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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.

August 2018

How Reliable is the Association Between Therapeutic Alliance and Patient Outcomes?

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000172

The therapeutic alliance is one of the most researched concepts in psychotherapy. The alliance, also called the working alliance or therapeutic alliance, consists of the collaborative agreement between patient and therapist on the tasks (what to do) and goals (what to achieve) of their therapeutic work together. Alliance also includes the relational or emotional bond between therapist and patient. It is different from therapist empathy, transference, countertransference, the real relationship and other concepts related to the therapeutic relationship. Researchers and clinicians have known for years about the importance of developing and maintaining an alliance to achieving patient outcomes. The growing research in this area now allows one to see how stable this finding is. Fluckiger and colleagues conducted a meta analysis of 306 studies with over 30,000 patients that assessed the alliance-outcome relationship. The research occurred in naturalistic settings (during regular clinical practice) and in randomized controlled trials. The overall effect size based on 295 independent comparisons was r = .278 (95% CI: .256, .299), indicating a statistically significant medium-sized association accounting for about 8% of treatment outcomes. To put this in perspective, this effect is as large as or larger than the effects of many common medical interventions. The type of therapy made no difference to this finding - the alliance was just as important to CBT as it was to psychodynamic, interpersonal, and emotionally focused therapies. The alliance-outcome correlation was somewhat smaller, though still significant among those with substance-use disorders, but otherwise was consistent for all other disorders tested (depression, anxiety, PTSD, borderline personality disorder). The alliance measure used, who rated the alliance, when it was assessed, and the outcome that was measured tended to have a small or no impact on the results. The alliance-outcome relationship was just as important to everyday clinical practice as it was in randomized controlled trials.

Practice Implications

The alliance-outcome association is highly reliable or stable across a number of therapies, diagnoses, measurements, and study designs. This very large body of research suggests that therapists should: (1) build and maintain an emotional bond, and agreement on tasks and goals with patients throughout therapy; (2) develop the alliance early by focusing on agreement on treatment and goals; (3) address ruptures in the alliance early and immediately; and (4) assess the strength and quality of the alliance regularly throughout treatment from the patient’s perspective using a well-known brief alliance measure.

July 2018

Do Common Factors Matter in Psychotherapy?

Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: a meta-analysis. Clinical psychology review, 32(4), 280-291.

The research evidence indicates that there is very little difference between different types of psychotherapy (CBT, IPT, PDT, EFT, and others) in patient outcomes, especially for depression. Nondirective supportive treatment (NDST) also shows positive outcomes for various disorders. NDST is often used as a “placebo” condition in psychotherapy trials to control for common or non-specific factors. Common factors refer to those aspects that are common to all therapies, but that are not specific to any one therapy (e.g., therapist interpersonal skills, therapeutic alliance, client expectations). NDST does not involve specific therapeutic interventions like cognitive restructuring, transference interpretations, two-chair techniques, etc. In this meta analysis, Cuijpers and colleagues assessed those randomized controlled trials for depression in which specific treatments (e.g., CBT, PDT, IPT, EFT) or no treatment control conditions were directly compared to NDST. By doing so, the authors were able to estimate how much of patient outcomes were attributable to: specific effects of treatments (the difference between a specific intervention and NDST), common effects of treatment (the difference between NDST and no treatment), and extra-therapeutic factors (the effects of no treatment). The meta analysis included 31 studies with over 2500 patients with depression. Twenty-one comparisons included CBT, and the rest included IPT, PDT, or EFT. NDST was significantly less effective than other specific therapies (e.g., CBT, IPT, PDT, or EFT) at post-treatments g = −0.20 (95% CI: −0.32 to −0.08), but the effect was quite small. The difference between NDST and CBT alone (the most researched treatment type) was not statistically significant. Interestingly, when the authors controlled for researcher allegiance (an indication of which treatment was preferred by the researcher), the superior effects of specific treatments over NDST disappeared. NDST was significantly more effective than no-treatment, and the effect was moderate, g=0.58 (95% CI: 0.45–0.72). Pre- to post-treatment change in symptoms in the control condition was statistically significant, g = 0.39 (95% CI: 0.03–0.74), indicating the positive effects of extra-therapeutic factors on depressive symptoms (e.g., events in the patient’s life not related to therapy). Overall, the authors were able to estimate that almost 50% of patient outcomes could be attributed to common factors (therapist interpersonal skills, therapeutic alliance, client expectations, etc.), about 17% was due to specific therapy techniques (cognitive restructuring, two chair techniques, IPT interventions), and about 33% was due to extra-therapeutic factors (e.g., the natural course of depressive symptoms or other events in the patient’s life).

Practical Implications

Factors like therapist interpersonal skills and managing the therapeutic relationship appear to account for most (50%) of why patients with depression get better. The specific interventions based on therapy models like CBT account for relatively less of patient outcomes (17%). The natural course of the disorder and other events in patients’ lives account for about a third of patient improvement. Therapists can learn how to maximize the effects of common factor skills through deliberate practice and training to identify and repair alliance ruptures to help their patients get better.
Placebo Response in Transcranial Magnetic Stimulation for Depression

Razza, L. B., Moffa, A. H., Moreno, M. L., Carvalho, A. F., Padberg, F., Fregni, F., & Brunoni, A. R. (2018). A systematic review and meta-analysis on placebo response to repetitive transcranial magnetic stimulation for depression trials. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 81, 105-113.

Transcranial magnetic stimulation (TMS) is a new treatment for depression thought to modulate brain activity through electromagnetic pulses delivered by a coil placed over the patient’s scalp. A meta analysis shows that TMS may be effective in treating depressive disorders when compared to a placebo control, although only 18.6% of those receiving TMS were no longer depressed at the end of treatment. The placebo control condition usually involves a sham version of TMS in which the coil is placed over the scalp but no magnetic stimulation is applied. In antidepressant trials, the placebo response is quite high such that approximately 40% of patients respond to the placebo condition (in antidepressant trials, the placebo condition includes an identical pill that is inert). In this meta analysis, Razza and colleagues assess the placebo response in TMS. They included only double blind randomized controlled trials (i.e., trials in which both the patient and physician were not aware if the treatment was real or a sham). The authors estimated the placebo response based on pre- to post-sham TMS scores of common measures of depression. The meta analysis included 61 studies of over 1300 patients. The main result showed that sham response was large (g = 0.80; 95%CI = 0.65–0.95). Trials including patients with only one episode of depression or who were not treatment resistant (g =0.67, 95%CI = 0.06–1.28, p= 0.03) had higher placebo responses than those trials in which patients previously had two or more failed antidepressant treatments (g = 0.5, 95%CI = 0.03–0.99, p = 0.048).

Practice Implications

The results of this meta analysis demonstrates a high placebo response in trials testing TMS. This is similar to the high level of placebo response commonly seen in patients in antidepressant medication trials. It appears that psychological factors like attention, instillation of hope, patient expectations of receiving benefit, and perhaps working alliance may account for an important portion of why pharmacological and other medical interventions appear to work for those with depressive disorders. This is particularly true for patients who are receiving treatment for the first time or for whom previous medical treatment was successful.
Are E-Health Interventions Useful for Weight Loss?

Podina, I. R., & Fodor, L. A. (2018). Critical review and meta-analysis of multicomponent behavioral e-health interventions for weight loss. Health Psychology, 37(6), 501-515.

Over 35% of Americans are overweight or obese, and this poses significant health-related challenges. Obesity likely contributes to heart disease, Type II diabetes, and some forms of cancer. Also, obesity is often co-morbid with mental health conditions including depression and binge-eating disorder. Practice guidelines list multicomponent behavioural interventions as state of the art treatment for weight loss. These include dietary counselling, increased physical activity, and behavioural methods to support behaviour change. However, such interventions often require direct in-person contact with a health or mental health professional, which can be expensive and create a barrier to accessing treatment for some. An option to increase access is to deliver the multicomponent behavioural intervention by internet or by another electronic format such as DVD. In this meta analysis, Podina and Fodor reviewed 47 randomized controlled studies representing over 1500 participants in which e-health interventions for weight loss in overweight or obese individuals were tested against in-person treatment or a control condition (no treatment or treatment as usual). E-health interventions were more effective than control conditions for weight loss outcomes at post-treatment, g = 0.34 (95% CI [0.24 to 0.44]). Similar results were found at follow-up. However, e-health interventions were significantly less effective than active in-person treatments, g = -0.31 (95% CI [-0.43 to -0.20]) for weight loss in overweight or obese individuals.

Practice Implications

E-health interventions (mostly internet delivered treatment) of multicomponent behavioral treatment for weight loss was more effective than no treatment or treatment as usual. However, e-health was significantly less effective than traditional face to face behavioral interventions to help people reduce their body weight. The authors raised concerns about the use of e-health interventions for weight loss as the first line treatment as the effects were small and the approach was less effective than in-person interventions.

June 2018

Side-Effects of Psychotherapy

Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted events and side effects in cognitive behavior therapy. Cognitive Therapy and Research, 42(3), 219-229.

Unwanted events are negative consequences for clients that may or may not be related to treatment (i.e., events outside of therapy or inside of therapy that may negatively affect clients). These might include: occupational problems, stigmatization, strains in personal relationships, changes in the social network, patients feeling overwhelmed, undermined self-efficacy, deterioration of symptoms, emergence of new symptoms, suicidality, and others. Side effects refer to negative reactions in clients directly related to appropriately delivered therapy. Research estimates that between 5% and 20% of patients report side effects of psychotherapy. One could argue that side effects may be inevitable even in well-delivered therapy, and therapists who are aware of the potential for side effects may be better equipped to help clients to manage. In this study, Schermuly-Haupt, interviewed 100 psychotherapists who provided CBT in outpatient clinics in Germany about side effects among their clients. All therapists were supervised as part of their work and so the authors assumed the therapy was appropriately delivered. Therapists had on average 5 years of experience and were trained to provide CBT. The interview asked therapists about their most recent treatment case in which the client attended at least 10 sessions. Clients typically had major depression, an anxiety disorder, or a personality disorder, and had attended 28 sessions of therapy on average. During the interview, therapists identified if an unwanted event occurred for a client from a standardized list, and then rated the duration and severity of the effects. They also rated the degree to which the unwanted event was directly related to therapy (i.e., a side effect). Prior to the interview, only 26% of therapists reported their client experienced side effects. However, the interview process found that almost all clients experienced an unwanted event (98%) that may or may have been related to therapy, and 43% experienced at least one side effect that was at least somewhat related to treatment. The most frequent side effects were: “negative wellbeing/distress” (27% of clients), “deterioration of symptoms” (9% of clients) and “strains in family relations” (6% of clients). Of the therapists, 46% rated the side effects as at least moderately severe, and 8.8% of side effects were rated as persistent (lasting more than a month).

Practice Implications

Unwanted events outside of therapy are very common among our clients, but so are side effects from appropriately delivered treatment. Psychotherapy is not always harmless, and it may be best to acknowledge and prepare both clients and therapists for side effects. These may represent ruptures in the alliance that can be managed through alliance-focused therapy, for example. That is, side effects may be caused a mismatch between the goals of a therapist and client, or a disagreement on how to proceed in therapy given what a client needs at the time. Goals and tasks of therapy may need to be renegotiated following the experience of a side effect.
Is Short-Term Prolonged Exposure Effective to Treat PTSD in Military Personnel?

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.

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Psychotherapy Practice Research Network (PPRNet)