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Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.

Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.

Practice Implications

Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.

Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta‐analytic review. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2180.

The therapeutic alliance refers to the collaborative agreement between therapist and client on the tasks of therapy (homework, treatment approach, intervention style) and goals of therapy (to reduce depressive symptoms, to improve interpersonal relationships, to cope better with stress), plus the emotional bond between therapist and client. The alliance is part of a larger concept of therapeutic relationship that also includes the real relationship between client and therapist and the transference relationship (maladaptive relational patterns in the client based on a history of relationships with parental figures). The alliance is thought to be a common factor across different therapeutic orientations, including cognitive behavioral therapy (CBT), time-limited psychodynamic psychotherapy (TLPP), and interpersonal psychotherapy (IPT). In fact, the alliance is known to have a moderate and robust relationship to client outcomes regardless of who rates the alliance (therapist, client, observer), which measure is used, and when in therapy the alliance is rated (early, middle, late). Although Beck emphasized the alliance as a key therapeutic principle in CBT, some CBT writers argue that the alliance is not so important. In this study, Cameron and colleagues conducted a meta analysis of 13 randomized controlled trials that assessed the relationship between therapeutic alliance and CBT outcomes for depression in adult clients. The overall mean correlation between therapeutic alliance and outcome was r = 0.26 (95% CI [.19–.32]), which indicates a moderate and significant relationship. This is very close to the value found in a larger meta analysis of over 200 alliance – outcome studies.

Practice Implications

The study demonstrates the importance of the therapeutic alliance to client outcomes in CBT. The association was at similar levels to those found in other types of therapy. Therapists conducting CBT should attend to building and maintaining an alliance, which provides a context to facilitate CBT interventions. If a client is not completing homework for example, it is likely that there is a lack of agreement on tasks of therapy, and this part of the alliance may need to be renegotiated. Therapists may also benefit from routinely assessing the alliance in therapy with their clients on a session by session basis using short and easy to use measures. Reviewing these scales regularly can alert a therapist to potential problems in the alliance and the need to repair any tensions or ruptures.

Yulish, N. E., Goldberg, S. B., Frost, N. D., Abbas, M., Oleen-Junk, N. A., Kring, M., . . . Wampold, B. E. (2017). The importance of problem-focused treatments: A meta-analysis of anxiety treatments. Psychotherapy, 54(4), 321-338.

Typically, meta-analyses indicate that the differences between treatments in client outcomes are small or non-existent. When a treatment is found to be more effective than a comparison condition, it is usually because the treatment (and not the comparison) is focused on the particular problem that is measured as the main outcome variable. The contextual model of change in psychotherapy posits three paths to client change: 1) therapist empathy and the real therapeutic relationship; 2) client expectations related to the therapist’s explanation of the problems and of how the therapy will reduce these problems (e.g., agreement on tasks and goals, which are aspects of therapeutic alliance); and 3) the direct specific interventions of the therapy to address these problems. In this meta-analysis, Yulish and colleagues examine aspects of the second and third component of the contextual model by examining if the difference between treatments for anxiety disorders is due to the relative differences in their focus on symptoms. In this systematic review, the authors identified 135 randomized controlled trials of direct comparisons of psychotherapy for anxiety disorders. They then rated each treatment and control condition for: the amount of explanation provided to clients for their symptoms, the amount of explanation provided to clients for the treatment approach, and the specificity of the interventions to address the symptoms. In a series of meta-regressions the authors found that: 1) explanations for the symptoms and for the treatment approach, and 2) treatments that were more symptom focused resulted in larger treatment effects. When the authors pit explanations against symptom focus to predict outcomes, they found that providing clients with an explanation for symptoms and interventions (which resulted in higher client expectations of receiving benefit) was more important than the symptom focus of the treatment.

Practice Implications

This study suggests three mechanisms by which psychotherapy may lead to symptom relief for anxiety disorders: 1) providing clients with a clear explanation of symptoms and of therapeutic interventions, 2) having an agreement about the tasks and goals of therapy (i.e., therapeutic alliance), and 3) engaging in specific therapeutic actions that derive from the explanation of symptoms. Sitting with a client, being warm and accepting, expressing empathy and understanding, but not providing the client an explanation for his or her distress or a means to overcoming that distress may not be good enough. Such approaches may be beneficial for some with anxiety disorders, but they fail to fully make use of the factors that lead to effective therapy. The expectations of benefit created by the explanation of symptoms and interventions, in addition to specific therapeutic actions that are consistent with the explanation, may play a critical role in reducing symptoms of anxiety.

Author email: bwampold@wisc.edu

Murphy, R. & Hutton, P. (2017). Therapist variability, patient reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment: A systematic review and meta-analysis. The Journal of Child Psychology and Psychiatry, doi:10.1111/jcpp.12767.

The therapeutic alliance refers to the affective bond between therapist and client, and their agreement on the tasks and goals of therapy. The alliance is a well-known predictor of outcomes in adult psychotherapy with a mean alliance-outcome correlation of r = .28. Less is known about the role of the alliance in the treatment of adolescents. Some reviews indicate that the alliance-outcome relationship in children and adolescents is weaker than observed among adults, but these reviews may have been flawed since they included both children and adolescents in the same review, and the number of studies they reviewed was small. A large rigorous systematic review of adolescents’ perceptions of the alliance can provide insight into their experience of psychological treatment and inform routine mental health practice. In their meta analysis, Murphy and Hutton reviewed studies of clinical samples of adolescents between the age of 12 – 19 who received psychological treatment. The authors made sure that the measures of alliance and outcomes were reliable, they excluded studies of those with medical and neurocognitive problems, and included only studies with adolescents (i.e., excluding studies with primarily children). Twenty-seven studies with almost 3,000 participants were included. Main presenting problems of adolescent patients were: substance use, eating disorders, behavioral difficulties, and a range of mood and anxiety disorders. The mean weighted effect size of the alliance-outcome relationship among studies of psychological treatment of adolescents was r = .29 (95% CI: 0.21, 0.37; p < .001) indicating a moderate effect.

Practice Implication

This is the largest meta analysis of the alliance-outcome relationship in the psychological treatment of adolescents with mental health problems. The alliance was moderately associated with outcomes, and so therapeutic alliance may be a reliable predictor of clinical progress in the treatment of adolescents. The findings suggest that those working with adolescents should routinely assess the alliance after each session in order to evaluate if they need to address relational barriers to positive outcomes. For example, if the alliance markedly declines from one session to the next, then clinicians should address potential problems in their relationship with the adolescent client, renegotiate goals, or renegotiate the tasks of therapy.

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.

Practice Implications

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.

Gueorguieva, R., Chekroud, A.M., & Krystal, J.H. (2017). Trajectories of relapse in randomised, placebo-controlled trials of treatment discontinuation in major depressive disorder: An individual patient-level data meta-analysis. Lancet Psychiatry.

Individuals with a history of depression who get better have a 30% to 50% chance of relapse in the first year. That is, major depression tends to take a recurrent course, so that about a third to half of patients who initially improve will then experience a re-emergence of symptoms. In this meta-analysis, Gueorguieva and colleagues looked at whether they could identify classes of patients who respond differently to antidepressant medications depending on whether they discontinued or continued with the medications after symptoms improved. The meta-analysis included over 1,400 patients from four studies of duloxetine or fluoxetine (i.e., Cymbalta or Prozac) who participated in a discontinuation trial. A discontinuation trial design involves randomly assigning patients who respond positively to the medication either (1) to stay on the effective medication or (2) to discontinue the treatment and receive a placebo. Such a design gives us an estimate of the advantage of maintenance versus discontinuation of medications to reduce relapse of depression in the longer term. Gueorguieva and colleagues found that 33% of those in the medication continuation condition relapsed (i.e., 33% those who responded well to the initial trial of medications and who then continued with medications had a recurrence of depressive symptoms). By contrast, 46% of those in the placebo/medication discontinuation condition relapsed (i.e., 46% of those who responded well to the initial trial of medications and who then received a placebo had a recurrence of depressive symptoms). In other words, continuation of antidepressant medications resulted in a small 13% reduction in relapse rates compared to continuation with a placebo.

Practice Implications

This meta analysis indicates that continuing with antidepressant medications after depressive symptoms remit provides only a modest level of protection against a relapse of depression. Thus continuation with antidepressants after symptoms improve may not be worth it for patients who struggle with medication side effects and complications, or who cannot afford continuation of the medications. There is growing evidence that psychotherapy is effective for preventing relapse, likely because psychotherapy teaches patients ways of coping and interacting with others that allows them to manage life stresses more effectively after the treatment is over.