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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.

Newman, M.G., Agras, W.S., Haaga, D.A.F., & Jarrett, R.B. (2021). Cognitive, behavioral, and cognitive-behavioral therapy. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 14.

Cognitive-behavioral therapy (CBT) is the most researched psychotherapy for many disorders including depressive disorders. Depression is a global health problem that affects physical and emotional health and is associated with many adverse effects (substance dependence, poverty, illness). And so, finding good treatment options for patients with depression is an important goal. Many treatment guidelines view CBT as one of the first-line treatments for depression based on the research that demonstrates its efficacy. In this chapter of the Handbook, Newman and colleagues review the research on the efficacy of CBT. Immediately post-treatment, the effect sizes for CBT were medium to large when compared to treatment as usual (g = .59, 95% CI [0.42, 0.76]), placebo control groups (g = 0.51, 95% CI [0.32, 0.69]) and wait list/no treatment control groups (g = 0.83, 95% CI [0.72, 0.94]). The effects of CBT for depression tend not to differ from other bona-fide psychotherapies including interpersonal psychotherapy (IPT) (g = –0.09, 95% CI [–0.39, 0.20]), psychodynamic therapies (g = 0.25, 95% CI [–0.07, 0.58]), and supportive psychotherapy (g = 0.15, 95% CI [–0.06, 0.25]). The effects of CBT are also similar to those achieved with anti-depressant medications (g = 0.03, 95% CI [-0.13, 0.18]). Approximately 41% of patients with major depression who receive CBT have significantly fewer depressive symptoms immediately post-treatment than the average patient treated in a placebo or waiting list/no treatment control group. There have been some criticisms of the effect size estimates for CBT in some of these studies. For example, research indicates that newer and higher quality studies have resulted in smaller effects. And so there remains concerns that the overall effects of CBT for depression may be over-estimated.

Practice Implications

Treatment guidelines indicate that CBT is one of the first-line treatment for depressive disorders along with anti-depressant medications and other psychological therapies. CBT appears to improve both short-term and longer-term outcomes for some adults. There is also some evidence that if CBT is combined with pharmacotherapy, then patients might experience even greater improvement. CBT may result in patients learning something about themselves and their depression, which might reduce relapse and recurrence of the depression, although evidence for the latter is still uncertain.

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148

Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.

Practice Implications

The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.

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.

Zimmermann, D., Wampold, B.E., Rubel, J., Schwartz, B., Poster, K., … & Lutz, W. (2020) The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome, Psychotherapy Research, DOI: 10.1080/10503307.2020.1847344

Researchers have known for many years that the number of social supports and the size of a patient’s social network have a positive impact on patient outcomes in psychotherapy. Social supports reduce loneliness, and higher loneliness is an important cause of distress. Research has also demonstrated quite convincingly that the relationship in psychotherapy plays an important role in patient mental health outcomes. The therapeutic alliance, for example, is one of the most researched concepts in psychotherapy and shows a clear and positive association with client improvement across a number of theoretical orientations and client problems. The therapeutic alliance is the collaborative agreement between client and therapist on the tasks and goals of therapy, and also their relational bond. The bond includes trust, respect, and confidence in the therapist. This is important because aspects of mental health, like emotion regulation, develop partly in social and intimate relationships, including in the therapeutic relationship. If the therapeutic relationship works to reduce loneliness and improve emotion regulation, then a positive therapeutic relationship will be particularly important for clients with less social support. In this study, Zimmerman and colleagues examined if an extra-therapeutic factor (social support) interacted with an intra-therapeutic factor (therapeutic alliance) to predict client outcomes. Over 1200 adult clients were treated by 164 experienced therapists who were guided by CBT manuals. Patients received 42.77 sessions on average (SD = 19.97), social support was assessed at the start of treatment, and alliance and outcomes were monitored after every session. On average, clients improved throughout treatment. Clients who had more social supports and who reported a better bond with their therapist improved the most. Of particular interest was the interaction between social support and bond. Those clients with lower social supports benefitted more if they also had a good therapeutic bond, and clients with a good therapeutic bond did well regardless of their level of social support.

Practice Implications

Both extra-therapeutic social support and intra-therapeutic bond with the therapist uniquely contributed to better outcomes for clients. However, a good therapeutic bond with the therapist appears to be particularly important for all clients, especially those with low levels of social supports. Psychotherapists would do well to assess the level and quality of their clients’ social support. And in all cases, especially for clients with low social support, therapists should work to develop and maintain a supportive and trusting therapeutic bond with their clients.

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.