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 psychotherapy for adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
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
January 2024
How Can Psychotherapists Accurately Measure a Therapeutic Alliance Rupture?
Babl, A., Rubel, J., Gómez Penedo, J. M., Berger, T., Grosse Holtforth, M., & Eubanks, C. F. (2023). Can session-by-session changes in self-reported alliance scores serve as a measure of ruptures in the therapeutic alliance? Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000861
The therapeutic alliance is a robust predictor of patient outcomes in psychotherapy. One can define the alliance as the collaborative agreement between patient and therapist on the goals of therapy (what is the desired outcome) and tasks of therapy (how therapy should proceed), and the relational bond between patient and therapist. Ruptures in the therapeutic alliance are breakdowns or tensions in the relationship between therapist and patient in any of the three core components of the alliance (agreement on goals and tasks, and the bond). If ruptures go unaddressed, they can lead to poor outcomes or patient dropout. Despite the practical importance of the alliance and of identifying alliance ruptures, therapists often feel at a loss when it comes to detecting a rupture. Ruptures can be characterized by patient behaviours that indicate withdrawal from the therapist (going silent, abstract, or vague responses) or confrontation with the therapist (complaining or rejecting interventions). However, therapists may not always be aware that a rupture in the alliance has occurred, and so they may need help to identify an alliance rupture. One source of help is to have patients complete a brief self-report measure of the state of the therapeutic alliance at the end of each session. In this study, Babl and colleagues asked 58 patients with depression who received CBT to rate the therapeutic alliance with a short validated scale (i.e., the Working Alliance Inventory [WAI]) after each of 20 sessions. The authors also video-recorded each session and rated alliance ruptures within each session with the 3RS a validated observer rating scale. Although the 3RS is the best way to assess alliance ruptures, 3RS ratings require an intensive process of coding by expert judges. And so, if the WAI, which is a relatively easy procedure, can reliably identify ruptures, then this may give clinicians a way of knowing when a rupture occurred. Rubl and colleagues defined an alliance rupture as a significant drop in the patient’s WAI score from one session to the next (i.e., technically, they used a score 2 standard deviations lower than the patient’s average WAI score in all preceding sessions). They found that sessions for which the WAI indicated a drop in alliance ratings had significantly more rupture markers (as rated by the 3RS) than sessions that did not show a drop in alliance ratings.
Practice Implications
Although somewhat preliminary, the results of this study suggest that clinicians can use changes in patient-self-reported WAI scores from session to session to identify if a therapeutic alliance rupture occurred. If there is a precipitous drop in WAI scores after a session, then therapists might enquire with the patient about the state of the therapeutic alliance in the next session. That is, therapists might ask if there is still an agreement on the goals of therapy or if the therapy is proceeding in a way that is congruent with what the patient expects. Alternatively, the therapist may check in on the state of the therapeutic relationship, that is, to assess if the patient may feel some tension, disappointment, or frustration with the therapist. The goal is for therapists to use relatively easy-to-use measures like the WAI to help them make the most of the therapeutic alliance.
Is CBT for Perfectionism Effective?
Smith, M. M., Hewitt, P. L., Sherry, S. B., Flett, G. L., Kealy, D., …, & Bakken, K. (2023, April 27). A meta-analytic test of the efficacy of cognitive behavioural therapy for perfectionism: A replication and extension. Canadian Psychology / Psychologie canadienne. Advance online publication. https://dx.doi.org/10.1037/cap0000360
Perfectionism is a multidimensional personality factor that can make one vulnerable to mental health problems and can interfere with therapeutic processes like the therapeutic alliance. The bulk of the research for treating perfectionism has focused on cognitive behavioural therapy (CBT), with meta-analyses concluding that CBT is efficacious. However, this research has certain limitations. First, the meta-analyses focus on standard mean differences (SMD) between treatments and control conditions, but SMDs are abstractions that are difficult to translate into real-world practice. What matters most to patients and clinicians is the proportion of patients who reliably improve beyond statistical error or the natural course of the problem. Second, the studies do not consistently report analyses related to drop-out rates. Drop-out is an indicator of the tolerability of a treatment for patients. If patients drop out at a high rate, then the treatment may not be acceptable, and many patients may not benefit. Third, the meta-analyses of CBT for perfectionism do not indicate whether treatment effects at the end of therapy are sustained in the longer term. In this re-analysis and extension of previous meta-analyses, Smith and colleagues look at the critical issues of the proportion of improved patients, drop-outs, and long-term outcomes for those with perfectionism treated with CBT. Like previous meta-analyses assessing SMDs, the authors found moderate to large effects of CBT versus control conditions on several of the dimensions of perfectionism. However, they also found no significant effects for several other dimensions of perfectionism that were more persistent and related to core personality (e.g., self-oriented perfectionism, other-oriented perfectionism, socially prescribed perfectionism, perfectionistic cognitions). Regarding the proportion of reliably improved patients, 13% to 55% of patients showed reliable improvement depending on the dimension of perfectionism that was assessed. But between 7.5% and 24.5% reliably improved without any treatment. So, the added value of CBT beyond no treatment was modest in most cases. Regarding dropouts, 27.0% of patients dropped out of CBT while only 15.7% dropped out of the control conditions. That is, those who received CBT had a 1.89 times increased risk of dropping out compared to those who were in control conditions (95% CI [1.37, 2.60], p = .005). Finally, very few studies assessed the longer-term effects of CBT, and those that did assess longer-term outcomes found that any effects at post-treatment disappeared at the follow-up assessments.
Practice Implications
The results of this meta-analysis suggest that it may not be enough to provide CBT to help patients who have the persistent relational aspects of perfectionism (i.e., self-oriented perfectionism, other-oriented perfectionism, socially prescribed perfectionism, and perfectionistic cognitions). It is also unclear if CBT is effective in the longer term as the small amount of evidence that exists does not inspire optimism. CBT may not be tolerable to some patients with perfectionism as evidenced by the moderately high drop-out rate. It may be necessary to adapt CBT or to include other models of treating perfectionism that use interpersonal and dynamic concepts and interventions that explicitly target core personality features of perfectionism.
October 2023
How Reliable is the Research on CBT Plus ERP for Obsessive-Compulsive Disorder?
Reid, J.E., Laws, K.R., Drummond, L., Vismara, M. Grancini, B., Mpavaenda, D., Fineberg, N.A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.
Cognitive-behavioural therapy (CBT) combined with exposure and response prevention (ERP) is considered by many the treatment of choice for obsessive-compulsive disorder (OCD). However, questions remain about the size of its effects, the reliability of the research, and the relative efficacy of CBT plus ERP compared to other psychological treatments. Reid and colleagues conducted a systematic review and meta-analysis of randomized controlled trials of CBT with ERP in patients of all ages with OCD. They included 36 studies with 2000 patients (537 children/adolescents and 1483 adults) receiving treatment and 1015 in control conditions. When compared against all control conditions, CBT with ERP showed a significant and large effect (g = 0.74: 95% CI = 0.51 to 0.97 k =36). While CBT with ERP was more effective than a “psychological placebo” (e.g., progressive relaxation; g = 1.13: 95% CI 0.71 to 1.55, k = 10) and no treatment control conditions (g = 1.27: 95% CI 0.79 to 1.75), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI −0.27 to 0.16, k = 8). When compared to pharmacological treatment with an adequate dosage of selective serotonin reuptake inhibitors, CBT with ERP was marginally better with a small effect (g = 0.32: 95% CI -0.00 to 0.64, p = 0.05). Researcher allegiance or bias had a big impact on the effects of CBT with ERP. Researcher allegiance refers to studies conducted by researchers who prefer, favour, or have a vested interest in the treatment they are testing. In the studies identified as having researcher allegiance, a large favourable effect for CBT with ERP emerged (g = 0.95: 95% CI 0.69 to 1.2). By contrast, in trials where the authors did not identify researcher allegiance (k= 8), CBT with ERP showed no significant effects (g = 0.02: 95% CI−0.29 to 0.33). This difference was statistically significant (Q = 20.33, p < 0.005). There was no evidence of publication bias, but 28 of the 36 studies had a high risk of bias (in which there were deficiencies in the research design, procedures, or data analyses).
Practice Implications
At this point, CBT plus ERP is the most studied treatment for OCD, and it appears to be effective in reducing symptoms post-treatment. However, this meta-analysis raises more questions than it answers about the reliability of the research. Other active treatments (e.g., CBT without ERP) appear just as effective, which suggests that ERP may not be necessary to treat OCD. Researchers who favor or have a vested interest in CBT plus ERP produce much larger effects for their preferred treatment, and the quality of most of the research is low. Such findings lower one’s confidence in the conclusions drawn from the research.
June 2023
Is CBT the Gold Standard for Psychotherapy?
Leichsenring, F. & Steinert, C. (2017). Is CBT the gold standard for psychotherapy? The need for plurality in treatment and research. JAMA, 318(14), 1323–1324. doi:10.1001/jama.2017.13737
Mental disorders are common in the population and are associated with significant impairment and economic costs. For many mental disorders, psychotherapy is considered as a first line treatment, and 75% of patients prefer psychotherapy to medications. For the past few decades CBT has been considered by some as the gold standard of the psychotherapeutic treatments, and this claim is based primarily on interpretations of the research evidence. The phrase “gold standard” implies a few things: that the evidence for the treatment’s efficacy is undisputable, and that the therapy is the most effective treatment available. In this viewpoint article, Leichsenring and Steinert raise concerns about the evidence for these claims about CBT. First, the quality of the evidence is quite low (based on ratings of randomization procedures, blind assessments, sufficient sample sizes). Only 17% of randomized controlled trials of CBT were considered high quality (83% were of low or moderate quality), and researchers have long known that lower quality studies inflate effect sizes. That is, the effects of CBT may be over-estimated, especially in the lower quality studies conducted in the early years of psychotherapy research. Second, there is evidence that researcher allegiance (the researcher’s belief in the superiority of the treatment) also inflates the effects of CBT. In some studies, for example, the therapy compared to CBT was designed to fail which made CBT look relatively more effective. Third, the true efficacy of CBT may be smaller than previously believed. Compared to treatment as usual (clinical management or medication reviews), the true effects of CBT may be small and yet inflated because of researcher allegiance. Publication bias (the tendency for researchers not to publish negative or neutral findings) may further diminish the perceived efficacy of CBT. Finally, there is no clear evidence that CBT is more effective than other psychotherapies for anxiety and depressive disorders. This has been a consistent finding over multiple meta-analyses published over the past 50 years.
Practice Implications
The research evidence does not support the claim that CBT is the “gold standard” (most effective) therapy for mental disorders. CBT is beneficial for some patients, but so are other bona fide therapies. CBT is the most studied therapy, but quantity of research does not translate into quality. Prematurely claiming that one therapy is the gold standard closes many doors for patients, clinicians, researchers, and trainees. Outcomes for patients need to be substantially improved perhaps by providing patients and clinicians with more options. Researchers should broaden their agendas to study what are the common therapeutic elements of psychotherapy. And trainees deserve more than a uniform approach to understanding the people they will treat.
February 2023
Cognitive Behavior Therapy vs. Control Conditions and Other Treatments
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: A comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22, 105–115.
Depression is a highly prevalent mental disorder, with about 280 million people worldwide who have the disorder. Several evidence-based treatments are available for depression, including pharmacotherapies and psychotherapies. Cognitive behavior therapy (CBT) is the most researched type of psychotherapy for depression. To date there are 409 trials with over 52,00 patients. In this study, Cuijpers and colleagues conduct the largest meta-analysis of CBT versus control conditions (treatment as usual [TAU], no treatment, other active psychotherapies, and pharmacotherapy). Although early trials of CBT were of low quality (small sample sizes, high risk of bias), the quality of studies have improved over time. In this meta-analysis Cuijpers and colleagues found that CBT had a large to moderate effect compared to TAU or to no treatment (g=0.79; 95% CI: 0.70-0.89), suggesting that CBT is better than receiving no or limited treatment. These results were stable up to one year follow-up. One would have to treat 4.7 patients with CBT to see improvement in one patient relative to no or limited treatment. CBT was compared to other active treatments in 87 trials. CBT was no more effective than other psychotherapies such that the average difference was miniscule (g=0.06; 95% CI: 0-0.12). One would have to treat 63 patients with CBT for one patient to receive a better outcome relative to another psychotherapy. However, if differences did emerge between CBT and other psychotherapies, they were not reliable. The effects of CBT did not differ significantly from those of pharmacotherapies (anti-depressant medications) at the short term, but the effects of CBT were significantly larger than pharmacotherapies at 6–12-month follow-up (g=0.34; 95% CI: 0.09-0.58). However, these follow-up findings also were not reliable. Combined treatment of CBT plus anti-depressant medications was more effective than pharmacotherapies alone at the short (g=0.51; 95% CI: 0.19-0.84) and long term (g=0.32; 95% CI: 0.09-0.55), but combined treatment was not more effective than CBT alone at either time point.
Practice Implications
The authors concluded that CBT is effective in the treatment of depression compared to no or limited treatment in the short and longer term. Although CBT gets the lion’s share of attention in the psychotherapy literature, there is no evidence that it is more effective than any other form of psychotherapy or antidepressant medication in the short term. There is evidence that combined CBT and medications may be more helpful than medications alone for depression.
August 2022
Does Treatment Fidelity Lead to Better Patient Outcomes?
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.