Blog
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.
This month...
…I blog about the impact of COVID-19 on mental health workers' well-being, the impact of working alliance and therapist cultural humility on the impact of microaggressions, and ways of addressing cultural topics in psychotherapy
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
December 2022
The Therapeutic Alliance in Child and Adolescent Psychotherapy
Roest, J.J., Welmers-Van de Poll, M.J., Van der Helm, G.H.P., Stams, G.J.J.M., & Hoeve, M. (2022). A three-level meta-analysis on the alliance-outcome association in child and adolescent psychotherapy. Research on Child and Adolescent Psychopathology.
Much of the research and writing about the therapeutic alliance has focused on adult individual psychotherapy. However, there have been several recent meta-analyses of the alliance-outcome association in child populations. In one meta-analysis of 28 studies, for example, the mean alliance-outcome correlation was r = .19, which represents a small but positive effect. Most of these previous meta-analyses only looked at alliance rated at one time point (usually early in therapy) rather than focusing on the growth in the alliance across sessions. These previous meta-analyses also did not investigate the effect of alliance agreement on treatment outcomes (i.e., whether therapist and child were congruent in their ratings of the alliance). In this meta-analysis by Roest and colleagues, the authors tried to parse out these various factors that might affect the alliance-outcome association in studies of child and adolescent psychotherapy. The authors included 99 studies representing 8,496 children and 3,442 parents. They found that associations between child-therapist alliance and child outcomes (r = .17), growth in child-therapist alliance across sessions and child outcomes (r = .19), and parent-therapist alliance and child outcomes (r = 0.13) tended to be positive but small. However, associations between child-therapist alliance agreement (i.e., their congruence in alliance ratings) and child outcomes (r = .21) and the association between parent-therapist alliance and parent outcomes (r = 0.24) were positive and moderately large.
Practice Implications
It appears that the therapeutic alliance plays a role in positive outcomes for child and adolescent patients. Overall, the effects seem to be small, indicating that developing a good alliance may have a modest effect on a child’s outcomes. A more important effect might be noted in the agreement or congruence between therapist and child or adolescent client on their experience of the alliance. That is, a therapist who is more attuned to their patient’s experience of the therapeutic relationship might promote better outcomes. Attunement might require therapists to accurately reflect on the child’s experience of the relationship and of the therapist. Mentalizing (understanding oneself and others in terms of intentions and mental states) may be a key skill to develop for a therapist who works with children and adolescents.
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
Practice Implications
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.
November 2022
The Efficacy of Psychotherapies and Pharmacotherapies for Mental Disorders in Adults
Estimates of the efficacy of psychological or pharmacological treatments depend in part on to what they are compared. One might expect, for example, that these first line treatments for mental disorders may appear more effective if compared to no treatment and may appear less effective when compared to treatment as usual or a placebo. Reviews indicate that compared to no treatment, psychotherapies demonstrate a moderate effect (g = .67). However, some argue that comparisons to no treatment represent “weak” controls that over-estimate the efficacy of treatments. Compounding this problem is that poorly designed randomized controlled trials tend to result in larger estimates of effects in favor of the treatments. In this large umbrella review, Leichsenring and colleagues conducted a meta-analysis of meta-analyses of randomized controlled trials in which psychotherapy and medications are compared to no treatment, treatment as usual, placebo, and to each other. Different forms of psychotherapy (CBT, psychodynamic, interpersonal, EFT) were included. This meta-review had 3,782 randomized controlled trials representing 650,514 patients with a range of mental disorders (depression, anxiety, eating disorders, OCD, PTSD…). The authors’ analyses resulted in a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. Usually, this is interpreted as a small effect such that about 7 patients need to be treated before one achieves remission. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: –0.05 to 0.26) indicating no significant difference between the two types of treatments. The SMD for the combined psychotherapy and medication compared to either monotherapy (psychotherapy alone or medications alone) was 0.31 (95% CI: 0.19-0.44), suggesting that some patients achieve better outcomes if they got combined treatment, but again the effect is small. A troubling finding of this meta-review was that between 1% and 17% of studies were high quality, meaning that most studies likely resulted in biased (inflated) results for both treatments.
Practice Implications
Psychotherapy and medications, or their combination as practiced in randomized controlled trials appear to help a relatively modest proportion of patients. Most of these trials involved short term highly manualized interventions that do not address the diversity and complexity of patients seen by psychotherapists in real world practices. For example, studies in clinically representative contexts show that most patients require many more therapy sessions than provided in clinical trials. Psychotherapy researchers and clinicians need to refocus efforts on therapeutic factors (therapeutic alliance, progress monitoring) and therapist interpersonal stances (interpersonal skill, empathy, countertransference management) that likely impact patient mental health outcomes.
October 2022
Progress Feedback Narrow the Gap Between More and Less Effective Therapists
Delgadillo, J., Deisenhofer, A.-K., Probst, T., Shimokawa, K., Lambert, M. J., & Kleinstäuber, M. (2022). Progress feedback narrows the gap between more and less effective therapists: A therapist effects meta-analysis of clinical trials. Journal of Consulting and Clinical Psychology, 90, 559–567.
Some therapists are more effective than others. This is often referred to as the therapist effect. Somewhere between 1% and 29% of patient outcomes can be attributed to which therapist the patient receives. In general, therapists with high facilitative interpersonal skills, high humility, and an ability to withstand difficulties in practice (i.e., ruptures, burnout) may be more clinically effective. To improve outcomes in therapy, some have suggested using routine outcome monitoring and progress feedback. This involves regularly measuring and tracking patient progress with standardized self-report scales throughout treatment and providing the clinician with this information during therapy. Progress feedback allows the therapist to compare their patient’s progress against norms and against the patient’s own progress in preceding sessions. If the patient is not progressing or is deteriorating, then the therapist is alerted to address the issue. Research indicates that progress feedback makes therapy more effective. Less is known about how progress feedback leads to better outcomes. In this meta-analysis, Delgadillo and colleagues assessed the impact of progress feedback on the therapist effect – that is, does progress feedback improve the outcomes of less effective therapists? The meta-analysis was of six clinical trials with data from 4,549 patients and 131 therapists who were randomly assigned to a progress feedback condition or to a control condition without progress feedback. The variability between therapists (ICC = .011) suggested that 1.1% of the overall variance in patient outcomes was due to therapist effects. However, feedback was associated with a significant reduction in the therapist effect (ICC = .009) by 18.2%. A closer look at the data indicated that progress feedback narrowed the gap between more and less effective therapists, such that patients of less effective therapists benefitted the most from their therapist receiving feedback.
Practice Implications
In this meta-analysis conducted on data from controlled studies, there were few under-performing therapists. However, implementing progress feedback was clinically important to achieve better outcomes among some of these therapists. That is, even a single underperforming therapist could attain relatively poor outcomes with dozens or even hundreds of patients. Who the therapist is matters – and some therapists (and their patients) can benefit from supplementing clinical judgement with reliable feedback about patient progress throughout the course of psychotherapy.
August 2022
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
There are now hundreds of controlled studies showing the efficacy of psychotherapy for depression. Most of these studies have focused on specific age groups, so that psychotherapies were tested for children, adolescents, adults, and older adults separately. Few studies have looked at whether psychotherapy has different effects across age groups. This information might be important because it may indicate that some therapies might have to be altered or specifically designed for the age group. In this meta-analysis, Cuijpers and colleagues collected all randomized controlled trials of psychotherapy vs no treatment, usual care, or some other control group for depression across age groups. They found 366 studies representing over 36,000 patients. The studies included those of children, adolescents, young adults, middle-aged adults, older adults, and older old adults. The overall effect size across all age groups was g = 0.75 (95% CI, 0.67-0.82) suggesting a moderate effect of psychotherapy for depressive symptoms at post-treatment. The effect size for children was the lowest (g = 0.35, 95% CI: 0.15-0.55, k = 15), and the effect size for adolescents (g = 0.55, 95% CI: 0.34-0.75, k = 28) was also low. Effects for middle-aged adults (g = 0.77, 95% CI: 0.67-0.87, k = 304), older adults (g = 0.66, 95% CI: 0.51-0.82, k = 69), and older old adults (g = 0.97, 95% CI: 0.42-1.52, k = 10) were not significantly different. Young adults consistently had significantly better outcomes (g = 0.98, 95% CI: 0.79-1.16) than the other age groups except when compared to older old adults.
Practice Implications
It is possible that psychotherapies for depression as currently tested in the research literature are less effective for children and youth. This may be because the treatments that are most often used with children and adolescents are age adapted versions of therapy originally designed for adults. Psychotherapy for children and adolescents are affected by parental and family characteristics, and that these contexts may not be adequately accounted for by the therapies as currently tested and practiced. In any case, this meta-analysis suggests that current therapies for childhood and adolescent depression may need to be reconsidered given their relatively lower effects.
April 2022
Multicultural Competence and Orientation
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Therapist multicultural competence is a commitment to increasing one’s knowledge of patient’s cultural background, tailoring interventions to a patient’s culture, and understanding the impact of one’s own cultural background. Multicultural competence research has looked at its impact on clinical interactions. In a meta-analysis of 15 studies, therapist multicultural competence was associated with lower levels of patient drop-out from therapy (r = 0.26) and with greater patient improvement (r = 0.24). An interesting finding of these meta-analyses is that whereas patient ratings of a therapist’s multicultural competence was significantly associated with better patient outcomes (r = 0.38), therapist ratings of their own multicultural competence was not significantly associated with outcomes (r = 0.06). In other words, if one is interested in a therapist’s multicultural competence then one should ask the patient, not the therapist. A related but broader concept is multicultural orientation. The multicultural orientation framework is not so much a theoretical approach but a “way of being” for a therapist. The three aspects of multicultural orientation include cultural humility (in which a therapist takes an open and curious stance towards the patient’s identities), cultural opportunities (in which the therapist actively explores a patient’s cultural beliefs and values), and cultural comfort (or the extent to which a therapist feels at ease working with cultural dynamics). A systematic review of multicultural orientation theory identified 9 articles that found that therapist cultural humility was associated with better therapeutic alliances, fewer in-session microaggressions, and greater patient improvement.
Practice Implications
The research on multicultural competence suggest that therapists should regularly assess a patient’s cultural identities for adapting the therapeutic approach. This assessment should focus on the patient’s, not the therapist’s, evaluation of the therapist’s multicultural competence. It is also important for therapists to build their knowledge of specific cultural groups when tailoring their treatments. Regarding a multicultural orientation, it appears that a therapist’s cultural humility is critically important. That is a therapist who is open, non-defensive, and curious regarding a patient’s identities will be most helpful to patients of various cultures.