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 psychotherapy for adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
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
January 2024
Is CBT for Perfectionism Effective?
Smith, M. M., Hewitt, P. L., Sherry, S. B., Flett, G. L., Kealy, D., …, & Bakken, K. (2023, April 27). A meta-analytic test of the efficacy of cognitive behavioural therapy for perfectionism: A replication and extension. Canadian Psychology / Psychologie canadienne. Advance online publication. https://dx.doi.org/10.1037/cap0000360
Perfectionism is a multidimensional personality factor that can make one vulnerable to mental health problems and can interfere with therapeutic processes like the therapeutic alliance. The bulk of the research for treating perfectionism has focused on cognitive behavioural therapy (CBT), with meta-analyses concluding that CBT is efficacious. However, this research has certain limitations. First, the meta-analyses focus on standard mean differences (SMD) between treatments and control conditions, but SMDs are abstractions that are difficult to translate into real-world practice. What matters most to patients and clinicians is the proportion of patients who reliably improve beyond statistical error or the natural course of the problem. Second, the studies do not consistently report analyses related to drop-out rates. Drop-out is an indicator of the tolerability of a treatment for patients. If patients drop out at a high rate, then the treatment may not be acceptable, and many patients may not benefit. Third, the meta-analyses of CBT for perfectionism do not indicate whether treatment effects at the end of therapy are sustained in the longer term. In this re-analysis and extension of previous meta-analyses, Smith and colleagues look at the critical issues of the proportion of improved patients, drop-outs, and long-term outcomes for those with perfectionism treated with CBT. Like previous meta-analyses assessing SMDs, the authors found moderate to large effects of CBT versus control conditions on several of the dimensions of perfectionism. However, they also found no significant effects for several other dimensions of perfectionism that were more persistent and related to core personality (e.g., self-oriented perfectionism, other-oriented perfectionism, socially prescribed perfectionism, perfectionistic cognitions). Regarding the proportion of reliably improved patients, 13% to 55% of patients showed reliable improvement depending on the dimension of perfectionism that was assessed. But between 7.5% and 24.5% reliably improved without any treatment. So, the added value of CBT beyond no treatment was modest in most cases. Regarding dropouts, 27.0% of patients dropped out of CBT while only 15.7% dropped out of the control conditions. That is, those who received CBT had a 1.89 times increased risk of dropping out compared to those who were in control conditions (95% CI [1.37, 2.60], p = .005). Finally, very few studies assessed the longer-term effects of CBT, and those that did assess longer-term outcomes found that any effects at post-treatment disappeared at the follow-up assessments.
Practice Implications
The results of this meta-analysis suggest that it may not be enough to provide CBT to help patients who have the persistent relational aspects of perfectionism (i.e., self-oriented perfectionism, other-oriented perfectionism, socially prescribed perfectionism, and perfectionistic cognitions). It is also unclear if CBT is effective in the longer term as the small amount of evidence that exists does not inspire optimism. CBT may not be tolerable to some patients with perfectionism as evidenced by the moderately high drop-out rate. It may be necessary to adapt CBT or to include other models of treating perfectionism that use interpersonal and dynamic concepts and interventions that explicitly target core personality features of perfectionism.
December 2023
Psychotherapies for the treatment of borderline personality disorder: A systematic review.
Crotty, K., Viswanathan, M., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Wines, R., Ratajczak, P., & Gartlehner, G. (2023, October 30). Psychotherapies for the treatment of borderline personality disorder: A systematic review. Journal of Consulting and Clinical Psychology. Advance online publication. https://dx.doi.org/10.1037/ccp0000833
Borderline personality disorder (BPD) is the most common of the personality disorders affecting about 1.8% of the population. BPD is particularly present in psychiatric outpatients (10%) and inpatients (15% to 25%). Those with BPD have severe functional impairment caused in part by high rates of comorbid mental disorders, substance use, self-harm, and suicidal ideation. Clinical practice guidelines recommend psychological therapies as the first-line treatment approach, with a particular emphasis on dialectical behaviour therapy (DBT). However, recent research shows that such treatment guidelines often do not rely on a systematic review of the literature that includes an analysis of the quality of the evidence. Low-quality evidence may not be reliable and lead to erroneous conclusions and recommendations. In this systematic review, Crotty and colleagues provide an update to clinical practice guidelines for BPD considering the quality of the evidence. The authors found 25 studies (20 of which were randomized controlled trials) of individuals 13 years and older diagnosed with BPD. These studies represented 2,545 participants in which a psychological treatment was compared to another treatment or treatment as usual (TAU). The most studied treatment in 6 studies was DBT. Other treatments included mentalization-based treatment, transference-focused psychotherapy, schema therapy, systems training for emotional predictability and problem-solving, dynamic deconstructive therapy, acceptance and commitment therapy, and CBT. Only 1 of the 25 studies had a low risk of bias (i.e., had no or few problems with randomization, data analysis, reporting of dropouts, sample size, blinding of assessment, etc.). Overall, TAU and the nine psychotherapies tested were effective in reducing the severity and symptoms of BPD. The authors did not find consistent evidence that DBT was superior to other psychotherapies.
Practice Implications
Psychological treatments in general are effective in reducing symptoms of BPD. However, the quality of the evidence is not high. Practice guidelines focus on DBT as a treatment for BPD, but this systematic review as well as previous meta-analyses, did not find that DBT was superior or that any psychotherapy is more beneficial than another. The authors concluded that generalized psychotherapies may be as effective as intensive specialized treatments for BPD that require expert training.
November 2023
Psychological Therapies Improve Patient Quality of Life
Kolovos, S., Kleiboer, A., & Cuijpers, P. (2016). Effects of psychotherapy for depression on quality of life: Meta-analysis. British Journal of Psychiatry, 209, 460-468. https://doi.org/10.1192/bjp.bp.115.175059.
It is well-documented that depression is the most common mental disorder among adults and is associated with substantial impairments in quality of life. Quality of life refers to a range of life domains including social relationships, physical abilities, mental health functioning, role functioning, and engagement in daily activities. Several meta-analyses exist demonstrating that a range of different psychotherapies are effective in reducing depressive symptoms. Until this study by Kolovos, there wasn’t a meta-analysis looking at the effects of psychotherapies for depression on patients’ quality of life. In this study, the authors meta-analyzed 44 studies that included over 5000 adult patients with depressive symptoms. The psychotherapies varied from CBT to acceptance and commitment therapy, to interpersonal psychotherapy that were compared to a control group in a randomized controlled trial. Quality of life was measured pre- and post-treatment. Typically, quality of life was assessed in two domains – mental health quality of life was defined as personal satisfaction with the current psychological state, and physical health quality of life referred to perceived competence to perform and function in everyday activities. Global quality of life refers to an overall assessment of the mental health and physical health domains. The mean effect size of psychotherapy for global quality of life after adjusting for publication bias was g = 0.30 (95% CI 0.21–0.40) indicating a small but significant effect. For the mental health domain, after adjustment for publication bias, the mean effect size was g = 0.37 (95% CI 0.28–0.47) indicating a small to moderate effect of psychotherapy. For the physical health domain, after adjusting for publication bias the mean effect size was g = 0.13 (95% CI 0.01–0.25) indicating a small significant effect. For both the global measure of quality of life and the mental health domain, the effects of psychotherapy were larger when patients had more severe symptoms.
Practice Implications
Overall, the authors concluded that psychotherapy for depression has a positive impact on various domains of patients’ quality of life like their mental functioning, social and work relationships, and engagement in everyday activities. These findings are especially large for those patients with more severe symptoms who received psychotherapy. It is possible that as depressive symptoms lift, patients begin to have the energy, self-esteem, and concentration necessary to engage in everyday life activities.
October 2023
Psychotherapies for borderline personality disorder reduce suicide risk by half.
Setkowski, K., Palantza, C., van Ballegooijen, W., Gilissen, R., … Cuijpers, P. (2023). Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis. Psychological Medicine, 1–20. https://doi.org/10.1017/S0033291723000685
Borderline personality disorder (BPD) is characterized by severe functional impairments, high levels of distress, and a high risk of suicide. The prevalence rate of suicide attempts is very high ranging from 55% to 85%. As many as 85% of patients with BPD achieve remission (no longer diagnosed with BPD) within 10 years. Treatment guidelines consider psychological therapies as the first-line therapies for BPD. Several previous meta-analyses of these therapies have resulted in varying results – with some showing that specific treatments are effective but other studies not reporting the same results. Some of the inconsistencies across meta-analyses can be explained by the fact that there are as many as 10 tested bona fide therapies with relatively few trials assessing each one to a control condition. In this study, Setkowski and colleagues used what is known as network meta-analysis which allows one to compare relative treatment effects even if some treatments were not compared to each other in the same study. There are pros and cons to this approach that are too technical to get into here, but suffice it to say that the network meta-analysis methodology has sparked debate. In this network meta-analysis, the authors reviewed a total of 43 randomized controlled trials of psychological therapy for adults with BPD compared to a treatment-as-usual (TAU) control condition. The main outcomes were BPD symptom severity, suicidal behaviours, and dropping out of treatment (as an index of acceptability of the treatment). The authors found that dialectical behaviour therapy (DBT), Schema Therapy (ST), and Mentalization-Based Therapy (MBT) were more effective than TAU and generic treatments (i.e., therapy not specifically for BPD) for reducing symptoms of BPD. There was some evidence that Schema Therapy was the most effective treatment, but this was based on very few studies and so the authors did not consider this to be a reliable finding. When comparing psychological treatments with each other, no one treatment was more effective relative to another psychotherapy. Regarding suicide risk, no psychotherapy was significantly superior to treatment as usual. However, several treatments reduced the risk of suicidal behaviour by almost 50%. Schema Therapy and Transference Focused Therapy (TFP) both had the lowest dropout rates thus indicating high acceptability of these treatments for patients, but again these findings were based on very few studies.
Practice Implications
Although this study adds to the discussion of which therapy is best for BPD, the results are muddied by the small number of studies for each treatment approach. And, unfortunately, the network meta-analysis approach did not clarify the issues. The authors’ decision to split up therapies of the same orientation (e.g., psychodynamic, transference-focused, mentalization-based) into separate sub-categories made it even more difficult to draw conclusions because the number of studies of each sub-category is small. The authors concluded that there is not strong enough evidence to answer the question of which treatment is most effective for BPD. On the positive side, psychological therapies in general reduced the risk of suicide attempts by half.
How Reliable is the Research on CBT Plus ERP for Obsessive-Compulsive Disorder?
Reid, J.E., Laws, K.R., Drummond, L., Vismara, M. Grancini, B., Mpavaenda, D., Fineberg, N.A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.
Cognitive-behavioural therapy (CBT) combined with exposure and response prevention (ERP) is considered by many the treatment of choice for obsessive-compulsive disorder (OCD). However, questions remain about the size of its effects, the reliability of the research, and the relative efficacy of CBT plus ERP compared to other psychological treatments. Reid and colleagues conducted a systematic review and meta-analysis of randomized controlled trials of CBT with ERP in patients of all ages with OCD. They included 36 studies with 2000 patients (537 children/adolescents and 1483 adults) receiving treatment and 1015 in control conditions. When compared against all control conditions, CBT with ERP showed a significant and large effect (g = 0.74: 95% CI = 0.51 to 0.97 k =36). While CBT with ERP was more effective than a “psychological placebo” (e.g., progressive relaxation; g = 1.13: 95% CI 0.71 to 1.55, k = 10) and no treatment control conditions (g = 1.27: 95% CI 0.79 to 1.75), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI −0.27 to 0.16, k = 8). When compared to pharmacological treatment with an adequate dosage of selective serotonin reuptake inhibitors, CBT with ERP was marginally better with a small effect (g = 0.32: 95% CI -0.00 to 0.64, p = 0.05). Researcher allegiance or bias had a big impact on the effects of CBT with ERP. Researcher allegiance refers to studies conducted by researchers who prefer, favour, or have a vested interest in the treatment they are testing. In the studies identified as having researcher allegiance, a large favourable effect for CBT with ERP emerged (g = 0.95: 95% CI 0.69 to 1.2). By contrast, in trials where the authors did not identify researcher allegiance (k= 8), CBT with ERP showed no significant effects (g = 0.02: 95% CI−0.29 to 0.33). This difference was statistically significant (Q = 20.33, p < 0.005). There was no evidence of publication bias, but 28 of the 36 studies had a high risk of bias (in which there were deficiencies in the research design, procedures, or data analyses).
Practice Implications
At this point, CBT plus ERP is the most studied treatment for OCD, and it appears to be effective in reducing symptoms post-treatment. However, this meta-analysis raises more questions than it answers about the reliability of the research. Other active treatments (e.g., CBT without ERP) appear just as effective, which suggests that ERP may not be necessary to treat OCD. Researchers who favor or have a vested interest in CBT plus ERP produce much larger effects for their preferred treatment, and the quality of most of the research is low. Such findings lower one’s confidence in the conclusions drawn from the research.
Hope and Expectancy Factors
Constantino, M.J., Muir, H.J., Gaines, A.N., & Ouimette, K. (2023). Hope and expectancy factors. In The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness, (pp.131 – 153), S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors). American Psychological Association. https://doi.org/10.1037/0000358-007
In the early days of psychotherapy research, Jerome Frank wrote cogently about hope and persuasion as the bedrock of psychotherapy’s effectiveness. These days, researchers refer to hope as outcome expectations – or the prognostic belief that a given course of treatment will be helpful. One might consider outcome expectations to be a factor behind the placebo effect – or positive outcomes in the absence of a specific therapeutic ingredient. Whereas pharmacological researchers try to control or reduce the placebo effect, psychotherapists often cultivate and take advantage of outcome expectations to improve client outcomes. In this chapter, Constantino and colleagues review the research on outcome expectations. A meta-analysis showed a small but significant positive effect on outcomes, with outcome expectations explaining approximately 3% of clients’ post-treatment outcomes. This is not a large effect by any means, but significant enough for clinicians to consider how to make the best use of these expectations. One of the mechanisms by which outcome expectations might affect patient outcomes is through the development and maintenance of a therapeutic alliance. In another meta-analysis, early outcome expectations predicted better client-rated alliance during treatment, which in turn predicted better post-treatment outcomes. That is, the client’s outcome expectations could facilitate a collaborative bond with the therapist, which in turn is associated with good client outcomes.
Practice Implications
As a therapist, one should be realistic about the potential effects of therapy for a client while at the same time taking advantage of the potential benefits of a client’s outcome expectations. It might be useful for therapists to gauge the client’s early treatment expectations and to prioritize promoting hopefulness when a client’s expectations are unrealistically low. This might involve collaboratively developing achievable treatment goals and coming to an agreement with the client on how therapy will proceed to meet these goals. That is, to develop a therapeutic alliance as a means of promoting a client’s hope that the agreed-upon treatment plan is credible and will be helpful.