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 how the therapeutic alliance works, psychotherapy with Indigenous Peoples, and th efficacy of psychotherapy and psychopharmacology
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
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.
April 2022
Multicultural Competence and Orientation
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Therapist multicultural competence is a commitment to increasing one’s knowledge of patient’s cultural background, tailoring interventions to a patient’s culture, and understanding the impact of one’s own cultural background. Multicultural competence research has looked at its impact on clinical interactions. In a meta-analysis of 15 studies, therapist multicultural competence was associated with lower levels of patient drop-out from therapy (r = 0.26) and with greater patient improvement (r = 0.24). An interesting finding of these meta-analyses is that whereas patient ratings of a therapist’s multicultural competence was significantly associated with better patient outcomes (r = 0.38), therapist ratings of their own multicultural competence was not significantly associated with outcomes (r = 0.06). In other words, if one is interested in a therapist’s multicultural competence then one should ask the patient, not the therapist. A related but broader concept is multicultural orientation. The multicultural orientation framework is not so much a theoretical approach but a “way of being” for a therapist. The three aspects of multicultural orientation include cultural humility (in which a therapist takes an open and curious stance towards the patient’s identities), cultural opportunities (in which the therapist actively explores a patient’s cultural beliefs and values), and cultural comfort (or the extent to which a therapist feels at ease working with cultural dynamics). A systematic review of multicultural orientation theory identified 9 articles that found that therapist cultural humility was associated with better therapeutic alliances, fewer in-session microaggressions, and greater patient improvement.
Practice Implications
The research on multicultural competence suggest that therapists should regularly assess a patient’s cultural identities for adapting the therapeutic approach. This assessment should focus on the patient’s, not the therapist’s, evaluation of the therapist’s multicultural competence. It is also important for therapists to build their knowledge of specific cultural groups when tailoring their treatments. Regarding a multicultural orientation, it appears that a therapist’s cultural humility is critically important. That is a therapist who is open, non-defensive, and curious regarding a patient’s identities will be most helpful to patients of various cultures.
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.
November 2021
Psychological Treatments for Panic Disorder
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.
September 2021
Mindfulness-Based Interventions Among People of Color
Sun, S., Goldberg, S.B., Loucks, E.B., & Brewer, J.A. (2021). Mindfulness-based interventions among people of color: A systematic review and meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2021.1937369.
In the United States, people of color (POC) are disproportionately affected by structural inequalities related to racism such as high rates of incarceration, poor housing, and economic difficulties. Racial disparities also exist in health care such that POC are less likely to use health services thus resulting in more persistent health problems. Research has shown that mindfulness-based interventions (MBIs) may be effective in improving health outcomes of conditions that are prevalent among POC like psychiatric symptoms and cardiovascular disease. Some argue that MBIs are especially culturally relevant to POC because of the focus on overall well-being, the emphasis on resilience, and communally delivered formats. In this meta-analysis, Sun and colleagues systematically reviewed 24 randomized controlled trials with a total of over 2000 participants in which MBI was compared to no treatment or to an active control (a control group that was meant to be therapeutic). Only trials in which the study sample was predominantly (>75%) POC were included. At post-treatment, MBIs showed small but statistically significant outcomes compared to active controls (k = 16, g = 0.11, 95% CI = [0.04, 0.18], p = .002) and to no treatment (k=8, g = 0.26, 95%CI = [0.07, 0.45], p = .007). These are smaller effects than reported in other populations. Drop-out rates for POC receiving MBI was about 22%, which is similar to what is reported in the general psychotherapy outcome literature.
Practice Implications
The results suggest a modest effect of MBI for POC, and that the effects may be smaller than reported in studies with other populations. Only two of the studies reported culturally adapting MBI for POC. Psychotherapists might consider cultural adaptation of MBI or providing MBI from a multi-cultural orientation framework that includes therapists’ cultural humility, making the best of cultural opportunities in therapy, and developing cultural comfort and competence.
August 2021
What Proportion of Patients Benefit from Short-Term Psychotherapy?
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Hisashi, N., &Furukawa, T.A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 10.1111/acps.13335. Advance online publication.
Many meta-analyses report that psychological therapies are effective to treat depression, that there are no differences between types or orientations of therapy in their outcomes, and that psychotherapy is as effective as medications in the short term and perhaps more effective in the longer term. But what do these findings mean for everyday practice? Many meta-analyses report a standardized mean effect size between treatment and control conditions. However, the effect size is an abstraction that may be difficult to interpret unless you understand the statistic. Clinicians may ask a more practical question: what is the proportion of patients that improve (have meaningful reductions in depression scores) and recover (improved and no longer are depressed)? This meta-analysis by Cuijpers and colleagues of 228 studies representing over 23,000 adult patients looked at the proportion of patients who improved and recovered after psychotherapy relative to those in control conditions (no treatment, care as usual, pill placebo). The psychotherapies were short term manualized treatments like CBT, behavioral activation, interpersonal psychotherapy delivered in individual, group, and self-help formats. About 41% of patients improved with psychotherapy for depression compared to 17% that improved with usual care and 31% for pill placebo. However, after statistically controlling for publication bias (i.e., the likelihood that some unflattering studies were never published), the improvement rate for psychotherapy was 38%. Recovery rates for psychotherapy ranged from 26% to 34%, and recovery in the control conditions ranged from 9% to 17%. There were no differences between therapy orientations. Highest rates of recovery or improvement were achieved by individual therapy and the lowest rates were seen in guided self-help. Deterioration rates were just below 5% in psychotherapy and about 7% to 13% in control conditions.
Practice Implications
The effects of time-limited manualized psychotherapies tested in randomized controlled trials were modest. About 40% of patients improved and about 30% recovered. On the positive side, psychotherapies resulted in only about 5% of patients getting worse. The authors argued that clinicians must consider more effective strategies beyond these approaches to improve outcomes for depression. Some have focused on improving psychotherapist effectiveness, rather than on specific interventions. Methods like progress monitoring, managing countertransference, and repairing therapeutic alliance ruptures are means of improving psychotherapists’ effectiveness.