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Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.

Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).

Practice Implications

The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.

Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.

Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.

Practice Implications

This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.

Norwood, C., Moghaddam, N.G., Malins, S., & Sabin-Farrell, R. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology and Psychotherapy, 25, 797-808.

The working alliance is the collaboration between client and therapist on the tasks and goals of therapy, and it also includes the emotional bond. The alliance is the most researched concept in psychotherapy, and it is reliably related to good client outcomes. However, the alliance has been rarely studied in the context of videoconferencing psychotherapy (VCP). Delivering psychotherapy remotely was already gaining popularity prior to COVID-19 because of its potential to improve access to mental health care especially for people who live in remote areas. Some argue that face to face therapy might result in a higher therapeutic alliance because of the rich interpersonal cues, like eye contact and body posture that may facilitate collaboration and the bond. There is emerging evidence that VCP can be effective and that it may have comparable outcomes to face-to-face therapy. But what about the working alliance – does it develop in VCP similarly to face to face therapy?  In this meta-analysis, Norwood and colleagues conducted a systematic review of the existing research on the working alliance in VCP. They found only 4 direct comparison randomized controlled studies on the topic, and on average VCP resulted in a lower working alliance compared to face to face therapy, but the difference was not statistically significant (n = 4; SMD = -0.30; 95% CI: -0.67, 0.07; p = 0.11). People who received treatment via VCP had similar levels of symptom reduction compared to those who received face to face therapy (n = 4; SMD = −0.03; 95% CI [−0.45, 0.40], p = 0.90).

Practice Implications

With only four direct comparison randomized trials to draw from, the results of this meta-analysis remained ambiguous with regard to the therapeutic alliance. Although the difference between VCP and face to face therapy was not statistically significant, it was not ignorable – an effect size of SMD = -0.30 suggests a small advantage for face to face therapy when it comes to the alliance. However, symptom outcomes were comparable between face to face and VCP. The results suggest that therapists who use VCP during a pandemic, must pay particular attention to developing and maintaining a therapeutic alliance by collaboratively agreeing on goals and tasks of therapy, and by focusing on establishing an affective bond with patients despite the limited nonverbal cues available with online psychotherapy.

Effectiveness and Adherence of Telephone-Administered Psychotherapy

Castro, A., Gili, M., Ricci-Cagello, I., Roca, M., Gilbody, S., Perez-Ara, A., Segui, A., & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526.

The COVID-19 pandemic has resulted in psychotherapy providers moving to online and telephone-delivered interventions. But questions remain about the efficacy of delivering psychotherapy in these formats to patients with depression. Depression is highly prevalent as it affects about 320 million people around the world and causes serious disability and lowered quality of life. Psychotherapy is effective in treating depression, however there are significant barriers to people accessing face-to-face psychotherapy including cost, stigma, distance, and disability. Telephone-delivered psychotherapy may minimize these barriers. One potential question that may arise is whether patients will adhere to telephone-delivered psychotherapy. That is, will patients find telephone sessions acceptable as indicted by the rate of starting therapy and of attending sessions? In this systematic review and meta-analysis, Castro and colleagues evaluated whether telephone-delivered psychotherapy for depression is as effective as other active treatments and more effective than no-treatment. The authors also examined the level of adherence/acceptability to telephone administered treatment, determined by the percent of scheduled sessions actually attended by a patient. The sample of studies was small such the authors only found a total of 11 direct comparison randomized controlled trials. These trials represented almost 1400 patients. The only treatment tested in these trials were CBT-oriented. Four studies found that telephone-delivered therapy produced significantly larger reductions in depressive symptoms when compared to no treatment controls (mean SMD = -0.48; 95% CI: -0.82 to -0.14). In four other studies telephone-administered therapy was just as effective as an active control (e.g., medication or self-help). The weighted average percentage of scheduled telephone sessions that patients attended was 73%, and the percent of patients who started telephone therapy after the initial referral was about 90%. These percentages indicating adherence and acceptability are similar to findings reported from individual psychotherapy studies.

Practice Implications

There are few randomized controlled trials that assess the efficacy of telephone-administered psychotherapy, and these studies were limited to only one type of intervention. However, the findings from this meta-analysis suggested that telephone-delivered psychotherapy may be efficacious and as effective as some other active treatments. Further, telephone therapy may be acceptable to patients in that they start and attend sessions at a rate similar to face-to-face therapy. These preliminary findings provide clinicians who provide telephone psychotherapy during this period of physical distancing due to COVID-19 with some evidence for the utility of telephone delivered treatment.

Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2020). Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 263, 413-419.

Depression is a leading cause of disability worldwide, and yet more than 50% of people do not have access to adequate therapy. One solution might be to provide individuals with smartphone apps to help screen, monitor, or provide treatment. Smart phones are ubiquitous, and depression apps are one of the most downloaded categories of apps by the public. Research seems to suggest that smartphone apps provide some positive results for members of the public, but these findings are compromised by the high drop-out rates reported in the primary studies. Further, one study found that although many people download the apps, only about 4% actually use them. Whereas smartphone apps appear attractive to the consumer, very few actually make use of and therefore benefit from them. In this systematic review, Torous and colleagues conduct a meta-analysis of drop-out rates from studies that test the use of smart phone apps. They found 18 independent studies representing data from 3,336 participants who received a psychological intervention for depression via a cell phone app, or who were in a placebo control condition. A total of 22 different apps were tested in the studies. Initially, the pooled drop-out rate from the depression app treatment arms appeared to be about 26.2% (95% C.I.=11.34% to 46.75%), which would be in line with average drop-out rates from randomized controlled trials of face to face psychotherapy. But, the authors noted two things. First, the drop-out rate from the placebo control conditions (14.2%; 95% C.I. = 8.236 to 23.406) was almost half as high as that found for the apps. Second, through some sophisticated statistical analyses, they found evidence of “publication bias” in this research area. This means that a number of studies testing these apps likely were completed but never published (i.e., these might be studies funded by an app manufacturer that demonstrated negative findings or high drop-out rates). When the authors statistically adjusted for publication bias, they found that the actual drop-out rate from the apps was about 47.8%. That is, almost half of users did not complete or dropped out of the studies. There were no differences in drop-out between types of interventions (CBT, mindfulness, or others), and studies with larger sample sizes (i.e., better quality studies) had higher drop-out rates.

Practice Implications

Although smartphone apps appear really attractive and may be potentially useful as an adjunct to face to face psychotherapy for depression, their utility is plagued by extremely low usage rates (4%) and high drop-out rates from studies (almost 50%). Leading writers and researchers define psychotherapy as primarily a healing relationship that also includes specific interventions. The key ingredient is the human relationship. Depressed or otherwise troubled individuals cannot (because of feeling demoralized) or will not interact with a machine for healing. One way or another, when it comes to smartphone apps, depressed individuals are voting with their feet. Given these findings, health care providers should consider the ethics of giving a depressed individual only e-therapy as the primary mode of treatment.

Client Stage of Change Predicts Their Outcomes in Psychotherapy

Krebs, P., Norcross, J.C., Nicholson, J.M., & Prochaska, J.O. (2018). Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of Clinical Psychology, 74, 1964-1979.

Next to the therapeutic alliance, client stage of change is one of the most researched concepts in psychotherapy. The theory posits that clients come for treatment with varying levels of motivation, preparation, and capacity for behavior change. And their overall readiness for change influences the process and outcome of the psychotherapy they receive. Researchers have identified five stages that clients may go through during the change process, and they identified most effective therapist stances to help clients move from one stage to the next. Precontemplation is the stage in which the client has no intention of changing, and they may have been coerced into coming to therapy. During this stage therapists may help the client increase their awareness of the advantages of changing and the costs of not changing. Contemplation is the stage in which the client is aware that there is a problem, but has not yet made a commitment to take action. During this stage the client may face the sadness or anxiety related to letting go of behaviors that no longer work. Therapists may help a client to re-evaluate themselves should they change their behaviors. Preparation is a stage in which the individual is fully intending to take action, and they may make small behavioral changes. Therapists may help clients in this stage to act on their belief that they have the ability to change their behavior. Action is the stage in which clients modify their behaviors or environment to overcome their problems. Therapists may help clients at this stage by ensuring clients perceive adequate reinforcements for their efforts and resist the tendency to avoid problematic situations or feelings. Finally, the maintenance stage is the point at which clients have made desirable changes and now work to prevent relapse and consolidate gains. Therapists may help individuals during the maintenance phase to be prepared for or to avoid situations that may induce relapse. A key aspect of therapist stances related to client stages of change is exemplified by the process of motivational interviewing, in which the therapist works with the client’s resistance rather than taking a confrontational stance. In this meta-analysis, Krebs and colleagues systematically reviewed the literature on stages of change and summarize 76 studies with over 21,000 clients. The association between stage of change and client outcome was significant and moderate in effect size (d = 0.41; 95% CI: 0.34, 0.48). That is the stage of change at which the client starts has a measurable impact on their outcomes, with pre-contemplation being related to poorest outcomes, and action being related to best outcomes. These results were consistent across theoretical orientations. In a second meta-analysis, the authors found that tailored interventions to move clients to more advanced stages of change were significantly related to better outcomes, though the effects were small (d = 0.18; 95% CI: 0.16, 0.20).

Practice Implications

The stage of change theory is transtheoretical – that is, it operates across most therapeutic situations and clients. The findings of this meta-analysis indicate that therapists who know the client’s stage of change and who act accordingly will improve their client’s outcomes. Many therapists tend to believe that their clients are at the action stage, but this may not be the case. Treating someone who is contemplating change as if they are ready to make changes may be counter-therapeutic as it represents a mismatch of goals. Hence, therapists should work with clients to set realistic goals for therapy, and therapists should keep in mind that a patient who is not ready to change will not likely change if confronted. The best strategy may be to discuss with the client the risks and benefits of their behaviors, and help them make a decision of how or if to move forward with therapy.