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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
The Efficacy of Group Therapy
Burlingame, G.M. & Strauss, B. (2021). Efficacy of small group treatments: Foundations for evidence-based practice. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 17.
Group therapy involves one or more therapists treating more than two individuals together in a group setting. Ideally, group therapy not only includes specific individualized interventions of a theoretical orientation (cognitive restructuring, behavioral activation, transference interpretations) but also makes use of group-specific factors known to predict patient outcomes (development of group cohesion, social learning, peer feedback). In this chapter, Burlingame and Strauss report on the efficacy of group therapy for a number of disorders and relative to individual therapy. In a meta-analysis of 68 studies for a variety of disorders and different theoretical orientations, there was no difference between individual therapy and group therapy in terms of primary symptom outcomes (g = -0.03). One of the challenges of practicing group therapy is that some patients and providers might perceive group therapy as less effective or less desirable than individual therapy. However, meta-analyses of patient acceptance of treatment (percent of patients assigned to group or individual therapy and who follow through with treatment) or of patient drop out after starting treatment shows no difference between individual and group therapy. Regarding outcomes for specific disorders, over 11 meta-analyses have been published in the past decade as part of an international effort to document the effects of group therapy. For major depressive disorder, group therapy was more effective than treatment as usual (g = 0.69) and as effective as pharmacotherapy (g = 0.08). Group therapy was more effective than no treatment for social anxiety disorder (g = 0.84), panic disorder (g = 1.08), OCD (g = 0.97), eating disorders (g = 0.79), substance use disorder (g = 0.28), and PTSD (g = 0.70). For all these disorders, group therapy was as effective as another active treatment to which it was compared (individual therapy or pharmacotherapy).
Patients and practitioners may have concerns about group therapy (that it is not private, that the time is divided among several patients, that outcomes may not be as good as individual therapy). Clinicians are advised to take these concerns seriously and to respond to them with an explanation based on the research – that is, that group therapy: is as effective as individual therapy, is probably more cost efficient than individual therapy, and is as well tolerated as individual therapy. Many group therapists use pre-group preparation of patients to help them understand the utility of group therapy. Referral sources may need to be educated about the accumulating research on the efficacy of group therapy. This seems particularly important as clinics, hospitals, private practices, and community agencies grapple with fewer resources to provide adequate care. Group therapy, when done well by clinicians who are adequately trained in group interventions may be a means of increasing accessibility to care for many.
Group Therapy for Mood Disorders: A Meta-Analysis
Janis, R.A., Burlingame, G.M., Svien, H., Jensen, J. & Lundgreen, R. (2020): Group therapy for mood disorders: A meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2020.1817603
Mood disorders are common mental health problems, with a 12-month prevalence of 7% in the population for major depressive disorder (MDD). Researchers have tested group therapy as a treatment for MDD and bipolar disorder. Recently, the American Psychological Association added group therapy as a specialty, attesting to the empirical evidence of group therapy’s efficacy and also the need for specialized education and training. Despite this, some treatment guidelines do not list group therapy as a first line therapy for major depression. Over the past 10 years, an international group of researchers have conducted a number of meta-analyses on the efficacy of group therapy for many disorders. In this particular meta-analysis, Janis and colleagues assessed the efficacy of group therapy to treat mood disorders by looking at randomized controlled trials of group therapy compared to waitlist controls, treatment as usual, and anti-depressant medications. They identified 42 randomized controlled trials of group therapy for mood disorders that included almost 3,000 patients. Treatment orientations included CBT, DBT, psychodynamic, and interpersonal therapies. For primary outcome measures of depressive symptoms at post treatment, the effect of group therapy versus waitlist controls was large and significant (g = .86, 95% CI [.66, 1.06], p < .001, k = 9), and those receiving group treatment were 6.81 times more likely to recover compared to those waiting for treatment (95% CI [3.70, 12.55]). Group therapy also resulted in better outcomes than treatment as usual on primary outcome measures of depression at post treatment with a medium sized effect (g = 0.46, 95% CI [0.22, 0.87], p < .001, k = 11), and those receiving group therapy were 2.75 times more likely to recover than those receiving treatment as usual (95% CI [1.59, 4.72]). Finally, there was no significant difference between group therapy and medications on rate of change in depressive symptoms or on rates of recovery.
Overall, group therapy was more effective than no treatment and treatment as usual for major depression symptoms. Group therapy was as effective as anti-depressant medications. Group therapy is likely more cost effective because it is a multi-person treatment. Many patients do not respond to medications or they struggle with medication adherence because of unpleasant side effects. And most patients prefer psychotherapy to medications if given the choice. And so, group therapy provides a cost-effective alternative and should be considered as a first line treatment for depression. As indicated by the American Psychological Association’s recognition of group therapy as a specialty, providing group therapy requires specialized education and training in order to offer effective care. Continuing education opportunities exist with the Society of Group Psychology and Group Psychotherapy and with the American Group Psychotherapy Association.
Group Psychotherapy for Borderline Personality Disorder
McLaughlin, S.P.B., Barkowski, S., Burlingame, G.M., Strauss, B., & Rosendahl, J. (2019). Group psychotherapy for borderline personality disorder: A meta-Analysis of randomized-controlled trials. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000211
Borderline personality disorder (BPD) is characterized by fear of abandonment, unstable intense relationships, rapid changes in identity and self-image, impulsivity, wide mood swings, periods of intense anger, and ongoing feelings of emptiness. These symptoms sometimes lead to suicidal behavior or non-suicidal self-injury. Often, those with BPD report a very stressful childhood that included sexual and/or physical abuse, and neglect. Borderline personality disorder is the most common of the personality disorders and is associated with severe social psychological impairment such that those with BPD often have unstable employment, are involved in abusive relationships, and engage in risky behaviors. A diagnosis of BPD is also associated with a high rate of mortality due to suicide. Practice guidelines indicate that psychotherapy is a key component to the treatment of BPD. Two psychological treatment approaches that incorporate group interventions are dialectical behavior therapy (DBT) and mentalization-based treatment (MBT). In DBT patients learn specific skills to alter maladaptive ways of regulating emotions in a group context. In MBT, an attachment-based treatment, the focus is on building trust in others through group interactions that generalize to other social relationships. In this meta-analysis, McLaughlin and colleagues reviewed 24 studies that compared group treatment for BPD to treatment as usual, which included a variety of interventions like supportive groups, pharmacotherapy, individual therapy, and others. Some of the treatments for BPD were stand-alone groups and some groups were part of a larger comprehensive program. Participants attended between 12 and 130 sessions, and group size ranged from 4 to 12 members. The meta-analysis revealed that group treatment for BPD versus treatment as usual resulted in moderate to large effect on BPD symptoms: g = .72, CI: [.41, 1.04], p < .001. The effects of group treatment versus treatment as usual on suicidality produced a moderate effect, g = .46, CI: [.22, .71], p < .001. The authors reported similar results for secondary outcomes like depression, anxiety, and general mental health. Drop-out rates were similar between group treatments (26.26%) and treatment as usual (28.26%). There were no differences in the effects of group therapy orientations on any of the outcomes or on drop-out rates.
The results of this meta-analysis indicated the value of group treatment for BPD not only for core symptoms and suicidality, but also for symptoms related to quality of life (depression, anxiety). Theoretical orientation did not explain any of the findings, suggesting that treatments like DBT and MBT in a group format are equally effective. Therapists and patients can feel confident that group treatment for BPD are among the most effective treatments available.
Author email: email@example.com
Cohesion in Group Psychotherapy
Burlingame, G. M., McClendon, D. T., & Yang, C. (2018). Cohesion in group therapy: A meta-analysis. Psychotherapy, 55, 384-398.
Many writers consider group cohesion to be one of the most important concepts in group psychotherapy and that is a pre-requisite for positive patient outcomes. That is, patients in a group must feel a bond with the group and its members, must value the relationships in the group, and must see the group experience as a vehicle by which to achieve the change that they want. As Burlingame once noted, over time cohesion has become synonymous with the therapeutic relationship in group therapy. Although an important concept, cohesion has been elusive to define partly because of the complexity of group therapy itself. From the patient’s point of view, relationships in group therapy can take on three structural aspects in the form of member to member, member to group, and member to leader interactions. And so, cohesion may refer to the quality of the member’s relationship: to other members, to the group as a whole, and/or to the group leader. By “quality of group relationships”, clinicians and researchers often mean the positive affective bond (warmth, empathy, attraction, compatibility, trust) and working relationship (consensus on tasks and goals, willingness to work) that members have with other members, the group as a whole, and/or the group leaders. In this meta-analysis, Burlingame and colleagues identified 55 group therapy studies including over 6,000 patients that investigated the cohesion – outcome relationship. The average correlation of cohesion to patient outcomes in the 55 studies was statistically significant, r = .26 (95% CI [.20, .31], p = .01), suggesting a moderate effect. Leaders who had an interpersonal orientation had the highest cohesion – outcome relationship (r = .48), although leaders of other theoretical orientations also posted statistically significant but lower values. A greater group process orientation (r = .36), emphasizing greater interactions among group members (r = .36), composing groups of members with similar diagnoses or problems (r = .23), and groups lasting more than 20 sessions (r = .41) also each produced significantly higher cohesion – outcome correlations.
The group cohesion – outcome relationship is highly reliable and suggests that clinicians of all theoretical orientations should routinely assess and enhance group cohesion to improve patient outcomes. Ways of increasing cohesion include emphasizing member to member interactions in a group, and discussing group processes as they occur. These processes may be related to members interacting with other members, with the group as a whole, or with the leader. In particular, group therapists should promote a positive emotional climate by handling conflict and avoidance when it arises in the group. This takes particular skills, training, and knowledge in group therapy processes, and so it is important for therapists to be aware of current practice guidelines for group therapy.
Author email: firstname.lastname@example.org
Association Between Insight and Outcome of Psychotherapy
Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847
For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.
The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.
Author email: Simone.Jennissen@med.uni-heidelberg.de
Group Psychotherapy for Eating Disorders
Grenon, R., Schwartze, D., Hammond, N., Ivanova, I., Mcquaid, N., Proulx, G., & Tasca, G. A. (2017). Group psychotherapy for eating disorders: A meta-analysis. International Journal of Eating Disorders. DOI: 10.1002/eat.22744
Group therapy has an evidence base indicating its efficacy for many disorders. Groups represent a social microcosm in which interpersonal factors that underlie psychological distress and symptoms can be effectively addressed. Group therapeutic factors include peer interpersonal feedback, social learning, emotional expression, and group cohesion. Theories of eating disorder symptoms include interpersonal problems and affect dysregulation as maintenance factors. Many treatment guidelines indicate that individual and group CBT are the treatments of choice for eating disorders. However, there are no meta analyses that specifically look at the efficacy of group therapy for eating disorders. In this study, Grenon and colleagues assess if: (a) group psychotherapy for eating disorders is efficacious compared to wait-list controls, (b) group therapy is effective compared to other active treatments (self help, individual therapy, medications), and (c) group CBT is more effective than other types of group therapy (group interpersonal therapy [GIPT], group psychodynamic-interpersonal psychotherapy [GPIP], or group dialectical behavior therapy [GDBT]). The authors reviewed 27 randomized controlled trials with over 1800 patients that provided direct comparisons of group therapy for eating disorders. The mean drop out rate from group therapy was 16.47% (SD = 13.46), which is similar to what is reported for psychotherapy trials in general. Group therapy was significantly more effective than wait list controls in achieving abstinence from binge eating and purging (RR = 5.51, 95% CI: 3.73, 8.12), decreasing the frequency of binge eating and/or purging (g = 0.70, 95% CI: 0.51, 0.90), and reducing related psychopathology (g = 0.49, 95% CI: 0.32, 0.66). Group psychotherapy had an overall rate of abstinence from binge eating of 51.38%, while wait-list control conditions had an overall abstinence rate of 6.51%. Similar findings were achieved a follow-ups. The effects of group psychotherapy and other active treatments (e.g., behavioral weight loss, self-help, individual psychotherapy) did not differ on any outcome at post-treatment or at follow-ups. Group CBT and other forms of group psychotherapy did not differ significantly on outcomes at any time point.
The results add to a growing body of research that indicates that group psychotherapy is as effective as other treatments, including individual therapy, to treat mental disorders. Despite the fact that practice guidelines indicate that CBT is the treatment of choice for eating disorders, this meta analysis did not provide evidence that group CBT was more effective than other types of group treatments. Clinicians considering group interventions for eating disorders or other mental health problems will do well to make use of group therapeutic factors like interpersonal learning, peer feedback, emotional expression, and group cohesion to improve patient outcomes.