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Hewison, D., Casey, P., & Mwamba, N. (2016). The effectiveness of couple therapy: Clinical outcomes in a naturalistic United Kingdom setting. Psychotherapy, 53, 377-387.

Current randomized controlled trials (RCTs) of couple therapy indicate that about 60% to 70% of couples improve to some degree, and that about 35% to 50% are no longer distressed by the end of therapy. But RCTs have been criticized for being somewhat artificial because their design is based on how pharmacological treatments are tested. Psychotherapy may be more complex than pharmacotherapy in its implementation, and compared to pharmacotherapy, psychotherapy relies more heavily on the qualities of the therapist and therapeutic relationship in order to achieve good outcomes. In an RCT, individuals often have to have a specific disorder to be included in the study, and those with co-morbid disorders may be excluded. This may limit what the findings have to say about real world applications of a particular treatment. Further, therapists in RCTs may receive unusual levels of supervision and support that is seldom seen in regular clinical practice. In this large study of over 435 couples, Hewison and colleagues assessed the effectiveness of a psychodynamically-oriented couple therapy as practiced in a large not-for-profit centre that provides psychological treatment (i.e., the Tavistock clinic in the United Kingdom). All participants received couple treatment and none were randomly assigned to a control group. The couple therapy focused on insight and emotional connection and expression within the context of a therapeutic relationship. The couple relationship rather than the individual partners were the object of the therapy. The unconscious meaning of couple communication was often discussed, and therapist countertransference was seen as a source of information about the couple. Most couples in the study identified as White (77.0%), heterosexual (93.9%), and married or living in a civil partnership (58.4%). More than half of the couples were in the relationship for over 5 years and had children. Therapists were qualified couple therapists or Masters level trainees, had a mean age of 50 (range: 26 – 71), tended to be White women (60%), and were all trained at the clinic. The average number of sessions that a couple attended was 23.3 (SD = 23.5), but with a wide range (2 to 150 sessions) as might be typical in a clinical setting. Overall, individual clients reported a large significant decrease in individual psychological distress (d = -1.04), and a moderate significant decrease in marital distress (d = -0.58). Half of individuals showed a reliable reduction in their individual distress, and over a quarter of couples reported a reliable decline in their couple distress.

Practice Implications

This is the largest study of couple therapy in a naturalistic setting. The psychodynamic couple therapy was effective in reducing individual distress for almost half of the participants although reliable change in couple distress was lower. The results of this field trial indicate that couple therapy that is offered in a functioning real-world clinic setting produces results similar to what is seen in highly controlled randomized trials.

Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.

With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.

Practice Implications

When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.

Connolly Gibbons, M.B., Gallop, R., Thompson, D., Luther, D., Crits-Christoph, K., Jacobs, J., Yin, S., & Crits-Christoph, P. (2016). Comparative effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: A randomized clinical noninferiority trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.1720.

Dynamic psychotherapy is widely practiced in the community, but there remain very few trials assessing its effectiveness. Dynamic therapy targets individuals’ problematic relationship conflicts. Cognitive therapy on the other hand has been established as effective for major depression in a number of controlled trials. This study by Connolly Gibbons and colleagues was designed to test if dynamic therapy was equivalent (not inferior) to cognitive therapy in treating major depressive disorder in a community setting. There are two important and novel aspects to this research. First, the study takes place with community-based therapists in a community mental health setting. This means that the usual critique that randomized controlled trials do not speak to what therapists do with real patients in everyday practice is addressed in this study. Second, the sample size is large enough and the study is sufficiently powered so that one can make conclusions about non-inferiority (statistics geeks will know that making a hypothesis of non-inferiority, equivalence, or no difference requires enough power and a large enough sample size – something that is quite rare in psychotherapy trials). Twenty therapists who worked in a community mental health center were trained by experts in dynamic therapy or cognitive therapy. The therapists treated 237 adults with major depressive disorder with 16 sessions of dynamic or cognitive therapy. Therapists were followed the treatment manuals and they were judged by independent raters as competent in delivering the treatment. Patients on average got significantly better regarding depressive symptoms (d = .55 to .65), and there were no significant differences in the rate of improvement between dynamic and cognitive therapy patients (d = .11). There were also no differences between treatments on several measures of quality of life. A noteworthy finding was that about 80% of patients continued to have some depressive symptoms by the end of treatment even though they improved.

Practice Implications

This study adds to research indicating that short-term dynamic psychotherapy is as effective as short term cognitive therapy for treating major depression. The study also indicates that the treatments under intensive supervision and training can be provided effectively by community therapists in real world settings. That 80% of patients continued to have some depressive symptoms suggests that the short term nature of the therapies may not have represented a large enough dose of treatment for most patients.

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

Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W. et al. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, Advance online publication: doi:10.1176/appi.ajp.2014.13111514.

Social anxiety disorder is a highly prevalent mental disorder, with lifetime prevalence of about 12% in the population. As Leichsenring and colleagues note, the disorder has an early onset and can have a chronic course leading to many psychosocial impairments. Also, social anxiety disorder often is comorbid with depression. There is good evidence for the efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder and some evidence for psychodynamic therapy (PDT), but most studies have only assessed short term outcomes. In this large mulit-center randomized controlled trial comparing CBT and PDT for social phobia, Leichsenring and colleagues report on outcomes up to 2 years post treatment. The study had 416 adult patients randomly assigned to one of the treatments, and 79 randomly assigned to a waiting list. Outcomes were reported at post, 6 months, 12 months, and 24 months post treatment, and included remission of social phobia, depression levels, and interpersonal problem scores. The CBT intervention for social phobia was based on the model by Clark and Wells. The PDT was based on Luborsky’s model but specifically adapted for social phobia. Participants received 25 sessions of individual therapy, and therapists received advanced training in the models. CBT resulted in significantly greater remission of social phobia than PDT at post treatment, but the difference was small. Remission rates at 6, 12, and 24 months post treatment were not different between treatments. At 2 years post treatment 39% of those receiving CBT and 38% of those receiving PDT no longer had clinical symptoms of social phobia.  Results were similar for interpersonal problems in which CBT showed an earlier response, but the two treatments were equivalent at each follow up. Depression scores improved for both interventions at post and follow ups.

Practice Implications

The findings of this large study suggest that both CBT and PDT are effective treatments for social phobia. Although CBT had a small advantage at post treatment, PDT appeared to have an “incubation effect” in which patients continued to work on interpersonal problems and symptoms of social phobia over the longer term. Despite these positive outcomes, Leichsenring and colleagues suggest that there remains room for improvement in treating social phobia. Those who do not respond to these interventions may require different forms of treatment that is more specific, intense, or of longer duration. Leichsenring and colleagues also suggest integrating elements of the effective treatments within a single protocol. Although intuitively appealing, this integrated approach has not been tested.

Barber, J.P., Muran, J.C., McCarthy, K.S., & Keefe, J.R. (2013). Research on dynamic therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 443-494). New York: Wiley.

In this part of their chapter, Barber and colleagues (2013) summarize the research on the efficacy of dynamic therapies for personality disorders. As the authors indicate, dynamic therapies refer to a family of interventions that: focus on the unconscious, affect, cognitions and interpersonal relationships; use interpretations and clarifications; consider transference and countertransference; and use the therapeutic relationship to improve self understanding and self-awareness. Following Magnavity (1997), the authors describe dynamic therapies specifically for personality disorders as identifying maladaptive, recurring patterns of thinking, behaving and emotional responding with the intent of restructuring these through linking current and transference patterns to early attachment and trauma. Barber and colleagues conducted meta analyses of available research on dynamic therapies for personality disorders. They combined several outcomes based on patient and observer reports as an index of general outcome. In seven studies representing 452 patients, dynamic therapies for personality disorders were more effective than control conditions (i.e., treatment as usual, or wait-lists), and the size of the effect was moderate. They found no significant differences between dynamic therapies and other types of therapy for personality disorders. Dynamic therapies had significant advantages over control conditions for general symptomatology, interpersonal problems, personality pathology, and suicidality. These therapeutic effects were maintained to short-term follow up.

Practice Implications

There are now several dynamic therapies for personality disorders that have substantial research evidence for their efficacy. For example, Transference Focused Psychotherapy for borderline personality disorder is considered a “well-established” treatment by the American Psychological Association Division 12. Mentalization-based treatment is also considered to be “probably efficacious”. Other “probably efficacious” dynamic therapies include: McCullough-Vaillant’s short term dynamic psychotherapy (STDP) and brief relational therapy for Cluster C personality disorders (i.e., avoidant, dependent, obsessive-compulsive); and intensive STDP for general personality disorder.