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.

November 2023

Psychological Therapies Improve Patient Quality of Life

Kolovos, S., Kleiboer, A., & Cuijpers, P. (2016). Effects of psychotherapy for depression on quality of life: Meta-analysis. British Journal of Psychiatry, 209, 460-468. https://doi.org/10.1192/bjp.bp.115.175059.

It is well-documented that depression is the most common mental disorder among adults and is associated with substantial impairments in quality of life. Quality of life refers to a range of life domains including social relationships, physical abilities, mental health functioning, role functioning, and engagement in daily activities. Several meta-analyses exist demonstrating that a range of different psychotherapies are effective in reducing depressive symptoms. Until this study by Kolovos, there wasn’t a meta-analysis looking at the effects of psychotherapies for depression on patients’ quality of life. In this study, the authors meta-analyzed 44 studies that included over 5000 adult patients with depressive symptoms. The psychotherapies varied from CBT to acceptance and commitment therapy, to interpersonal psychotherapy that were compared to a control group in a randomized controlled trial. Quality of life was measured pre- and post-treatment. Typically, quality of life was assessed in two domains – mental health quality of life was defined as personal satisfaction with the current psychological state, and physical health quality of life referred to perceived competence to perform and function in everyday activities. Global quality of life refers to an overall assessment of the mental health and physical health domains. The mean effect size of psychotherapy for global quality of life after adjusting for publication bias was g = 0.30 (95% CI 0.21–0.40) indicating a small but significant effect. For the mental health domain, after adjustment for publication bias, the mean effect size was g = 0.37 (95% CI 0.28–0.47) indicating a small to moderate effect of psychotherapy. For the physical health domain, after adjusting for publication bias the mean effect size was g = 0.13 (95% CI 0.01–0.25) indicating a small significant effect. For both the global measure of quality of life and the mental health domain, the effects of psychotherapy were larger when patients had more severe symptoms.

Practice Implications

Overall, the authors concluded that psychotherapy for depression has a positive impact on various domains of patients’ quality of life like their mental functioning, social and work relationships, and engagement in everyday activities. These findings are especially large for those patients with more severe symptoms who received psychotherapy. It is possible that as depressive symptoms lift, patients begin to have the energy, self-esteem, and concentration necessary to engage in everyday life activities.

October 2023

Psychotherapies for borderline personality disorder reduce suicide risk by half.

Setkowski, K., Palantza, C., van Ballegooijen, W., Gilissen, R., … Cuijpers, P. (2023). Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis. Psychological Medicine, 1–20. https://doi.org/10.1017/S0033291723000685

Borderline personality disorder (BPD) is characterized by severe functional impairments, high levels of distress, and a high risk of suicide. The prevalence rate of suicide attempts is very high ranging from 55% to 85%. As many as 85% of patients with BPD achieve remission (no longer diagnosed with BPD) within 10 years. Treatment guidelines consider psychological therapies as the first-line therapies for BPD. Several previous meta-analyses of these therapies have resulted in varying results – with some showing that specific treatments are effective but other studies not reporting the same results. Some of the inconsistencies across meta-analyses can be explained by the fact that there are as many as 10 tested bona fide therapies with relatively few trials assessing each one to a control condition. In this study, Setkowski and colleagues used what is known as network meta-analysis which allows one to compare relative treatment effects even if some treatments were not compared to each other in the same study. There are pros and cons to this approach that are too technical to get into here, but suffice it to say that the network meta-analysis methodology has sparked debate. In this network meta-analysis, the authors reviewed a total of 43 randomized controlled trials of psychological therapy for adults with BPD compared to a treatment-as-usual (TAU) control condition. The main outcomes were BPD symptom severity, suicidal behaviours, and dropping out of treatment (as an index of acceptability of the treatment). The authors found that dialectical behaviour therapy (DBT), Schema Therapy (ST), and Mentalization-Based Therapy (MBT) were more effective than TAU and generic treatments (i.e., therapy not specifically for BPD) for reducing symptoms of BPD. There was some evidence that Schema Therapy was the most effective treatment, but this was based on very few studies and so the authors did not consider this to be a reliable finding. When comparing psychological treatments with each other, no one treatment was more effective relative to another psychotherapy. Regarding suicide risk, no psychotherapy was significantly superior to treatment as usual. However, several treatments reduced the risk of suicidal behaviour by almost 50%. Schema Therapy and Transference Focused Therapy (TFP) both had the lowest dropout rates thus indicating high acceptability of these treatments for patients, but again these findings were based on very few studies.

Practice Implications

Although this study adds to the discussion of which therapy is best for BPD, the results are muddied by the small number of studies for each treatment approach. And, unfortunately, the network meta-analysis approach did not clarify the issues. The authors’ decision to split up therapies of the same orientation (e.g., psychodynamic, transference-focused, mentalization-based) into separate sub-categories made it even more difficult to draw conclusions because the number of studies of each sub-category is small. The authors concluded that there is not strong enough evidence to answer the question of which treatment is most effective for BPD. On the positive side, psychological therapies in general reduced the risk of suicide attempts by half.
Hope and Expectancy Factors

Constantino, M.J., Muir, H.J., Gaines, A.N., & Ouimette, K. (2023). Hope and expectancy factors. In The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness, (pp.131 – 153), S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors). American Psychological Association. https://doi.org/10.1037/0000358-007

In the early days of psychotherapy research, Jerome Frank wrote cogently about hope and persuasion as the bedrock of psychotherapy’s effectiveness. These days, researchers refer to hope as outcome expectations – or the prognostic belief that a given course of treatment will be helpful. One might consider outcome expectations to be a factor behind the placebo effect – or positive outcomes in the absence of a specific therapeutic ingredient. Whereas pharmacological researchers try to control or reduce the placebo effect, psychotherapists often cultivate and take advantage of outcome expectations to improve client outcomes. In this chapter, Constantino and colleagues review the research on outcome expectations. A meta-analysis showed a small but significant positive effect on outcomes, with outcome expectations explaining approximately 3% of clients’ post-treatment outcomes. This is not a large effect by any means, but significant enough for clinicians to consider how to make the best use of these expectations. One of the mechanisms by which outcome expectations might affect patient outcomes is through the development and maintenance of a therapeutic alliance. In another meta-analysis, early outcome expectations predicted better client-rated alliance during treatment, which in turn predicted better post-treatment outcomes. That is, the client’s outcome expectations could facilitate a collaborative bond with the therapist, which in turn is associated with good client outcomes.

Practice Implications

As a therapist, one should be realistic about the potential effects of therapy for a client while at the same time taking advantage of the potential benefits of a client’s outcome expectations. It might be useful for therapists to gauge the client’s early treatment expectations and to prioritize promoting hopefulness when a client’s expectations are unrealistically low. This might involve collaboratively developing achievable treatment goals and coming to an agreement with the client on how therapy will proceed to meet these goals. That is, to develop a therapeutic alliance as a means of promoting a client’s hope that the agreed-upon treatment plan is credible and will be helpful.

September 2023

Clients’ Negative Experience of Psychotherapy

Vybíral, Z., Ogles, B.M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023) Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2023.2226813

Psychotherapy research tends to focus on positive patient outcomes – or patients who get better. More recently, psychotherapy researchers have focused on negative outcomes and client experiences of negative events in psychotherapy. Approximately 5% of clients get worse, 20% of clients in clinical trials drop out, and about 66% of clients do not recover by the end of treatment. All of this suggests that some clients have negative experiences during therapy that may interfere with their progress. One can learn a lot from studying processes that do not go well. Potentially, therapists can learn what not to do, how to avoid pitfalls, how to recognize when the client has a negative experience, and how to repair an error. In this qualitative meta-analysis, Vybiral and colleagues reviewed 51 studies that recorded client statements from post-treatment interviews. Through qualitative analysis, the authors reported four major clusters representing clients' negative experiences, specific therapist behaviours within each cluster, and the percentage of studies in which clients noted these specific behaviors. The first cluster was Therapist Misbehaviors including therapists not listening (17% of studies), therapists not understanding (37%), therapists perceived incompetence (37%), therapists devaluing clients (56%), therapists judging (33%), and therapists using the client for their own benefit (27%). The second cluster was Hindering Aspects of the Therapeutic Relationship including therapists’ lack of empathy (44%), lack of trust in the therapist (21%), clients experiencing confusion (23%), and poor interpersonal match (25%). The third cluster was Poor Treatment Fit including negative evaluation of the procedures or practical aspects of treatment (33%), unmet client expectations about therapy (33%), lack of fit with the interventions (65%), and dissatisfaction with how therapy ended (50%). The fourth cluster was Negative Impacts of Treatment including that therapy was unhelpful (46%), that problems increased (37%), fearing the therapy process (50%), loss of hope (23%), unpleasant feelings during therapy (60%), negative thoughts caused by therapy (35%).

Practice Implications

This research indicates that the qualities of the therapist, the therapeutic relationship, the treatment provided, and the outcomes are key to clients’ perceptions of their therapy experience. A therapist's positive regard, genuineness, and empathy have long been considered necessary conditions for successful therapy. In addition, there is substantial research on the importance of the therapist and client developing a collaborative agreement on the goals of therapy and how therapy proceeds, that is – aspects of the therapeutic alliance. Therapists also must keep in mind that clients must develop realistic expectations of therapy like its duration, what gets discussed, and how therapy proceeds. Expectations are well-known predictors of client outcomes. Finally, therapists must monitor patient outcomes and processes, and modify what they are doing if the client experiences a precipitous increase in symptoms or a decrease in the alliance from one session to the next.
Preparing Patients for Psychotherapy

Swift, J. K., Penix, E. A., & Li, A. (2023, March 13). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000475

Many patients struggle with the start of psychotherapy. In fact, many patients drop out of psychotherapy within the first few sessions likely because of anxiety or their expectations not being met. One way of helping patients start therapy on the right foot is to prepare them for what to expect and how therapy will proceed. Patient preparation, also known as role induction, is the process of providing patients with education for psychotherapy to ensure they have accurate expectations of their role, their therapist’s role, a rationale for treatment activities, and approximate treatment duration. This discussion with patients often occurs early in therapy and sometimes in the initial assessment session. Therapists might provide the information on their websites, on paper when the patient comes to the first session, or verbally during the session. In this meta-analysis, Swift and colleagues did a systematic review of the research on patient preparation and found 17 studies on the topic that met their criteria. Patients who received role induction had more positive behaviours during the subsequent session (accurate knowledge, appropriate expectations, higher satisfaction) compared to patients who did not get the preparation (d = 0.64, 95% CI [0.25, 1.03], p < .01, r = .31). Patients who received pre-therapy preparation were 1.64 times less likely to drop out of therapy than those who were not given the preparation (95% CI [1.06, 2.53], p = .03). The overall effect on post-treatment outcomes (symptom reduction) was statistically significant, such that those who received the role induction were more likely to have better outcomes than those who did not (d = 0.33, 95% CI [0.11, 0.55], p < .01, r = .16), although the effect was small. The largest effect occurred when role induction focused on the expected roles of the patient and therapist and on the duration of therapy. Also, larger effects occurred when therapists provided patients with the information in person and verbally rather than in a written format.

Practice Implications

It might be useful to assess the patient’s knowledge of psychotherapy, including what they expect their roles to be, what the therapist’s role is, how treatment will proceed, and the expected duration of treatment. This information might lead to a discussion about what to expect and what is realistic in therapy and this discussion should occur at the very start of therapy. A therapist might provide more information on those areas in which a patient may misunderstand or may have unrealistic expectations. Regardless, it is a good idea to discuss patient and therapist roles and to provide a rationale for the treatment. Preparing patients will have a greater impact if therapists provide the information as part of a verbal discussion that is personalized to the patient and is culturally appropriate.

April 2023

Short-term Psychodynamic Psychotherapy for Depression

Wienicke, F.J., Beutel, M.E., Zwerenz, R. et al. (2023). Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data, Clinical Psychology Review.

Depression affects 264 million adults worldwide making it one of the most prevalent mental health conditions. Depression affects quality of life, health care costs, and mortality making it a leading cause of disability in the world. Previous meta-analyses have looked at psychological treatments for depression and found CBT, short term psychodynamic psychotherapy (STPP), interpersonal psychotherapy (IPT), and others are effective in reducing depressive symptoms among adult patients. STPP, for example, works by focusing on the underlying personality factors of the patient (defense mechanisms, emotion regulation, interpersonal style, self-concept, attachment) that may lead to depressive experiences. There are very few studies that look specifically at what patient characteristics are associated with better outcomes for a specific type of psychotherapy. The challenge with such patient level analyses is that most researchers report aggregated individual patient data at the study level thus possibly obscuring important variability among patients. In this meta-analysis, Wienicke and colleagues identified 13 studies of STPP compared to a control group. The authors were able to get 11 of the study authors to provide individual patient data of 771 participants. This allowed Wienicke and colleagues to do a meta-analysis of individual patient data. At post-treatment, STPP was significantly more efficacious than control conditions on measures of depression (d = -0.62, 95%CI [-0.76, - 0.47], p <.001), anxiety (d = -0.29, 95%CI [-0.45, -0.12], p <.001), general psychopathology (d = -0.38, 95%CI [-0.59, -0.17], p <.001), and quality of life (d = 0.44, 95%CI [0.23, 0.64], p <.001). At follow-up, STPP was again superior to control conditions on depression outcomes (d = -0.21, 95%CI [-0.38, -0.05], p = .011), but not more efficacious on other outcomes. When the authors looked at individual patient characteristics related to outcomes, they found that length of the current depressive episode was found to moderate post-treatment depression levels, such that STPP was more efficacious for participants reporting longer rather than shorter episode durations (d = -0.006, 95%CI [-0.01, -0.001], p = .002).

Practice Implications

Like what was reported in previous meta-analyses, STPP was efficacious to reduce depressive symptoms in the shorter and longer term. Patients with a longer duration or chronicity of depressive symptoms experienced the most benefit from STPP. It is likely that individuals with longer episode durations have depressive symptoms that are more influenced by their underlying personality vulnerabilities resulting in more complex working alliances and transference feelings with therapists. Training in psychodynamic principles of treatment may allow therapists to identify and work with these therapeutic relational aspects if necessary.

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November 2023

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October 2023

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September 2023

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April 2023

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