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Alexandersson, K., Wågberg, M., Ekeblad, A., Holmqvist, R., & Falkenström, F. (2022) Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression. Psychotherapy Research, DOI: 10.1080/10503307.2022.2025626.

There has been a long-standing debate in psychotherapy about whether a therapist’s capacity to be adherent to treatment manual and to be competent in delivering specific treatment interventions leads to better patient outcomes. Some argue that rigid adherence may lead to worse outcomes, and meta-analytic research suggests that specific treatment adherence or competence has no impact on outcomes. Others argue that facilitative therapist behaviors (empathy, warmth, involvement, support) and the therapeutic alliance plays a more important role in whether patients get better. It is possible that psychotherapy research designs and rudimentary data analytic methods obscure the effects of therapist treatment adherence. In this study, Alexandersson and colleagues collected data from a randomized controlled trial of cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for depression. The researchers rated therapist behaviors (adherence to the treatment manual, facilitative behaviors) from recorded therapy sessions. They also assessed patient ratings of the therapeutic alliance after every session. Alexandersson and colleagues used a statistical modeling procedure that allowed them to look specifically at the effects of therapist adherence in a previous session on a patient’s depressive symptoms in a subsequent session. Their results did not show any effects of therapists’ use of specific CBT or IPT techniques on patient outcomes. Facilitative therapist behaviors in a previous session predicted better patient outcomes in the next session for CBT but not for IPT. The effects of facilitative therapist behaviors on outcomes were partially explained by levels of the therapeutic alliance. That is, facilitative behaviors among CBT therapists led to higher therapeutic alliance ratings by patients, which in turn led to lower patient depression scores in the subsequent session.

Practice Implications

The authors were a little surprised that facilitative therapist behaviors (empathy, warmth, involvement, support) led to better outcomes in CBT but not in IPT. They speculated that therapist relational competence might be especially relevant early in CBT to facilitate a strong alliance, which in turn reduces depressive symptoms among patients. The demanding tasks of CBT (behavioral activation, homework) might mean that therapists’ warmth, support and engagement are important precursors to patients benefitting from the therapy.

Once-Weekly or Twice-Weekly Sessions of Psychotherapy?

Bruijniks, S., Lemmens, L., Hollon, S.D., Peeters, F.P., ….Huibers, M.J. (2020). The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients. The British Journal of Psychiatry, doi: 10.1192/bjp.2019.265. [Epub ahead of print].

Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.

Practice Implications

This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.

Foa, E., McLean, C.P., Zang, Y., Rosenfield, D., Yadin, E… Peterson, A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. Journal of the American Medical Association, 319, 354-364.

Post-traumatic stress disorder (PTSD) can affect 10% to 20% of military personnel returning from combat. PTSD is often chronic and debilitating, and is associated with symptoms that are distressing, that lower quality of life, and that negatively impact family and loved ones. Prolonged exposure therapy (PE) has been tested in the past, and researchers have claimed that it is an efficacious treatment in civilians and veterans. PE is a form of behavior therapy and cognitive behavioral therapy characterized by re-experiencing the most traumatic event through remembering it and engaging with, rather than avoiding reminders of the trauma. In their treatment guidelines, the American Psychological Association (APA) proposed PE as a recommended treatment for PTSD. In this randomized controlled trial, Foa and colleagues assess if providing PE in intensive short time frame (massed exposure; 10 sessions over 2 weeks) was as effective as standard exposure (10 sessions over 8 weeks) for 370 military personnel in the US with PTSD. That is, the authors were interested to see if providing the same amount of therapy based on exposure in a shorter time was just as effective. They also compared the two versions of PE (massed and standard exposure) to two control conditions: present centred therapy (PCT) that is largely supportive therapy that does not rely on exposure to the trauma, and a no treatment control condition. The main outcomes were reductions in level of PTSD symptoms and reductions in PTSD diagnoses at post-treatment and up to 6 months post-treatment. Massed and standard PE were equally effective in reducing symptoms and diagnoses of PTSD compared to no treatment. However, PE was not more effective than PCT in reducing symptoms and diagnoses, and PCT was more effective than no treatment. Overall, reductions in PTSD symptoms and reduction in PTSD diagnoses were modest. Drop out rates were high at about 50% for all conditions.

Practice Implications

Drop out rates were high and outcomes were modest for these short-term psychological treatments for PTSD in military personnel, such that over 60% still had a diagnosis of PTSD at 6 months follow up. And PE therapy did no better than a control condition (PCT) that simply provided support with no exposure to the trauma. These findings are similar to other research in this area. Psychotherapy for trauma may require more time to work, and perhaps different models of understanding and treating the disorder. As Shedler recently remarked, it takes at least 20 sessions/weeks before 50% of clients improve. So it may not be surprising that 2 or 8 weeks of therapy had only a small impact on PTSD symptoms.

Goodyear, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., ….Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, Online first publication: http://dx.doi.org/10.1016/S2215-0366(16)30378-9.

Major depression affects a large proportion of adolescents worldwide. The Global Burden of Disease Study Found that depressive disorders accounted for over 40% of disease burden caused by all mental and substance use disorders, with the highest burden occurring for those between the ages of 10 and 29. Although there is good evidence for cognitive-behavioral therapy (CBT) to treat depression in adolescents, data is scarce for long term outcomes – which is an important issue because maintaining treatment gains reduces the risk for relapse. There is also little research on alternative treatments to CBT and their long term effects. In this large study, Goodyear and colleagues (2016) randomly assigned 470 adolescents with major depression to receive CBT, short-term psychoanalytical therapy (STPT), or a brief psychosocial intervention (BPI). CBT was based on a commonly used model but adapted to include parents and emphasized behavioural techniques. The STPT model emphasized the child – therapist relationship in which the therapist emphasized understanding feelings and difficulties in ones life. STPT also included some family meeting. BPI on the other hand focused on psychoeducation about depression, was task and goal oriented, and emphasized interpersonal activities. The study also compared cost-effectiveness of the three treatments – that is, whether the treatments’ costs relative to their effectiveness were different. There were some advantages in terms of reduced depression to both CBT and STPT compared to BPI at 36 weeks and 52 weeks post treatment, but these advantages disappeared by 86 weeks follow-up. Across all three treatments, about 77% of adolescents with depression were in remission (i.e., no longer depressed) by 86 weeks post-treatment. There were no differences between the three treatments in terms of cost-effectiveness.

Practice Implications

This is one of those rare studies that is large enough to adequately compare the efficacy of alternative treatments for adolescents with major depression. CBT, STPT, and BPI were all associated with reduced depression in adolescents, and with maintenance of these improvements 1 year after the start of treatment. Both BPI and STPT provide alternative choices to CBT for patients and therapists.

Connolly Gibbons, M.B., Gallop, R., Thompson, D., Luther, D., Crits-Christoph, K., Jacobs, J., Yin, S., & Crits-Christoph, P. (2016). Comparative effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: A randomized clinical noninferiority trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.1720.

Dynamic psychotherapy is widely practiced in the community, but there remain very few trials assessing its effectiveness. Dynamic therapy targets individuals’ problematic relationship conflicts. Cognitive therapy on the other hand has been established as effective for major depression in a number of controlled trials. This study by Connolly Gibbons and colleagues was designed to test if dynamic therapy was equivalent (not inferior) to cognitive therapy in treating major depressive disorder in a community setting. There are two important and novel aspects to this research. First, the study takes place with community-based therapists in a community mental health setting. This means that the usual critique that randomized controlled trials do not speak to what therapists do with real patients in everyday practice is addressed in this study. Second, the sample size is large enough and the study is sufficiently powered so that one can make conclusions about non-inferiority (statistics geeks will know that making a hypothesis of non-inferiority, equivalence, or no difference requires enough power and a large enough sample size – something that is quite rare in psychotherapy trials). Twenty therapists who worked in a community mental health center were trained by experts in dynamic therapy or cognitive therapy. The therapists treated 237 adults with major depressive disorder with 16 sessions of dynamic or cognitive therapy. Therapists were followed the treatment manuals and they were judged by independent raters as competent in delivering the treatment. Patients on average got significantly better regarding depressive symptoms (d = .55 to .65), and there were no significant differences in the rate of improvement between dynamic and cognitive therapy patients (d = .11). There were also no differences between treatments on several measures of quality of life. A noteworthy finding was that about 80% of patients continued to have some depressive symptoms by the end of treatment even though they improved.

Practice Implications

This study adds to research indicating that short-term dynamic psychotherapy is as effective as short term cognitive therapy for treating major depression. The study also indicates that the treatments under intensive supervision and training can be provided effectively by community therapists in real world settings. That 80% of patients continued to have some depressive symptoms suggests that the short term nature of the therapies may not have represented a large enough dose of treatment for most patients.

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, Tharmanathan, P....White, D. (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): Large scale pragmatic randomised controlled trial. BMJ, 351, h5627. Doi: 10.1136/bmj.h5627.

Depression is one of the most common reasons why people see family physicians for consultation. The personal and economic burden of depression is high, such that depression is the leading cause of disability worldwide. Effective treatments for depression include antidepressant medications and psychotherapy. Cognitive behavioral therapy (CBT) is an effective treatment for depression, but is not always accessible for those who live in remote areas, and for those who cannot easily find or afford a trained psychotherapist. One solution, touted by some is to provide computerized CBT (cCBT) via internet or CD. In fact, the National Institute for Health and Care Excellence (NICE) in the UK recommend cCBT programs as a first step of care for depression. Commercially available cCBT programs include “Beating the Blues”, and freely available programs include “MoodGYM”. Previous research shows a large effect of cCBT for reducing depressive symptoms, but non-adherence (i.e., not completing the modules) and patient dropout rates tend to be high. Another issue is that most of the studies of cCBT were conducted by the developers of the programs, and so there may be researcher allegiance effects that could bias the findings. In this large trial, Gilbody and colleagues asked: “How effective is supported computerized cognitive behavior therapy (cCBT) when it is offered in addition to usual primary care in adults with depression?” The authors recruited 691 depressed patients seen in primary care with a general practitioner (GP) in the UK. All participants had access to a computer and high speed internet. The participants were randomly assigned to receive: (1) usual GP care plus 8 50-minute sessions of Beating the Blues, or (2) usual GP care plus 6 weekly modules of MoodGYM, or (3) only usual GP care. Usual GP care included providing antidepressants, counselling, or brief psychotherapy which are all offered as part of the UK National Health Service. Computerized CBT was supported by weekly telephone calls followed by reminder emails to encourage participants to access, use, and complete the programs. At 4 months after the start of treatment, about half of all participants were no longer depressed, and there were no differences between the three study conditions on any of the outcomes (e.g., depression, quality of life). The results were consistent up to 2 years post treatment. However, only about 17% of those receiving one of the cCBT treatments completed all of the sessions. The average number of sessions completed of cCBT was very low (Beating the Blues = 2 out of 8 sessions; MoodGYM = 1 out of 6 sessions). The authors concluded that there was no significant benefit of adding supported cCBT to usual GP care.

Practice Implications

Adding cCBT to usual GP care did not provide added benefit to depressed patients. Low adherence and low engagement with cCBT likely reduced the utility of computerized delivery of therapy. It is possible that more intensively supported cCBT (i.e., with weekly face to face contacts) might have improved the added value of cCBT, but would also have reduced the practically utility and accessibility of cCBT. Those who are depressed might have difficulty with summoning the energy and concentration necessary to repeatedly log on to computers and engage in computerized or internet based treatment.