues assess if standalone psychological interventions delivered by smartphone apps are efficacious for mental disorders. Their systematic review found 19 randomized controlled trials that directly compared a smartphone app to a control group (e.g., no treatment) for a variety of disorders (depression, anxiety, PTSD, sleep problems, substance use, suicidal behavior). Almost half of the interventions were CBT-based. Only 1 of the 19 studies had a low risk of bias – that is only 5% of studies were high quality in terms of sampling, randomization, data analysis, and so on. More than half of studies were very low quality. The pooled effect size from six comparisons for depression showed a positive effect of smartphone apps at post-treatment to reduce depressive symptoms (g = 0.33; 95% CI: 0.10–0.57, p = .005). Similar positive findings were found for smoking cessation. These effects are considered small by most standards. However, the findings from four comparisons for anxiety disorders were not significant (g = 0.30, 95% CI: −0.1 to 0.7, p = 0.145). Similar non-significant results were found for most other disorders as well. There were not enough studies to assess the longer-term effects of apps beyond immediately post-treatment.
Practice Implications
The main problem with this research area is that the quality of the studies generally is very low. Researchers have known for some time that lower quality studies tend to result in inflated treatment effects. So even if the meta-analysis found small significant effects of mental health apps for depression and smoking cessation, these findings are not likely reliable. Further, there is almost no research on the longer-term outcomes to assess if any positive effects are lasting. The research does not support the use of apps and computerized interventions as standalone treatments. They may be useful as an adjunct to traditional therapy or when they are provided with sufficient guidance by a therapist.
November 2020
Therapist and Client Emotional Expression: A Meta-Analysis
Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.
Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.
Practice Implications
This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.
October 2020
Group Therapy for Mood Disorders: A Meta-Analysis
Mood disorders are common mental health problems, with a 12-month prevalence of 7% in the population for major depressive disorder (MDD). Researchers have tested group therapy as a treatment for MDD and bipolar disorder. Recently, the American Psychological Association added group therapy as a specialty, attesting to the empirical evidence of group therapy’s efficacy and also the need for specialized education and training. Despite this, some treatment guidelines do not list group therapy as a first line therapy for major depression. Over the past 10 years, an international group of researchers have conducted a number of meta-analyses on the efficacy of group therapy for many disorders. In this particular meta-analysis, Janis and colleagues assessed the efficacy of group therapy to treat mood disorders by looking at randomized controlled trials of group therapy compared to waitlist controls, treatment as usual, and anti-depressant medications. They identified 42 randomized controlled trials of group therapy for mood disorders that included almost 3,000 patients. Treatment orientations included CBT, DBT, psychodynamic, and interpersonal therapies. For primary outcome measures of depressive symptoms at post treatment, the effect of group therapy versus waitlist controls was large and significant (g = .86, 95% CI [.66, 1.06], p < .001, k = 9), and those receiving group treatment were 6.81 times more likely to recover compared to those waiting for treatment (95% CI [3.70, 12.55]). Group therapy also resulted in better outcomes than treatment as usual on primary outcome measures of depression at post treatment with a medium sized effect (g = 0.46, 95% CI [0.22, 0.87], p < .001, k = 11), and those receiving group therapy were 2.75 times more likely to recover than those receiving treatment as usual (95% CI [1.59, 4.72]). Finally, there was no significant difference between group therapy and medications on rate of change in depressive symptoms or on rates of recovery.
Practice Implications
Overall, group therapy was more effective than no treatment and treatment as usual for major depression symptoms. Group therapy was as effective as anti-depressant medications. Group therapy is likely more cost effective because it is a multi-person treatment. Many patients do not respond to medications or they struggle with medication adherence because of unpleasant side effects. And most patients prefer psychotherapy to medications if given the choice. And so, group therapy provides a cost-effective alternative and should be considered as a first line treatment for depression. As indicated by the American Psychological Association’s recognition of group therapy as a specialty, providing group therapy requires specialized education and training in order to offer effective care. Continuing education opportunities exist with the Society of Group Psychology and Group Psychotherapy and with the American Group Psychotherapy Association.
September 2020
The Reciprocal Relationship Between the Alliance and Outcomes
Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., . . . Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843.
The therapeutic alliance (patient and therapist agreement on tasks and goals of therapy and their emotional bond) is the most researched concept in psychotherapy. The research clearly indicates that a positive alliance reliably predicts patient outcomes in terms of reduced symptoms. However, researchers still debate whether the alliance is at all necessary. That is, some argue that the alliance is the result of patients feeling better early in therapy, and so the alliance is only an outcome of early symptom reduction. If that is the case, then the alliance is an artifact of symptom reduction, and clinicians need not pay much attention to it. In this meta-analysis, Fluckiger and colleagues collected 17 studies representing over 5000 patients that evaluated whether alliance in a previous session predicted outcomes in a subsequent therapy session, and vice versa. In other words, they looked at all studies that evaluated if change in alliance preceded change in symptoms and if change in symptoms preceded change in the alliance. What is unique about this meta-analysis is that they gathered patient-level data from the original studies. That allowed them to test the therapeutic alliance theory for each individual patient on a session by session basis for the first 7 sessions of therapy. (For the stats geeks out there, the authors analysed within-person [between-session] effects using multilevel time-lagged models). Their analyses found that high alliance at a preceding session was related to lower symptoms at the subsequent session (B adjusted = -.065 (95% CI [-.092, -.038]; p < .0001)), and higher symptoms at the start of a session was related to lower post session alliance (B adjusted = -.148 (95% CI [-.215, -.081]; p < .0001). They also found that patients who generally reported high alliance scores showed a stronger alliance – outcome relationship, and those with greater symptoms had a weaker alliance - outcome relationship.
Practice Implications
This meta-analysis is another indication of the importance of therapists and patients coming to a collaborative agreement on the tasks of therapy (what is done during sessions) and the goals of therapy (what issues to work on), and of their relational bond. The alliance is not always easy to establish – especially with regard to agreeing on goals. Also, the alliance should not be forgotten once established – alliance ruptures or tensions occur frequently and can have a negative effect on patients’ mental health outcomes. Patients of psychotherapists who repair alliance tensions generally have better mental health outcomes.