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 transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
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
April 2023
Preparing Patients for Psychotherapy
Swift, J. K., Penix, E. A., & Li, A. (2023). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy. Advance online publication.
Starting psychotherapy can be hard for some patients likely because they must face the unknown about themselves, the therapy process, and the therapist. Some patients might think that they must behave in a certain way, or they may have expectations of what might occur in therapy or about outcomes. Those expectations might be unrealistic, or they may be different from what their therapist intends. One road to success in therapy is for patients to know how to effectively engage with their psychotherapist. Role induction might be one means of preparing patients therapy and could include several activities. First, establishing rapport is key so that the patient and therapist experience an empathic bond. Second, providing an explanation of psychotherapy might include discussing why psychotherapy can be effective, what change the patient might experience, and how the therapy will work from session to session. Third, describing the roles of patient and therapist is key, including encouraging the patient to be open and honest, and discussing how the therapist might behave (directive/less directive, emotion/cognitive focused, and present/past focused). Fourth, anticipating challenges for the patient to complete therapy may also be useful to help patients deal with frustrations or thoughts of dropping out. In this meta-analysis, Swift and colleagues examined 17 studies in which patients who received a role induction were compared to those who were treated as usual. The overall effect of role induction on psychotherapy dropout was significant, OR = 1.64, 95% CI [1.06, 2.53], p = .03. Patients who were prepared were 1.64 times less likely to drop out than patients who were not prepared. The overall effect on posttreatment outcomes was also significantly in favor of role induction, d = 0.33, 95% CI [0.11, 0.55], p < .01, although the effect was small. In moderator analyses, preparing patients for therapy was more effective for older patients, when done by more experienced therapists, and when provided verbally as opposed to in writing.
Practice Implications
The research suggests that preparing patients for psychotherapy by establishing a relational bond, providing information on how therapy will proceed, and providing information on the roles of the patient and therapist can be useful to reduce dropouts and improve patient outcomes. It may be helpful for therapists to assess what a patient knows about psychotherapy and their expectations of theirs and therapists’ roles. Therapists can use this information to personalize the preparation for patients so that it helps them to understand patient and therapist roles, rationale for treatment, and how therapy works. The assessment may also help therapists to adapt therapy to patient preferences when feasible. Patient preparation works best if done verbally and personalized to a patient rather than giving the patient a generic written handout or directing them to a web page.
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.
March 2023
Psychotherapy for Borderline Personality Disorder
Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., Kernberg, O.F. (2023). Borderline personality disorder: A review. Journal of the American Medical Association, 329(8):670–679.
Borderline personality disorder (BPD) occurs in 0.7% to 2.7% of adults and has significant negative impacts on social, vocational, and psychological functioning (inability to hold a job, high rates of comorbid medical and mental health problems, high rates of suicide). Patients with BPD can experience intense anxiety and depressive affect and impulsive behavior. Comorbid rates of depression, anxiety, PTSD, or substance use are very high (30% to 85%). Rates of BPD are slightly higher for women (3%) than for men (2.7%). The etiology of BPD might include genetic factors that interact with adverse childhood events like sexual and physical abuse. BPD is characterized by sudden shifts between extremes of idealization (extremely positive views of self and others) and devaluation (extremely negative views of self and others). These shifts have a significant negative impact on self-image, emotion regulation, and interpersonal relationships. In this extensive review, Leichsenring and colleagues discuss the clinical management and psychotherapy of patients with BPD. A series of meta-analyses that included 75 randomized controlled trials of 4507 patients indicated that psychotherapy is efficacious in treating symptoms of BPD (SMD = -0.52 [95% CI: -0.70 to -0.33]). The meta-analysis looked at 17 studies that compared different forms of psychotherapy (DBT, psychodynamic, CBT, eclectic) and found no difference in the efficacy of these treatments. Stronger evidence was available for DBT and for psychodynamic therapy relative to usual care. DBT focuses on increasing a patient’s motivation and to identify problem solving strategies to help regulate emotions and interpersonal relationships. Psychodynamic therapy emphasizes identifying recurring patterns of behaviors related to self and others, exploring defense mechanisms related to avoidance, and discussing past experiences that influenced current problems. Despite the overall efficacy of psychotherapy for BPD, almost half of patients do not benefit from treatment. Although pharmacotherapy might be useful to reduce comorbid symptoms of depression and anxiety, the research suggests that medications are not effective in reducing symptoms of BPD.
Practice Implications
The treatment of patients with BPD is complicated by the interpersonal impact of the disorder on the therapist and on the therapeutic relationship. Often therapists might be embedded in the patient’s relational patterns of idealization and devaluation (“all good” and “all bad”) that can strain the therapeutic relationship. Sometimes therapists might have strong personal reactions to such patients (i.e., experience countertransference) which might manifest as anti-therapeutic behaviors on the part of the therapist (over- or under-involvement with the patient) which can be stressful. Leichsenring and colleagues make recommendations to help therapists manage the patient-clinician relationship such as: setting clear boundaries while maintaining empathy, developing and maintaining a therapeutic alliance including setting realistic goals, avoiding stigmatizing the patient as “difficult”, collaborating and communicating with other treating clinicians to avoid splitting (one as “all good” and the other as “all bad”), being aware of and managing one’s own feelings and reactions to the patient (countertransference), and using one’s knowledge of the patient’s biographical information (history of abuse) to help to understand the patient’s strong emotional reactions.
February 2023
Quality of Life Outcomes in the Psychological Treatment of Persistent Depression
McPherson, S., & Senra, H. (2022). Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes. Psychotherapy, 59(3), 447–459.
The World Health Organization ranks depression as the largest cause of global disability accounting for 7.5% of all years lived with disability. Persistent forms of depression contribute to years lived with disability due to its chronic nature and its association with low levels of social and physical functioning, high rates of suicide, and high health care use. One way to look at disability as an outcome is to assess quality of life, which refers to performance in daily and social functioning and satisfaction with these activities. In this meta-analysis, McPherson and Senra examine 14 randomized controlled trials of psychological therapies for chronic or persistent depression in adults. The control condition included no treatment, waiting list, treatment as usual, or only antidepressant medication. The psychotherapies were mindfulness-based cognitive therapy (MBCT), CBT, interpersonal psychotherapy (IPT), long term psychoanalytic psychotherapy (LTPP), and DBT. Chronic depression was defined as a course of depression of at least 2 years and/or non-response to at least two treatments. The quality of life measure had to assess satisfaction with physical health, psychological state, level of independence, and social relationships. In general, the psychological treatments were associated with improvements in patients’ quality of life at the end of treatment (N=11; g=0.24; 95%CI: 0.13, 0.34). At follow up, the effect size was g=.21 (95%CI: 0.10, 0.32). That is, the effects were significant and positive, but small. The psychological interventions resulted in improvements in patient functioning at the end of treatment, g=.35 (95%CI: 0.21, 0.48), which is consistent with previous meta-analyses showing small to moderate effects of psychological treatments for persistent depression. Although there were too few studies to properly assess differences between therapy types, MBCT, IPT, and LTPP in combination with antidepressant medications had the largest effects among the therapies studied.
Practice Implications
In international surveys, patients seeking treatment for depression, informal caregivers, and health professionals list quality of life and social functioning as just as important or as more important than symptom reduction. Yet, these outcomes related to quality of life are not often assessed in clinical trials. This meta-analysis of a modest number of studies, suggests that some psychological therapies (MBCT, IPT, LTPP), in combination with antidepressant medications have the largest positive effects on quality of life for those persistent depression.
Cognitive Behavior Therapy vs. Control Conditions and Other Treatments
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: A comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22, 105–115.
Depression is a highly prevalent mental disorder, with about 280 million people worldwide who have the disorder. Several evidence-based treatments are available for depression, including pharmacotherapies and psychotherapies. Cognitive behavior therapy (CBT) is the most researched type of psychotherapy for depression. To date there are 409 trials with over 52,00 patients. In this study, Cuijpers and colleagues conduct the largest meta-analysis of CBT versus control conditions (treatment as usual [TAU], no treatment, other active psychotherapies, and pharmacotherapy). Although early trials of CBT were of low quality (small sample sizes, high risk of bias), the quality of studies have improved over time. In this meta-analysis Cuijpers and colleagues found that CBT had a large to moderate effect compared to TAU or to no treatment (g=0.79; 95% CI: 0.70-0.89), suggesting that CBT is better than receiving no or limited treatment. These results were stable up to one year follow-up. One would have to treat 4.7 patients with CBT to see improvement in one patient relative to no or limited treatment. CBT was compared to other active treatments in 87 trials. CBT was no more effective than other psychotherapies such that the average difference was miniscule (g=0.06; 95% CI: 0-0.12). One would have to treat 63 patients with CBT for one patient to receive a better outcome relative to another psychotherapy. However, if differences did emerge between CBT and other psychotherapies, they were not reliable. The effects of CBT did not differ significantly from those of pharmacotherapies (anti-depressant medications) at the short term, but the effects of CBT were significantly larger than pharmacotherapies at 6–12-month follow-up (g=0.34; 95% CI: 0.09-0.58). However, these follow-up findings also were not reliable. Combined treatment of CBT plus anti-depressant medications was more effective than pharmacotherapies alone at the short (g=0.51; 95% CI: 0.19-0.84) and long term (g=0.32; 95% CI: 0.09-0.55), but combined treatment was not more effective than CBT alone at either time point.
Practice Implications
The authors concluded that CBT is effective in the treatment of depression compared to no or limited treatment in the short and longer term. Although CBT gets the lion’s share of attention in the psychotherapy literature, there is no evidence that it is more effective than any other form of psychotherapy or antidepressant medication in the short term. There is evidence that combined CBT and medications may be more helpful than medications alone for depression.
December 2022
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.