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Kivlighan, D.M., Goldberg, S.B., Abbas, M., Pace, B.T., …Wampold, B.E. (2015). The enduring effects of psychodynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal meta-analysis. Clinical Psychology Review, 40, 1-14.

There is a great deal of evidence that indicates uniform efficacy of a variety of psychotherapies for many common disorders. For example, in the July 2014 PPRNet Blog, I reviewed a meta-analysis comparing 7 psychotherapies for depression indicating no differences between the various treatments in terms of patient outcomes. Nevertheless proponents of cognitive behavioural therapy have claimed superiority to alternative treatments for decades. On the other hand proponents of psychodynamic therapies have argued that these treatments focus on personality change rather than symptoms, and so benefits of psychodynamic therapies will be longer lasting. In this meta analysis, Kivlighan and colleagues put these claims to the test. They selected studies in which a psychodynamic therapy was compared to one or more alternative treatment. Both the psychodynamic therapy and the alternative (most often CBT) had to be judged as “bona fide” therapies by independent raters (i.e., they had to be therapies that were delivered in a manner in which they could be expected to be effective by clients and therapists). Outcomes not only included specific symptoms (e.g., depression), but also non-targeted outcomes (e.g., improved self esteem in a study of treatment of anxiety), and personality outcomes. Effect sizes for outcomes were assessed at post-treatment and also at follow-ups. Twenty five studies directly comparing psychodynamic and non-psychodynamic therapies were included, representing 1690 patients. At post treatment, no significant differences were found between psychodynamic and non-psychodynamic treatments on targeted outcomes, non-targeted outcomes, and personality measures (all gs < .10). There was also no significant or meaningful effect of time to follow up on outcomes, indicating no differences between treatment types at any of the follow up periods.

Practice Implications

Psychodynamic and non-psychodynamic treatments were equally effective at post treatment and at follow ups for all outcomes, including personality variables. This challenges the belief that psychodynamic treatments uniquely affect personality and have longer lasting effects compared to other treatments. It also challenges the notion that CBT (by far the most common comparison treatment) is a superior therapy for patient outcomes. Pan-theoretical psychotherapy factors (client contributions, expectations, therapeutic alliance) may be more promising factors in understanding the long term benefits of psychotherapy. 

Author email: kivlighan@wisc.edu

Mallinckrodt, B. & Jeong, J. (2015). Meta-analysis of client attachment to therapist: Associations with working alliance and pretherapy attachment. Psychotherapy, 52, 134-139.

Attachment theory has become one of the most important conceptualizations of affect regulation and interpersonal relationships. John Bowlby and others suggested that attachment behaviour is hard wired so that infants can gain proximity to caregivers which is necessary for infant survival. Repeated interactions with caregivers coupled with the variety of caregiver responses (i.e., available, unavailable, or inconsistently available caregiving) lead to children developing internal working models of attachment. These models become the basis for attachment styles in adulthood. Attachment security in adults is associated with the ability to give and receive caring and love, and to adaptively regulate emotions. Attachment avoidance is associated with a tendency to dismiss relationships as important, and to downregulate emotional experiences. Attachment anxiety is associated with a preoccupation with relationships, and to upregulated emotional experiences. In a previous meta analysis, client general attachment security was modestly but significantly associated with higher levels of therapeutic alliance (r = .17). In another meta analysis, higher client general attachment anxiety was associated with poorer client outcomes (r = -.22). In this meta analysis, Mallinckrodt and Jeong assessed whether client attachment to the therapist was associated with client general attachment style and with the therapeutic alliance with the therapist. They included 13 studies representing 1051 client-therapist dyads. Client pre-therapy general attachment avoidance and anxiety were negatively associated with client-therapist attachment security, and the effects were modest but significant (r = -.12, r = -.13). Client-therapist attachment security was positively associated with therapeutic alliance (r = .76) and client-therapist attachment avoidance was negatively associated with therapeutic alliance (r = -.63), and these effects were large.

Practice Implications

Client pre-therapy attachment styles appear to have an impact on their attachment to the therapist. A client pre-therapy attachment style characterized by preoccupation with relationships and an over-emphasis on emotions (i.e., attachment anxiety) will likely lead to similar behaviors and preoccupations in the relationship with the therapist. Mallinckrodt and Jeong suggest that this might be the basis for transference-related phenomenon that therapists and clients experience in the therapeutic relationship. That is, client attachment anxiety and avoidance likely interfere with developing a secure attachment to the therapist. Further, client attachment avoidance with regard to the therapist may result in lower therapeutic alliance, which is key to achieve improved patient outcomes. Despite these challenges, therapists who can facilitate a secure psychotherapy attachment experience for their clients are more likely to see improvements in their clients’ functioning.

Author email: bmallinc@utk.edu

Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no

Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical Psychology, 83, 115-128.

Existential therapies are a group of psychological interventions that address questions about existence, and they assume that by overcoming existential distress, psychological problems may be decreased. Underlying existential therapy is the assumption that: people need a meaning or purpose, individuals have a capacity to choose and actualize this potential, people will do better when they face challenges rather than avoid them, and human experiencing is related to others’ experiences. Vos and colleagues list four main schools of existential therapies: Daseinanalysis which focuses on free expression and greater openness to the world; logo-therapies which are aimed at helping clients establish meaning in their lives through didactics, British existential therapy which encourages clients to explore their experiences, and the existential-humanistic approach which help clients face mortality, freedom, isolation, and meaninglessness. Vos and colleagues review the research literature showing that meaning in life and positive well-being are associated with coping with stressful life events including life threatening illnesses. In this meta-analysis, the authors review the randomized controlled trials of different types of existential therapies to assess the efficacy of the treatments compared to a control condition like social support groups, being on a waiting list, or receiving care as usual. They grouped outcomes into four areas: meaning in life, psychopathology, self-efficacy, and physical well-being. Their meta-analysis included 15 studies of 1,792 participants, 13 of the studies were with medically ill patients, and 10 of those studies were aimed at patients with cancer. Effects of existential therapy versus a control condition on meaning in life tended to be positive and moderate. Effects on psychopathology and self-efficacy were positive and small. The effects of existential therapies versus a control condition on physical well-being were not significant. There were no differences between the types of existential therapy, though the number of studies was small to adequately assess these differences.

Practice Implications

Clients seem to benefit from group therapy interventions focused on meaning compared to social support groups, being on a waiting list, or receiving care as usual. Medically ill patients who received existential therapy found greater meaning in their lives, and the effects were moderate to large. Their psychopathology and self-efficacy also improved significantly but effects were small. The quality and number of studies was not optimal which limits the confidence one can have in these findings. The authors conclude that despite the small number of studies, existential therapies that use structured interventions that incorporate psychoeducation and discussions on meaning in life are a promising treatment for physically ill patients.

Hayes, J.A., Gelso, C.J., & Hummel, A.M. (2011). Managing countertransference. Psychotherapy, 48, 88-97.

This is another in a series of meta-analyses on relationship factors that work in psychotherapy that appeared also in John Norcross’ book Psychotherapy Relationships That Work. As I mentioned in previous blogs, meta-analyses represent the state of the art in systematically reviewing a research literature. In meta-analyses, the effect sizes from many studies are aggregated into an estimate of an overall effect that is much more reliable than any single study. In these meta-analyses, Hayes and colleagues assessed whether therapist countertransference had a negative effect on patient outcomes, and whether successful management of countertransference is related to better therapy outcomes. Traditionally, countertransference was seen as solely related to therapist unconscious conflicts, and countertransference was to be avoided. Broader conceptualizations view countertransference as representing all of the therapist’s reactions to the client. More interpersonal or relational models view countertransference as therapist reactions that complement a patient’s ways of relating, or see countertransference as mutually constructed by therapist and patient, so that the needs and conflicts of both patient and therapist contribute to the manifestation of countertransference in therapy. Hayes and colleagues argue that the definition of countertransference must include some aspect of therapist unresolved conflicts, and that countertransference in the therapist is potentially useful to understanding patient dynamics and personality style. Countertransference may be reflected in therapist anger, boredom, anxiety, despair, arousal, etc. These feelings range in intensity as well. According to Hayes and colleagues, successful management of countertransference might involve: self-insight (therapist being aware of their own feelings, attitudes, personality, etc.); self integration (therapist’s healthy character structure); anxiety management (therapist’s ability to control and understand own anxiety); empathy (the ability to put one’s self in the other’s shoes in order to focus on the client’s needs); and conceptualizing ability (therapist’s ability to draw on theory to understand the patient’s role in the therapeutic relationship). Hayes’ and colleagues meta-analyses included between 7 to 11 studies of 478 to 1065 participants. The findings showed that countertransference in the therapist was associated with negative patient outcomes, though the effect was small. Successful management of countertransference was associated with better therapy outcomes, and the effect was large.

Practice Implications

Successful management of countertransference is a characteristic of effective therapists. Therapists can work on a number of issues to reduce the negative impact of countertransference and to increase its utility in helping to understand certain patients. Therapists can work to gain self-understanding and work on their own psychological health. The research suggests the importance of therapists resolving their own major conflicts through personal therapy and clinical supervision. Having a good grasp of psychological theory and theories of therapy can also help with using countertransference effectively, as long as the theory is not used defensively by the therapist. Further, there is value in therapists admitting mistakes and acknowledging that their own conflict was the source of the error. Although countertransference theory and research focuses on the therapist, Hayes and colleagues acknowledge that some clients evoke greater and more intense countertransference reactions that others.

Lindheim, O., Bennett, C.B., Trentacosta, C.J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.

Giving clients a choice about treatments or to receive their preferred treatment might improve treatment outcomes. Preference usually means clients passively receiving the treatment they prefer. Choice involves clients actively making a decision about which treatment option to receive. Clients may also make informed or uninformed preferences and choices. Informed preferences and choices refer to providing clients with information or education about treatment options. Having a choice or getting one’s preference between two or more efficacious treatments might have several beneficial effects. For example, some research shows that treatment preferences positively affect therapeutic alliance, possibly because clients may enter treatment with a more positive outlook about what intervention they receive. Patients receiving a preferred treatment may also have better overall communication with their providers which may lead to better outcomes. In their meta-analysis, Lindheim and colleagues were interested in the effects of client preference or choice on treatment satisfaction, completion, and clinical outcomes. The meta-analysis included 34 different studies. Client preference or choice of treatment was modestly but significantly and consistently related to satisfaction, completion rates, and to client outcomes. Clients who were involved in shared decision making, who chose a treatment condition, or who received their preference had higher satisfaction, increased completion rates, and better clinical outcomes compared to clients who were not involved in the decision, who did not choose, or who did not receive their preference. Setting (inpatient vs outpatient) or diagnosis did not have an effect on these findings.

Practice Implications

The findings highlight the clinical benefits of assessing client preferences and providing treatment options when two or more efficacious options are available. Increasingly, two or more efficacious options are available for common mental disorders like depression and anxiety. Many times, patients prefer psychotherapy over medications, for example. However, whereas medication prescriptions for mental disorders like depression rose dramatically in the past decades, rates of psychotherapy use remained stable or slightly declined. For those disorders for which two or more treatment options have comparable efficacy, client preference should be the deciding factor.