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The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.

April 2017

Efficacy of Psychotherapies for Borderline Personality Disorder

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

December 2016

The Poor State of Psychotherapy Research for Indigenous People

Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.

Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.

Practice Implications

The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.

July 2016

Direct Psychological Interventions Reduce Suicide and Suicide Attempts

Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S., & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry.

The World Health Organization reports that more than 800,000 people die of suicide per year around the world. However suicide prevention efforts over the past decade have fallen short of targets. In fact, the prevalence rates of suicide in the US have risen steadily since 2000 to about 1.3% of the population in 2014. Many who kill themselves have a mental disorder like depression, anxiety disorders, substance abuse, psychoses, or personality disorders. Best practices suggest that directly addressing suicidal thoughts and behaviors during treatment, rather than only addressing symptoms like depression and hopelessness, are most effective in reducing suicide. However, there are no meta analyses of randomized controlled trials that specifically assess the relative utility of direct versus indirect psychological interventions. In their meta analysis, Meerwijk and colleagues looked at psychosocial interventions aimed to prevent suicide or to treat mental illness associated with suicide. They included 31 studies representing over 13,000 participants. Interventions included cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), case management, social skills training, and supportive telephone calls. Depending on the target problem, the interventions either directly addressed suicidal behavior or they indirectly addressed suicidal behavior. Mean duration of treatment was over 11 months. Studies that looked at direct or indirect interventions were each compared to control groups that received some form of usual care in the community, or psychiatric management, or general practitioner care. Individuals who received usual care were 1.5 times more likely to die of or attempt suicide compared to those receiving direct or indirect psychological interventions. There was a 35% lower odds of suicide and attempts with direct interventions compared to usual care; and an 18% lower odds of suicide and attempts with indirect interventions compared to usual care. The difference between the effectiveness of direct versus indirect interventions was large (d = .77), suggesting that direct interventions were more effective than indirect interventions at reducing suicide and suicide attempts.

Practice Implications

This is the largest meta analysis of its kind. Most direct interventions to prevent suicide and suicidal behaviors were based on CBT and DBT. Indirectly addressing suicide by focusing on depressive symptoms, anxiety, and hopelessness was somewhat effective compared to usual care. However, direct interventions that included talking about the patient’s suicidal thoughts and behaviors and how best to cope were most effective.

May 2016

Organizational Factors That Reduce Suicide Rates in the Population

Kapur, N., Ibrahim, S., While, D., Baird, A.,... Appleby, L. (2016). Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. The Lancet Psychiatry.

Suicide is a major cause of death worldwide, and many recent public health efforts have focused on suicide prevention. Many studies have looked at social, psychological, and biological factors that may cause suicide, but few studies have examined the effects of health service contexts on suicide rates. In this large retrospective population-based study, Kapur and colleagues looked at over 19,000 suicides that occurred within England’s health services from 1997 to 2012. This represented 26% of all suicides in England. The researchers: evaluated economic climate, surveyed the clinic administrators and clinicians involved, and they reviewed policy, service, and staffing changes at each time point. Health care in England is organized nationally through the National Health Service, and the government also collected confidential survey data on deaths by suicide between 1997 and 2012. The researchers examined if specific policy changes and organizational factors affected suicide rates. Health system changes such as: (a) implementing the National Institute for Health and Care Excellence depression guidelines, (b) making available crisis and home treatment teams, (c) implementing policies on transfer from youth to adult care and (d) new procedures for managing patients with dual diagnosis were all associated with reduced suicide rates during the study period. One of the most interesting findings was that these changes to the treatment and management of depression, youth, crises, and dual diagnoses were much more effective in reducing suicide rates under two organizational contexts: (1) when non-medical staff turnover was low, and (2) when there was greater reporting of patient safety incidents. Lower staff turnover likely means that patients in those organizations received greater continuity of care and that suicidal or depressed patients were more likely to receive treatment from highly trained and experienced professionals. Greater reporting of patient safety incidents tend to occur in organizations in which the staff feels sufficiently safe and secure to report and discuss negative clinical events without fear of reprisal or punishment. Such reflective practice is likely critical to increasing staff expertise in providing psychological treatment.

Practice Implications

Psychotherapists often do not think about the organizational context within which they work when considering the treatment they provide to those with mental health issues including people who may attempt suicide. Yet many psychotherapists work within an organizational context (e.g., hospitals, group practices, clinics, community health care centers, etc.). The findings from this study indicate that stability in staffing (i.e. low turnover) and working within a system that encourages reporting and discussing negative events likely has a positive impact on mental health outcomes like suicide.
Common Factors Across 5 Therapies for Suicidal Patients with Borderline Personality Disorder

Sledge, W., Plukin, E.M., Bauer, S., Brodsky, B.,... Yoemans, F. (2014). Psychotherapy for suicidal patients with borderline personality disorder: An expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation, 1:16. doi:10.1186/2051-6673-1-16.

Treating patients with suicidal ideation and borderline personality disorder (BPD) can cause significant anxiety, concern, anger, and guilt in clinicians. Strong emotional reactions can lead to risky therapeutic interventions, poor clinical decisions, and professional burn out. The outcome of therapy can have serious consequences for such patients. Recently, a panel of 13 experts reviewed the efficacy of the most common treatments for suicidal ideation in BPD. As part of the review, they identified the common factors that may be useful for all clinicians who work with these clients. The five therapies they reviewed included the following. Dialectical behavior therapy, which emphasizes the role of emotional dysregulation and impulsivity in suicide. Treatment includes distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Schema therapy decreases suicide risk by challenging negative thoughts with cognitive and behavioral techniques while using the therapeutic relationship to improve the patient’s capacity to attach to others. Mentalization based therapy works toward improving the patient’s capacity to keep in mind the patient’s own mind and the mind of the other. This encourages new perspectives on relationships and emotion regulation. Transference focused psychotherapy views suicidal behavior in BPD as related to distorted images of the self and others. The treatment emphasizes gaining greater awareness of self in relation to others, and integrating a more realistic experience of the self. Good psychiatric management is an integrative approach that uses both psychodynamic and behavioral concepts. The approach sees BPD as a problem with interpersonal hypersensitivity, but the management tends to be more pragmatic than theoretically based. The expert panel defined six common factors among these treatments. (1) Negotiation of a frame for treatment – in which roles and responsibilities of therapist and patient are defined before the start of treatment, including an explicit crisis plan. (2) Recognition of the patient’s responsibilities within therapy. (3) The therapist having a clear conceptual framework for understanding the disorder that then guides the interventions. (4) Use of the therapeutic relationship to engage the patient and to address suicide actively and explicitly. (5) Prioritizing suicide as a topic whenever it comes up in the therapy. (6) Providing support for the therapist through supervision, consultation, and peer support.

Practice Implications

Suicidal ideation in patients with BPD can have serious consequences for the patient and can be highly stressful for the clinician. This expert panel identified six common features of most major treatment approaches to suicidal ideation in BPD. Even if clinicians are not explicitly trained in any one of the approaches, ensuring that these six factors are present in their work will improve the likelihood that their patients will experience a good outcome.

January 2015

Psychological Therapy After a Suicide Attempt: A Nationwide Study

Erlangsen, A., Lind, B. D., Stuart, E. A., Qin, P., Stenager, E., Larsen, K. J., ... & Nordentoft, M. (2014). Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: A register-based, nationwide multicentre study using propensity score matching. The Lancet Psychiatry. Early Online Publication: doi:10.1016/S2215-0366(14)00083-2.

Between 9 million and 35 million suicide attempts occur yearly in the world, and suicide accounts for over 800,000 deaths every year worldwide. Suicide attempts are associated with future attempts and with mortality. Within the first year, 16% of people attempt suicide again. Despite the occurrence of suicide attempts and its effects, there has been inconclusive evidence of the effectiveness of interventions to reduce future attempts and death. That is why this Danish nationwide study by Erlangsen is so important. Another impressive aspect of this study is its size and scope. Since 1992, psychological therapies have been offered to people at risk of suicide in specialized clinics throughout Denmark. The aim of Erlangsen and colleagues’ study was to assess if those who received these psychological interventions had a reduced risk of suicidal behavior and mortality compared to people who did not receive the interventions. The authors collected data from 1992 to 2010 from Danish national health registries. This procedure was possible in Denmark because the health system is nationally coordinated and each individual has a traceable national health ID. In order to be included in the study, those who were offered specialized psychological interventions had to receive at least one session of treatment. Therapy included cognitive behavioral therapy, problem solving therapy, dialectical behavior therapy, psychodynamic therapy, systemic therapy and others. The interventions consisted of up to 8 to 10 individual outpatient sessions. The comparison group received “standard care” that consisted of admission to hospital, referral to a general practitioner, or discharge with no referral. The primary outcomes were: repeated self-harm, death by suicide, and death by any other cause. Of the people receiving psychotherapy, 5,678 had useable data. The “standard care” sample was much larger and consisted of 58,281 individuals who were matched to the psychological intervention group on many variables including sex, age, education, antidepressant medications, and psychiatric diagnosis. For those receiving psychotherapy, the rate of repeated suicide attempts in the first year was 6.7% and 15.5% at 10 years. For those receiving standard care, rate of repeated suicide attempts in the first year was 9.0% and 18.4% at 10 years. The odds of another suicide attempt one year post treatment was 73% lower among those receiving psychotherapy. Death by any other cause at the 10 year mark was also significantly lower in the psychological therapy group (5.3%) versus the no-therapy group (7.9%). The authors estimated that over the 20 year span of their data, psychological therapy: prevented repeated suicide attempts in 145 people, prevented deaths by any other cause in 153 people, and prevented 30 suicide deaths. Psychosocial interventions were associated with fewer repeated suicide attempts in women but not in men, and adolescents and young adults benefited most from psychological therapies.

Practice Implications

This is the largest long term follow up study ever of psychological interventions after a suicide attempt. Psychotherapy was associated with reduced risk of self-harm and mortality in the short and long term. This was especially true for women and in adolescents and young adults. Those receiving psychotherapy might have been a select group resulting in biased results. However, the extensive matching of the psychotherapy group to the no-therapy control group reduced the likelihood that factors other than psychotherapy influenced the findings. The study indicates strong support for providing psychological interventions to people at risk of suicide.

This month...

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April 2017

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December 2016

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July 2016

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May 2016

Practice Implications

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January 2015

Practice Implications

Psychotherapy Practice Research Network (PPRNet)