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 the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
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
September 2021
Mindfulness-Based Interventions Among People of Color
Sun, S., Goldberg, S.B., Loucks, E.B., & Brewer, J.A. (2021). Mindfulness-based interventions among people of color: A systematic review and meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2021.1937369.
In the United States, people of color (POC) are disproportionately affected by structural inequalities related to racism such as high rates of incarceration, poor housing, and economic difficulties. Racial disparities also exist in health care such that POC are less likely to use health services thus resulting in more persistent health problems. Research has shown that mindfulness-based interventions (MBIs) may be effective in improving health outcomes of conditions that are prevalent among POC like psychiatric symptoms and cardiovascular disease. Some argue that MBIs are especially culturally relevant to POC because of the focus on overall well-being, the emphasis on resilience, and communally delivered formats. In this meta-analysis, Sun and colleagues systematically reviewed 24 randomized controlled trials with a total of over 2000 participants in which MBI was compared to no treatment or to an active control (a control group that was meant to be therapeutic). Only trials in which the study sample was predominantly (>75%) POC were included. At post-treatment, MBIs showed small but statistically significant outcomes compared to active controls (k = 16, g = 0.11, 95% CI = [0.04, 0.18], p = .002) and to no treatment (k=8, g = 0.26, 95%CI = [0.07, 0.45], p = .007). These are smaller effects than reported in other populations. Drop-out rates for POC receiving MBI was about 22%, which is similar to what is reported in the general psychotherapy outcome literature.
Practice Implications
The results suggest a modest effect of MBI for POC, and that the effects may be smaller than reported in studies with other populations. Only two of the studies reported culturally adapting MBI for POC. Psychotherapists might consider cultural adaptation of MBI or providing MBI from a multi-cultural orientation framework that includes therapists’ cultural humility, making the best of cultural opportunities in therapy, and developing cultural comfort and competence.
August 2021
What Proportion of Patients Benefit from Short-Term Psychotherapy?
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Hisashi, N., &Furukawa, T.A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 10.1111/acps.13335. Advance online publication.
Many meta-analyses report that psychological therapies are effective to treat depression, that there are no differences between types or orientations of therapy in their outcomes, and that psychotherapy is as effective as medications in the short term and perhaps more effective in the longer term. But what do these findings mean for everyday practice? Many meta-analyses report a standardized mean effect size between treatment and control conditions. However, the effect size is an abstraction that may be difficult to interpret unless you understand the statistic. Clinicians may ask a more practical question: what is the proportion of patients that improve (have meaningful reductions in depression scores) and recover (improved and no longer are depressed)? This meta-analysis by Cuijpers and colleagues of 228 studies representing over 23,000 adult patients looked at the proportion of patients who improved and recovered after psychotherapy relative to those in control conditions (no treatment, care as usual, pill placebo). The psychotherapies were short term manualized treatments like CBT, behavioral activation, interpersonal psychotherapy delivered in individual, group, and self-help formats. About 41% of patients improved with psychotherapy for depression compared to 17% that improved with usual care and 31% for pill placebo. However, after statistically controlling for publication bias (i.e., the likelihood that some unflattering studies were never published), the improvement rate for psychotherapy was 38%. Recovery rates for psychotherapy ranged from 26% to 34%, and recovery in the control conditions ranged from 9% to 17%. There were no differences between therapy orientations. Highest rates of recovery or improvement were achieved by individual therapy and the lowest rates were seen in guided self-help. Deterioration rates were just below 5% in psychotherapy and about 7% to 13% in control conditions.
Practice Implications
The effects of time-limited manualized psychotherapies tested in randomized controlled trials were modest. About 40% of patients improved and about 30% recovered. On the positive side, psychotherapies resulted in only about 5% of patients getting worse. The authors argued that clinicians must consider more effective strategies beyond these approaches to improve outcomes for depression. Some have focused on improving psychotherapist effectiveness, rather than on specific interventions. Methods like progress monitoring, managing countertransference, and repairing therapeutic alliance ruptures are means of improving psychotherapists’ effectiveness.
June 2021
Psychotherapy for Sub-Clinical Depression in Children and Adolescents
Cuijpers, P., Pineda, B.S., Ng, M.Y, Weisz, J.R., Muñoz, R.F., Gentili, C., Quero, S., Karyotaki, E. (2021). A meta-analytic review: Psychological treatment of subthreshold depression in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, Online first publication.
Depression occurs in 2.6% of children and adolescents, with as many as 14% of adolescents meeting criteria for a depressive disorder before the age of 18. Depression in youths is related to a number of impairments, negative health outcomes, and to increased risk of depression as an adult. Subthreshold depression represents clinically important depressive symptoms that does not meet diagnostic criteria for major depression or dysthymia. Like major depression, subthreshold depression is related to impairment and increased mortality. Subthreshold depression in adolescents is related to increased risk for developing other disorders including future depressive disorders in adulthood. In this meta analysis, Cuijpers and colleagues present a review of direct comparison randomized controlled trials of psychological interventions for children and adolescents with subthreshold depression. The meta-analysis included 12 trials representing over 1500 children and adolescents. Eight studies tested CBT, and the others tested IPT or supportive therapy. The pooled effect size of the difference between the psychological interventions and control conditions at post treatment was g = 0.38 (95% CI: 0.14 to 0.63), indicating a small to moderate effect of psychological therapies to reduce subthreshold depression in children and adolescents. The authors found some evidence of publication bias (i.e., the likelihood that some studies were conducted but never published) and after adjusting for this bias, the effect size dropped to g = .24 (95% CI: -0.06 to 0.54) which was not statistically significant. There were only two studies of the treatment of children which showed small non-significant effects, g = 0.01 (95% CI: -1.16 to 1.18), however the effects of treatment for adolescents were considerably better, g = .44 (95% CI: 0.16 to 0.71). Longer term follow-up data (6 to 18 months) did not show sustained effects of treatment. Children and adolescents had a 48% lower chance of developing a depressive disorder if they received treatment, although this was not statistically significant.
Practice Implications
The small number of studies limits what one can say about the effects of psychological treatment for subthreshold depression in children and adolescents. The effects were small to moderate at post treatment, but the effects were statistically significant only for adolescents and not for children. Longer term effects of treatments were non-significant, and there was no significant effect on the incidence of depressive disorders at follow up. Despite the disappointing findings, the authors concluded that interventions for subthreshold depression may have positive immediate effects at post treatment for adolescents.
Psychotherapies for Depression
Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.
Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.
Practice Implications
Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.
May 2021
Therapists Are Mostly Responsible for the Therapeutic Alliance
Del Re, A. C., Flückiger, C., Horvath, A. O., & Wampold, B. E. (2021). Examining therapist effects in the alliance–outcome relationship: A multilevel meta-analysis. Journal of Consulting and Clinical Psychology. Advance online publication.
The therapeutic alliance has been consistently found to be a reliable predictor of patient outcomes. The alliance in therapy refers to the patient and therapist collaborative agreement on the tasks of therapy and the goals of therapy, as well as their emotional bond. Previous research suggested that the therapist contribution to the alliance accounted for a significant proportion of patient outcomes. That is, some therapists are better than others at forming a good alliance across a variety of patients, and those therapists who can form a good alliance have patients that achieve better outcomes. If therapists are responsible for most of the effects of a positive therapeutic alliance, then efforts should be directed toward training therapists to improve the alliance. In this meta-analysis of 152 studies, Del Re and colleagues used Patient-Therapist Ratio (PTR) as a proxy to estimate the contribution of the therapist to the alliance. Large PTR refers to many patients per therapist, whereas a low PTR refers to few patients per therapist. A significant effect of low PTR on the alliance – outcome relationship would indicate that most of the effect of the alliance on outcomes was due to the therapist. The overall effect of the alliance on patient outcomes was moderately large (r = .275, 95% CI = .247, .302) and similar to what was found in previous research. In other words, a higher therapeutic alliance between patient and therapist was related to better patient outcomes. PTR was a significant moderator of the alliance – outcome relationship (ß = −0.006, 95% CI = −0.010, −0.002). That is, the therapist had a significant contribution to the alliance – outcome association. There was no evidence of publication bias in the research, and other potential confounds did not significantly reduced the effect of the therapist on the alliance and outcomes.
Practice Implications
The strength of the relationship of the therapeutic alliance to patient outcomes is mostly due to the therapist’s characteristics or actions. That is, therapists are largely responsible for the therapeutic alliance and its impact on patient outcomes. Previous research suggested that more effective therapists have the interpersonal skills to manage interpersonally challenging situations. More effective therapist interpersonal skills include: verbal fluency, instilling hope, persuasiveness, emotional expression, warmth, empathy, and the capacity to repair alliance ruptures. Therapists who are capable of engaging in these facilitative interpersonal behaviors across a range of patients are more likely to achieve outcomes for their patients.
April 2021
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.