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Once-Weekly or Twice-Weekly Sessions of Psychotherapy?

Bruijniks, S., Lemmens, L., Hollon, S.D., Peeters, F.P., ….Huibers, M.J. (2020). The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients. The British Journal of Psychiatry, doi: 10.1192/bjp.2019.265. [Epub ahead of print].

Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.

Practice Implications

This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.

The Interactive Nature of Countertransference

Connery, A. L., & Murdock, N. L. (2019). An interactive view of countertransference: Differentiation of self and client presentation. Psychotherapy, 56(2), 181–192.

Countertransference in psychotherapy is ubiquitous – it is experienced by every therapist with many clients. An early supervisor of mine once quipped, “You might not be interested in countertransference, but it is certainly interested in you.” Countertransference refers to a therapist’s emotional, cognitive, behavioral responses that are triggered by a client, and that are caused in part by the therapist’s unresolved conflicts, sensitivities, or vulnerabilities. So, it is useful to consider countertransference as a result of an interaction between client factors and therapist factors. Research indicates that therapists’ experience of countertransference is related to negative outcomes in their clients, and that identification and management of countertransference results in better client outcomes. In this study, Connery and Murdoch posited that therapists who had lower levels of differentiation of self would experience higher countertransference reactions. That is, those therapists with lower ability to balance the inherent pulls of separateness and togetherness in interpersonal relations, and who had more difficulty maintaining a sense of self in intimate relationships would be more susceptible to the interpersonal pressures inherent in some psychotherapy relationships. The authors conducted a clever study in which 262 practicing psychotherapists of varying professions, orientations, experience, and ages completed some questionnaires. Then the researchers randomly assigned the therapists either to watch 10 video clips simulating a hostile and dominant patient (i.e., with features of narcissism or paranoia) or to watch 10 video clips simulating a hostile and submissive patient (i.e., with features of passive-aggression). After viewing the videos, researchers asked the therapists to describe their own emotional reactions to the client they viewed using a questionnaire that rates countertransference. In general, therapists tended to respond with over-involvement to the videos of hostile and submissive clients. However, those therapists with more problems with maintaining their sense of self in close relationships were particularly susceptible to feelings of over-involvement with these clients. On the other hand, therapists in general tended to respond with more under-involvement to the videos of hostile and dominant clients. However, those therapists who had more problems with maintaining a sense of self in relationships were not any more susceptible to these countertransference reactions compared to therapists with better differentiation of self.

Practice Implications

Differentiation of self indicates the capacity to develop a healthy balance of interpersonal relatedness and self-differentiation that allows one to balance emotional reactions and rational thought when under stress. This study suggests that therapists’ ability to manage closeness and distance in relationships affects the intensity with which they experience countertransference reactions towards clients who have passive-aggressive qualities. This provide further evidence that not only client characteristics, but also some therapist vulnerabilities play a role in determining countertransference reactions. The findings point to the importance of continued peer supervision and of personal therapy for psychotherapists so that they may be less susceptible to the stress inherent in their work, and so that their clients can achieve optimal outcomes.

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.

De Smet, M. M., Meganck, R., De Geest, R., Norman, U. A., Truijens, F., & Desmet, M. (2020). What “good outcome” means to patients: Understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective. Journal of Counseling Psychology, 67(1), 25–39.

Many researchers consider the randomized controlled trial (RCT) as the best research design for testing medical and psychological treatments. However, critics of the design point to its limitations. For example, in order to collect homogenous samples of patients, researchers may exclude those with complex comorbidities. As a result, patient samples in RCTs may not represent patients one might see in real clinical practice. Also, researchers, and not patients, tend to define the meaning of what is a “good outcome” in these studies. It is possible that researchers and patients may not share the same definition of what it means to have a good outcome from psychotherapy. One key statistical and measurement method that researchers use to define outcomes is the reliable change index, which calculates the degree of change on a symptom scale from pre-treatment to post-treatment relative to the unreliability of the measurement. Using this method, researchers classify patients as “recovered” (reliably changed and passing a clinical cut-off score), “improved” (reliably changed but remaining in the clinical range), “not improved”, or “deteriorated”. However, this commonly used approach does not indicate whether the changes are actually meaningful to the patients. In this study, De Smet and colleagues interviewed patients from a randomized controlled trial of time-limited psychotherapy (16 sessions of CBT vs psychodynamic therapy) for depression who were classified as “recovered” or “improved” at post-treatment based on the reliable change index of a commonly used depression self-report scale. The authors asked how the patients experienced their depression symptom outcome, and what changes the patients valued since the start of therapy. In the original treatment trial of 100 patients, 28 were categorized as “recovered” and 19 patients were categorized as “improved”. During the post-therapy interview, the “recovered” and “improved” patients typically reported a certain degree of improvement in their symptoms. However, the patients categorized as “improved” reported that their gains were unstable from day to day, some reported having relapsed, and half did not feel that they improved at all. None of the “recovered” patients indicated that they felt “cured” of depression. Patients identified three domains of change that they experienced and valued. First, they felt empowered – that is, they had increased self-confidence, greater independence, and new coping skills. Second, they found a personal balance – that is, they had better relationships with loved ones, felt calmer, and had greater insight into their problems. Third, patients tended to identify ongoing struggles despite positive changes in the other domains – that is, certain key problems remained unresolved. “Improved” patients, and even some in the “recovered” group, indicated that their core difficulties had not been altered by the therapy.

Practice Implications

Although measurement of symptom change can give a clinician a general sense of how the patient is doing with regard to their symptoms and whether the patient is on track, such measurement may not capture the complexity of patients’ experiences of the therapy and any broader changes they may value. Patients in this trial, especially those classified as “improved”, had varied experiences. Aside from symptom reduction, clinicians should assess what their patients may value, such as: better relationships, greater self-understanding, more self-confidence, and feeling calmer. Most patients, including some who “recovered”, felt that they were engaged in an ongoing struggle, even after therapy. These findings suggest that addressing some of the core difficulties patients face may require longer term psychotherapy.

Negative Effects of Psychotherapy

Cuijpers, P., Reijnders, M., Karyotaki, E., de Wit, L., & Ebert, D.D. (2018). Negative effects of psychotherapy for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders, 239, 138-145.

Several types of psychotherapy are effective to treat depression, and there appears to be very little difference among the treatments in term of their effectiveness. Despite the documented effectiveness of psychotherapies to treat depression, there is also a growing interest in the clinical and research community about negative effects. Negative effects refer to the deterioration or worsening of depressive symptoms during treatment. Some may also refer to drop-out or non-response as a negative effect because these events are demoralizing and may prevent a patient from seeking more adequate care. Some researchers estimated that 5% to 10% of patients deteriorate during therapy. Deteriorations may not be due solely to the therapy itself, but instead may reflect the natural course of depression. In this meta-analysis, Cuijpers and colleagues examined studies in which a psychotherapy for depression was compared to a control condition in which patients did not receive an active treatment. In such studies, one might expect the control condition to represent what would happen in terms of symptoms if the patient received no treatment. Despite over 100 randomized controlled trials of a psychotherapy versus a non-active treatment control condition for depression, only 18 studies reported enough information to estimate negative effects. There was a median deterioration rate in the psychotherapy groups of about 4%, whereas the risk of deterioration in the control groups was about 11%. There were no differences in deterioration rates among types of psychotherapy (CBT vs others), treatment format (group vs individual), or type of control group (wait-list vs care as usual).

Practice Implications

Only 6.2% of research studies reported enough information to estimate negative effects, making it difficult to get a good estimate that represents all studies and patients. Nevertheless, receiving psychotherapy reduced deterioration rates by more than 61% compared to untreated control conditions, suggesting that psychotherapy can help some patients who might get worse with no treatment. Therapists should work to recognize and evaluate deterioration rates in therapy because they do occur for an important minority of patients. Some have suggested ongoing progress monitoring as a means of reducing the number of patients who might get worse during psychotherapy.

Adverse Events During Psychotherapy

Meister, R., Lanio, J., Fangmeier, T., Harter, M., Schramm, E., … Kriston, L. (2020). Adverse events during a disorder‐specific psychotherapy compared to a nonspecific psychotherapy in patients with chronic depression. Journal of Clinical Psychology, 76, 7-19.

Adverse events refer to negative or unwanted outcomes of psychotherapy that may be due to the therapy itself when delivered correctly, or to the application of the therapy when delivered incorrectly. For example, patients may report worsening of symptoms, relationship problems with partners or family, problems at work, stigma, and other disadvantages. Adverse events during pharmacologic treatment are well studied and are often considered when making treatment decisions. However, adverse events in psychotherapy are largely ignored in the research and clinical literature. A recent meta analysis reported that the median deterioration rates in psychotherapy studies is about 4%, which is likely less than half the rate of deterioration seen in regular clinical practice. In this study, Meister and colleagues look at deterioration rates in a randomized controlled trial comparing the Cognitive Behavioral Assessment System of Psychotherapy (CBASP) versus non-supportive psychotherapy (NSP). In that study that was previously summarized in this blog, 262 depressed patients were randomly assigned to receive 24 weeks of either CBASP or NSP. Participants who received CBASP were slightly better off than those who got NSP, and the drop-out rates were equivalent between conditions. Therapists asked patients at each session if the patient experienced an adverse event in the previous week. Patients reported an average of about 12 adverse events during the 24 weeks of psychotherapy, and there was no difference in the number of adverse events between CBASP and NSP. However, patients receiving CBASP reported more severe adverse events related to their personal life and work life compared to patients receiving NSP. Suicidal thoughts were infrequently reported by patients, and their frequency did not differ between CBASP and NSP.

Practice Implications

The study highlights that symptoms and interpersonal conflicts may temporarily increase as a result of being in psychotherapy. The authors argued that the increases in problems with work and personal relationships may be due to the specific interpersonal treatment elements of CBASP that require changes in the patient’s interpersonal behaviors that temporarily may be disruptive to their lives. Therapists may consider informing patients about the possible temporary negative effects of psychotherapy on their relationships or functioning. This preparation might help patients to make informed decisions about psychotherapy and to prepare them to cope with changes in their relationships.