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.

April 2021

Therapeutic Alliance Predicts Patient Outcomes Over and Above Other Factors

Flückiger, C., Del Re, A. C., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020, March 26). Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. Advance online publication.

The therapeutic alliance is probably the most researched concept in psychotherapy. The alliance refers to a collaborative agreement on the tasks of therapy (what patients and therapists do in therapy, like homework, or examine the past or relationship issues), a collaborative agreement on the goals of therapy (what the desired outcomes might be), and the relational bond between patient and therapist (liking and respect for one another). The most recent meta-analysis of the alliance included 296 studies. The meta-analysis showed a moderate and robust relationship between higher alliance and better patient outcomes regardless of type of therapy, who rated the alliance, or how it was rated. Nevertheless, some still think that the alliance is a byproduct of other factors like patient symptom severity (less symptomatic patients may report a better alliance with therapists) or adherence to treatment manuals (higher therapist adherence may lead to a better alliance). In other words, some argue that the alliance may not directly affect outcomes and may not be that important. In this meta-analysis, Fluckiger and colleagues examined 60 studies with over 6,000 patients that reported the alliance-outcome relationship, and also the effects of patient characteristics like symptom severity and adherence to treatment manuals. Overall, the therapeutic alliance was significantly related to patient outcomes, r = .304 (95% CI [.253, .354], p < .001, k = 53). When the authors of the primary studies controlled for patient characteristics like symptom severity, the adjusted alliance - outcome correlation remained significant, r = .286 (95% CI [.226, .344], p = .001, k = 35). When the authors of primary studies controlled for the effects of therapist adherence to a treatment manual, the adjusted alliance – outcome correlation still remained significant, r = .242 (95% CI [.179, .306], p = .001, k = 13). The slight reduction in the alliance-outcome correlation caused by the effects of patient symptom severity or therapist adherence to a manual was not significant.

Practice Implications

Therapists’ capacity to develop a therapeutic alliance is a key factor to patients experiencing a good outcome from psychotherapy. This is true for many types of patients with differing levels of symptom severity, and also true regardless of type of therapy or level of therapist adherence to a treatment protocol. Developing shared treatment goals and agreeing on the tasks of therapy are important first steps. In addition, therapists and clients who like working together and share a sense of mutual respect are more likely to experience a successful therapy. Maintaining the alliance throughout therapy is also important. The alliance fluctuates across time indicating subtle or obvious ruptures or tensions that occur. Therapists’ skills at identifying and repairing alliance ruptures is critical to an ongoing collaborative relationship and to patients achieving the best possible outcomes.
Does Mindfulness Lead to Greater Empathy Among Psychotherapists?

Cooper, D., Yap, K., O’Brien, M. et al. (2020). Mindfulness and empathy among counseling and psychotherapy professionals: A systematic review and meta-analysis. Mindfulness, 11, 2243–2257.

Just about every theoretical model of psychotherapy recognizes that therapist empathy is a necessary and fundamental component of treatment. A meta-analysis showed that higher therapist empathy as rated by patients was a moderately strong predictor of outcomes. Despite its importance, training programs in counseling, clinical psychology, and psychotherapy have not found effective ways of increasing empathy among trainees. Some might argue that more mindful therapists might be more attentive and accepting of aversive emotions and therefore more open to entering a client’s world or experiences. Rogers defined empathy as the capacity to enter into the private perceptual world of the other, and it involves taking another’s perspective and being emotionally moved. Measures of empathy assess dimensions such as personal distress, empathic concern, fantasy, and perspective taking. Mindfulness, on the other hand is defined by some as an open and receptive attention and awareness to one’s own present experiences. The theory is that having this receptive mindful attitude is necessary to develop empathy for others. If this is the case, then mindfulness training might foster a greater empathic attitude among psychotherapists and trainees. In this study, Cooper and colleagues (2020) conducted a meta-analysis to examine the relationship between dimensions of mindfulness and empathy among psychotherapy trainees. They also looked at studies that examined if training in mindfulness was associated with greater empathy among trainees. The results from up to 10 studies showed that greater levels of mindfulness were associated with less personal distress, r = − .42, 95% CI [− .55, − .27], and greater perspective taking, r = .28, 95% CI [.15, .40]. However, there was no significant relationship between mindfulness and empathic concern or fantasy. When aggregating the findings of the six studies that examined the effect of mindfulness training on increasing trainee therapist empathy, there were no significant effects on any of the empathy scales.

Practice Implications

This is not a well-developed research area because of the few studies and small sample sizes, and so results should be taken with a grain of salt. Meta-analyses clearly show that therapist empathy is important to patients and their outcomes. Higher levels of mindfulness were associated with greater perspective taking and lower personal distress. Mindfulness might help therapists to disengage from internal experiences and free up resources to be empathic to patients’ distress. However, the existing research does not support the use of mindfulness training to improve therapist empathy.
Adding Psychotherapy to Pharmacotherapy for Depression

Guidi, J. & Fava, G.A. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder: A systematic review and meta-analysis. JAMA Psychiatry, 78, 261-269.

A sequential model of treatment suggests that one apply two treatments consecutively in order to reduce relapse of symptoms. This might include pharmacotherapy followed by psychotherapy, or vice versa. One reason to consider a second consecutive treatment for depression is that many individuals continue to have symptoms after a first treatment, and having residual symptoms is related to higher relapse rates. Another reason is that many with depressive disorders have comorbid symptoms of anxiety or other disorders, and so one course of treatment may not be enough for such complex situations. In this study, Guidi and Fava conducted a meta-analysis to examine if sequential combination of medications and psychotherapy reduced the risk of relapse for major depression. They reviewed 17 randomized controlled trials representing 2283 adult patients that examined the sequential use of psychotherapy following medications. The primary outcome was remission of depressive symptoms. The methodological quality of the studies was high. After adjusting for publication bias, the sequential approach was significant (RR = 0.885; 95% CI, 0.793-0.988), indicating that sequencing treatment resulted in a lower risk of relapse or recurrence. Continuing versus discontinuing medications during psychotherapy did not result in any advantage for patients. However, providing psychotherapy while continuing with antidepressant medications reduced rates of relapse and recurrence, RR = 0.821 (95% CI, 0.710-0.949).

Practice Implications

The chronic and recurrent nature of major depression is an important clinical challenge. The results of Guidi and Fava’s meta-analysis suggests that adding psychotherapy following pharmacotherapy, either alone or in combination with pharmacotherapy, will reduce the risk of relapse from major depression. Discontinuing medications is reasonable after adding psychotherapy in order to help patients with major depression to stay symptom free. The results support the notion that psychotherapy results in patients acquiring skills to regulate their emotions, and that this might result in reduced relapse of depressive symptoms. Such skill acquisition does not take place with pharmacotherapy alone.

March 2021

Adding Psychodynamic Therapy to Antidepressant Medications

Dreissen, E., Dekker, J.J.M., Peen, J., Van, H.L., Maiana, G…. Cuijpers, P. (2020). The efficacy of adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression: A systematic review and meta-analysis of individual participant data. Clinical Psychology Review, 80.

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.

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April 2021

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March 2021

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December 2020

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Psychotherapy Practice Research Network (PPRNet)