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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.

November 2016

When Clients and Therapists Agree on Client Functioning

Bar-Kalifa, E., Atzil-Slonim, D., Rafaeli, E., Peri, T., Rubel, J., & Lutz, W. (2016, October 24). Therapist–client agreement in assessments of clients’ functioning. Journal of Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/ccp0000157.

There has been a lot of research in the past decade on progress monitoring (i.e., regularly providing reliable feedback to therapists on client outcomes, the alliance, and client functioning). This research indicates that client outcomes can be enhanced if therapists have ongoing information on how their client or the relationship is progressing. In this innovative research by Bar-Kalifa and colleagues, the authors studied 77 therapists who saw a total of 384 clients. The therapists were experienced at providing cognitive-behavioral therapy. Clients for the most part had a depressive or anxiety disorder and were seen for an average of 36 sessions. Client outcomes were measured pre- and post-treatment. Emotional and psychological functioning during the past week was rated by the client before each session, and the same measure was given to the therapist to rate their client at the end of each session. After therapists made their rating, they were given ongoing feedback (i.e., progress monitoring) about how their clients’ rated their own functioning during the past week. Did clients and therapists agree on level of client functioning, was this agreement stable over time, and was this agreement or disagreement related to client outcomes? The authors used sophisticated statistical modeling to separate the effects of client ratings of their functioning from therapists’ ratings, and to examine the impact of the changing relationship between therapist and client ratings over time on client outcomes. The authors found little difference in the level of client and therapist ratings of client functioning, and they found that therapists tended to be accurate (i.e., congruent with clients) in tracking client functioning over time. More importantly, the ability of therapists to accurately track client functioning from session to session was related to better client outcomes in terms of key symptoms of depression and anxiety.

Practice Implications

The ability of therapists to accurately track client functioning over time was related to better client outcomes. This means that therapists who were aware of their clients’ functioning through feedback methods were better equipped to help their clients. In particular, information about how client functioning was changing from session to session might have allowed therapists to take corrective action for clients who were not doing well from one session to another. This information might have allowed therapists to reconsider a treatment formulation for a particular client, for example. Therapists should be aware of how a client is doing at a particular session, but more importantly therapists should be sensitive to fluctuations in client functioning across sessions. This might be best achieved with ongoing progress monitoring.

October 2016

Clients’ Experiential Depth in Therapy Predicts Better Outcomes

Pascual-Leone, A. & Yeryomenko, N. (2016). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process, Psychotherapy Research, DOI: 10.1080/10503307.2016.1152409

A key issue in existential-humanistic psychotherapy is the degree to which therapy encourages clients to explore new feelings and meanings in relation to the self. This is often called ‘experiential depth’ or simply ‘experiencing’. Carl Roger highlighted the need for clients to increase their awareness, accept their feelings, and use their feelings as information to further explore and understand themselves. The notion of ‘depth of experiencing’ refers to the degree to which clients engage and explore their feelings moment by moment in therapy to increase personal meaning-making. One way of assessing experiential depth is with the Client Experiencing Scale. Low scores on the scale indicate unengaged levels of experiencing, in which clients recount events in an emotionally neutral or disengaged manner. High scores indicate more introspection as clients begin to process their experiences and identify feelings that lead to creating new meanings that contribute to resolving their problems. In this meta analysis of the Client Experiencing Scale, Pascual-Leone and Yeryomenko systematically reviewed the research literature and found 10 studies of 406 clients that evaluated the scale`s association with client outcomes. The therapies in the meta analysis included experiential-humanistic approaches, CBT, and interpersonal psychotherapy. Overall, they found a moderate association (r = .25; 95% CI: .16, .33) between higher client experiencing and better treatment outcomes. The association was similar for different therapeutic orientations and stages of therapy. On average, client depth of experiencing tended to increase from the early to later stages of treatment.

Practice Implications

Compared to those who did not engage with their experiences in a meaningful way, clients who were internally focused, engaged in exploration, referred to their emotions, and who reflected on their experiences had better outcomes. Experiential depth allowed clients to create new meanings to resolve personal problems. Therapist interventions that deliberately point the client to a deeper level of experiencing, are likely to result in clients following suit and deepen their own process.
The Quality of Psychotherapy Research Affects The Size of Treatment Effects for CBT

Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M., Huibers, M.J.J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245-258.

You might think that an esoteric topic like study quality should not really be of interest or concern to clinicians – but it is an important topic with practice implications. In this meta analysis Pim Cuijpers and his research group updated the meta analytic evidence for the efficacy of cognitive behavioral therapy (CBT) for a variety of disorders (major depressive disorder [MDD], generalized anxiety disorder [GAD], panic disorder [PAD], and social anxiety disorder [SAD]). The important thing about meta analyses is that the method combines the effect sizes from all relevant studies into a single metric – an average effect size. These average effect sizes are much more reliable than findings from any one single study. In fact, whenever possible, clinical decision-making should be based on a meta analysis and systematic review and not on a single study. Meta analyses also allow one to give more weight to those studies that have larger sample sizes, and that employ better methodologies. Even more, meta analytic techniques allow one to adjust the averaged effect size by taking into account publication bias (i.e., an indication of the effects from studies that might have been completed but were never published, likely because they had unfavorable findings). Usually, average effect sizes are lower when they are adjusted for study quality and publication bias. Cuijpers and colleagues’ meta analyses found that the unadjusted average effects of CBT were large for each of the disorders (ranging from g = .75 to .88 [confidence intervals not reported]). However adjusting for publication bias reduced the effects to medium-sized for MDD (g = .65) and GAD (g = .59). Only 17.4% of the individual studies of CBT were considered to be of “high quality” (i.e., studies that use the best methodology to reduce bias, like random allocation, blinding, using all the available data, etc.). After adjusting for study quality, the effects of CBT for SAD (g = .61) and PAD (g = .76) were also reduced to medium-sized. Not surprisingly, the effects of CBT were largest when the treatment was compared to a wait-list no-treatment control group. The effects were small to moderate when CBT was compared to treatment as usual or to a placebo.

Practice Implications

Even when adjusting for study quality and publication bias, the average effects of CBT were medium-sized for a variety of common disorders compared to control conditions. Unfortunately, the quality of the studies was not high for most trials, reducing the effect sizes and lowering our confidence in the efficacy of the treatment. Nevertheless, the findings of this meta analysis suggest that CBT will likely have moderate effects for the average patient with MDD, SAD, PAD, and GAD.

September 2016

Cognitive Therapy and Dynamic Psychotherapy for Major Depression in a Community Setting

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.

July 2016

Long-Term Efficacy of Psychological Therapies for Irritable Bowel Syndrome

Laird, K.T., Tanner-Smith, E.E., Russell, A.C., Hollon, S.D., & Walker, L.S. (2016). Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology.

Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that affects 5% to 16% of the population. People with IBS have reduced quality of life similar to those with heart disease, heart failure, and diabetes. Previous meta analyses indicated that psychological therapies are just as effective as antidepressant medications immediately after treatment for improving symptoms of IBS. However, whether psychological therapies have longer lasting effects is unknown. It is important to patients and providers to know the longer term effects of psychological treatments for IBS because the disorder has a fluctuating course, and so symptoms may reappear after treatment is completed. In their meta analysis, Laird and colleagues reviewed 41 studies that recruited almost 2,300 adult patients. [A note about meta analysis: Meta analysis combines the standardized effect sizes (d) across many studies to estimate an average effect size. This means that meta analyses are much more reliable than any single study, and when possible they should be the basis for practice recommendations]. Psychological therapies for IBS often included cognitive behavioral therapy (CBT), but also included relaxation therapy, mindfulness, hypnosis, behavioral treatment, and psychodynamic therapies. Control conditions often were: supportive therapy, education, fake treatment for biofeedback or hypnosis, online discussion groups, treatment as usual, or wait-list controls. Psychological therapies were more effective than control conditions immediately post-treatment in improving GI symptoms, and the effects were moderately large (d = .69). Psychological therapies remained more effective than control conditions up to 6 months post-treatment (d = .76), and from 6 months to 1 year post-treatment (d = .73). CBT and other treatments (e.g., relaxation, hypnosis) were equally effective; and individual and group delivered treatments were no different in their efficacy. The number of sessions, duration of sessions, and frequency of sessions did not impact the efficacy of psychological interventions.

Practice Implications

Determining the longer term efficacy of psychological treatment for IBS is important because the symptoms tend to be recurrent and sometimes are chronic. Psychological treatments reduce GI symptoms in adults with IBS, and the effects appear to be long lasting – at least up to 1 year post-treatment. The average individual who received psychotherapy was better off than 75% of control condition participants.

February 2016

How Effective is Computerized CBT in Treating Depression in Primary Care?

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.

This month...

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November 2016

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October 2016

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September 2016

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July 2016

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February 2016

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Psychotherapy Practice Research Network (PPRNet)