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 therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
March 2023
Psychotherapy for Borderline Personality Disorder
Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., Kernberg, O.F. (2023). Borderline personality disorder: A review. Journal of the American Medical Association, 329(8):670–679.
Borderline personality disorder (BPD) occurs in 0.7% to 2.7% of adults and has significant negative impacts on social, vocational, and psychological functioning (inability to hold a job, high rates of comorbid medical and mental health problems, high rates of suicide). Patients with BPD can experience intense anxiety and depressive affect and impulsive behavior. Comorbid rates of depression, anxiety, PTSD, or substance use are very high (30% to 85%). Rates of BPD are slightly higher for women (3%) than for men (2.7%). The etiology of BPD might include genetic factors that interact with adverse childhood events like sexual and physical abuse. BPD is characterized by sudden shifts between extremes of idealization (extremely positive views of self and others) and devaluation (extremely negative views of self and others). These shifts have a significant negative impact on self-image, emotion regulation, and interpersonal relationships. In this extensive review, Leichsenring and colleagues discuss the clinical management and psychotherapy of patients with BPD. A series of meta-analyses that included 75 randomized controlled trials of 4507 patients indicated that psychotherapy is efficacious in treating symptoms of BPD (SMD = -0.52 [95% CI: -0.70 to -0.33]). The meta-analysis looked at 17 studies that compared different forms of psychotherapy (DBT, psychodynamic, CBT, eclectic) and found no difference in the efficacy of these treatments. Stronger evidence was available for DBT and for psychodynamic therapy relative to usual care. DBT focuses on increasing a patient’s motivation and to identify problem solving strategies to help regulate emotions and interpersonal relationships. Psychodynamic therapy emphasizes identifying recurring patterns of behaviors related to self and others, exploring defense mechanisms related to avoidance, and discussing past experiences that influenced current problems. Despite the overall efficacy of psychotherapy for BPD, almost half of patients do not benefit from treatment. Although pharmacotherapy might be useful to reduce comorbid symptoms of depression and anxiety, the research suggests that medications are not effective in reducing symptoms of BPD.
Practice Implications
The treatment of patients with BPD is complicated by the interpersonal impact of the disorder on the therapist and on the therapeutic relationship. Often therapists might be embedded in the patient’s relational patterns of idealization and devaluation (“all good” and “all bad”) that can strain the therapeutic relationship. Sometimes therapists might have strong personal reactions to such patients (i.e., experience countertransference) which might manifest as anti-therapeutic behaviors on the part of the therapist (over- or under-involvement with the patient) which can be stressful. Leichsenring and colleagues make recommendations to help therapists manage the patient-clinician relationship such as: setting clear boundaries while maintaining empathy, developing and maintaining a therapeutic alliance including setting realistic goals, avoiding stigmatizing the patient as “difficult”, collaborating and communicating with other treating clinicians to avoid splitting (one as “all good” and the other as “all bad”), being aware of and managing one’s own feelings and reactions to the patient (countertransference), and using one’s knowledge of the patient’s biographical information (history of abuse) to help to understand the patient’s strong emotional reactions.
February 2023
Quality of Life Outcomes in the Psychological Treatment of Persistent Depression
McPherson, S., & Senra, H. (2022). Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes. Psychotherapy, 59(3), 447–459.
The World Health Organization ranks depression as the largest cause of global disability accounting for 7.5% of all years lived with disability. Persistent forms of depression contribute to years lived with disability due to its chronic nature and its association with low levels of social and physical functioning, high rates of suicide, and high health care use. One way to look at disability as an outcome is to assess quality of life, which refers to performance in daily and social functioning and satisfaction with these activities. In this meta-analysis, McPherson and Senra examine 14 randomized controlled trials of psychological therapies for chronic or persistent depression in adults. The control condition included no treatment, waiting list, treatment as usual, or only antidepressant medication. The psychotherapies were mindfulness-based cognitive therapy (MBCT), CBT, interpersonal psychotherapy (IPT), long term psychoanalytic psychotherapy (LTPP), and DBT. Chronic depression was defined as a course of depression of at least 2 years and/or non-response to at least two treatments. The quality of life measure had to assess satisfaction with physical health, psychological state, level of independence, and social relationships. In general, the psychological treatments were associated with improvements in patients’ quality of life at the end of treatment (N=11; g=0.24; 95%CI: 0.13, 0.34). At follow up, the effect size was g=.21 (95%CI: 0.10, 0.32). That is, the effects were significant and positive, but small. The psychological interventions resulted in improvements in patient functioning at the end of treatment, g=.35 (95%CI: 0.21, 0.48), which is consistent with previous meta-analyses showing small to moderate effects of psychological treatments for persistent depression. Although there were too few studies to properly assess differences between therapy types, MBCT, IPT, and LTPP in combination with antidepressant medications had the largest effects among the therapies studied.
Practice Implications
In international surveys, patients seeking treatment for depression, informal caregivers, and health professionals list quality of life and social functioning as just as important or as more important than symptom reduction. Yet, these outcomes related to quality of life are not often assessed in clinical trials. This meta-analysis of a modest number of studies, suggests that some psychological therapies (MBCT, IPT, LTPP), in combination with antidepressant medications have the largest positive effects on quality of life for those persistent depression.
November 2022
The Efficacy of Psychotherapies and Pharmacotherapies for Mental Disorders in Adults
Estimates of the efficacy of psychological or pharmacological treatments depend in part on to what they are compared. One might expect, for example, that these first line treatments for mental disorders may appear more effective if compared to no treatment and may appear less effective when compared to treatment as usual or a placebo. Reviews indicate that compared to no treatment, psychotherapies demonstrate a moderate effect (g = .67). However, some argue that comparisons to no treatment represent “weak” controls that over-estimate the efficacy of treatments. Compounding this problem is that poorly designed randomized controlled trials tend to result in larger estimates of effects in favor of the treatments. In this large umbrella review, Leichsenring and colleagues conducted a meta-analysis of meta-analyses of randomized controlled trials in which psychotherapy and medications are compared to no treatment, treatment as usual, placebo, and to each other. Different forms of psychotherapy (CBT, psychodynamic, interpersonal, EFT) were included. This meta-review had 3,782 randomized controlled trials representing 650,514 patients with a range of mental disorders (depression, anxiety, eating disorders, OCD, PTSD…). The authors’ analyses resulted in a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. Usually, this is interpreted as a small effect such that about 7 patients need to be treated before one achieves remission. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: –0.05 to 0.26) indicating no significant difference between the two types of treatments. The SMD for the combined psychotherapy and medication compared to either monotherapy (psychotherapy alone or medications alone) was 0.31 (95% CI: 0.19-0.44), suggesting that some patients achieve better outcomes if they got combined treatment, but again the effect is small. A troubling finding of this meta-review was that between 1% and 17% of studies were high quality, meaning that most studies likely resulted in biased (inflated) results for both treatments.
Practice Implications
Psychotherapy and medications, or their combination as practiced in randomized controlled trials appear to help a relatively modest proportion of patients. Most of these trials involved short term highly manualized interventions that do not address the diversity and complexity of patients seen by psychotherapists in real world practices. For example, studies in clinically representative contexts show that most patients require many more therapy sessions than provided in clinical trials. Psychotherapy researchers and clinicians need to refocus efforts on therapeutic factors (therapeutic alliance, progress monitoring) and therapist interpersonal stances (interpersonal skill, empathy, countertransference management) that likely impact patient mental health outcomes.
August 2022
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
There are now hundreds of controlled studies showing the efficacy of psychotherapy for depression. Most of these studies have focused on specific age groups, so that psychotherapies were tested for children, adolescents, adults, and older adults separately. Few studies have looked at whether psychotherapy has different effects across age groups. This information might be important because it may indicate that some therapies might have to be altered or specifically designed for the age group. In this meta-analysis, Cuijpers and colleagues collected all randomized controlled trials of psychotherapy vs no treatment, usual care, or some other control group for depression across age groups. They found 366 studies representing over 36,000 patients. The studies included those of children, adolescents, young adults, middle-aged adults, older adults, and older old adults. The overall effect size across all age groups was g = 0.75 (95% CI, 0.67-0.82) suggesting a moderate effect of psychotherapy for depressive symptoms at post-treatment. The effect size for children was the lowest (g = 0.35, 95% CI: 0.15-0.55, k = 15), and the effect size for adolescents (g = 0.55, 95% CI: 0.34-0.75, k = 28) was also low. Effects for middle-aged adults (g = 0.77, 95% CI: 0.67-0.87, k = 304), older adults (g = 0.66, 95% CI: 0.51-0.82, k = 69), and older old adults (g = 0.97, 95% CI: 0.42-1.52, k = 10) were not significantly different. Young adults consistently had significantly better outcomes (g = 0.98, 95% CI: 0.79-1.16) than the other age groups except when compared to older old adults.
Practice Implications
It is possible that psychotherapies for depression as currently tested in the research literature are less effective for children and youth. This may be because the treatments that are most often used with children and adolescents are age adapted versions of therapy originally designed for adults. Psychotherapy for children and adolescents are affected by parental and family characteristics, and that these contexts may not be adequately accounted for by the therapies as currently tested and practiced. In any case, this meta-analysis suggests that current therapies for childhood and adolescent depression may need to be reconsidered given their relatively lower effects.
February 2022
Psychological Therapies for Culturally Diverse Populations
Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 5.
Psychological therapies are culturally bound practices with certain values built into them. For example, common therapies prize independence in patients and rapport in the therapeutic relationship. However, some cultures may value community rather than independence, and respect rather than rapport. In this part of the chapter, Barkham and Lambert ask: what is the effect of a conventional psychotherapy that is based on the values of a dominant culture when applied to a different ethnic or racial group? In one small meta-analysis of 9 and 16 studies, culturally adapted interventions were significantly more effective than unadapted interventions g = 0.52 (95% CI [0.15, 0.90]) and resulted in close to 5 times greater odds of remission. Adaptation usually refers to incorporating some cultural practices into the therapy, adapting the language of the therapist, or providing a therapist who is from the same culture as the patient. Similarly, there is research on the effects of a multicultural competency and multicultural orientation of the therapist. These competencies refer to therapists who learn about a patient’s culture, use culturally relevant treatment strategies, and are aware of their own assumptions and biases regarding the patient’s culture. A meta-analysis of 18 studies reviewed the impact of a therapist’s multicultural competence on various aspect of therapy. Therapist multicultural competence accounted for 37% of the working alliance, 52% of patient satisfaction, 38% of a patient’s perception of therapist competence, and 34% of depth of the session. However, therapist multicultural competence accounted for only 8% of patient outcomes. More recently, some authors have discussed the importance of multicultural orientation, which refers to a therapist’s cultural humility as an attitude towards the patient’s culture, a therapist’s willingness to explore the patient’s racial and cultural identities, and the therapist’s comfort with cultural diversity.
Practice Implications
The research on the impact of psychotherapy on diverse patient populations is still rather small, but some practice implications can be gleaned. Adapting therapies to the patient’s culture and identity likely will improve patient mental health outcomes. The adaptation might include incorporating cultural practices, metaphors, and values into the therapy, and providing therapy in the language of the patient, or finding a therapist from the same cultural background as the patient. Similarly, there is evidence that therapists who are multiculturally competent (learn about the patient’s culture and checks their own biases) can provide a deeper therapeutic experience for their patients. Emerging research on therapist multicultural orientation suggests that a therapist’s cultural humility, willingness to engage in cultural conversations, and comfort with diverse cultures may lead to better experiences of therapy for their patients.
June 2021
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.