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 therapist empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
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 2023
Psychotherapies for the treatment of borderline personality disorder: A systematic review.
Crotty, K., Viswanathan, M., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Wines, R., Ratajczak, P., & Gartlehner, G. (2023, October 30). Psychotherapies for the treatment of borderline personality disorder: A systematic review. Journal of Consulting and Clinical Psychology. Advance online publication. https://dx.doi.org/10.1037/ccp0000833
Borderline personality disorder (BPD) is the most common of the personality disorders affecting about 1.8% of the population. BPD is particularly present in psychiatric outpatients (10%) and inpatients (15% to 25%). Those with BPD have severe functional impairment caused in part by high rates of comorbid mental disorders, substance use, self-harm, and suicidal ideation. Clinical practice guidelines recommend psychological therapies as the first-line treatment approach, with a particular emphasis on dialectical behaviour therapy (DBT). However, recent research shows that such treatment guidelines often do not rely on a systematic review of the literature that includes an analysis of the quality of the evidence. Low-quality evidence may not be reliable and lead to erroneous conclusions and recommendations. In this systematic review, Crotty and colleagues provide an update to clinical practice guidelines for BPD considering the quality of the evidence. The authors found 25 studies (20 of which were randomized controlled trials) of individuals 13 years and older diagnosed with BPD. These studies represented 2,545 participants in which a psychological treatment was compared to another treatment or treatment as usual (TAU). The most studied treatment in 6 studies was DBT. Other treatments included mentalization-based treatment, transference-focused psychotherapy, schema therapy, systems training for emotional predictability and problem-solving, dynamic deconstructive therapy, acceptance and commitment therapy, and CBT. Only 1 of the 25 studies had a low risk of bias (i.e., had no or few problems with randomization, data analysis, reporting of dropouts, sample size, blinding of assessment, etc.). Overall, TAU and the nine psychotherapies tested were effective in reducing the severity and symptoms of BPD. The authors did not find consistent evidence that DBT was superior to other psychotherapies.
Practice Implications
Psychological treatments in general are effective in reducing symptoms of BPD. However, the quality of the evidence is not high. Practice guidelines focus on DBT as a treatment for BPD, but this systematic review as well as previous meta-analyses, did not find that DBT was superior or that any psychotherapy is more beneficial than another. The authors concluded that generalized psychotherapies may be as effective as intensive specialized treatments for BPD that require expert training.
October 2023
How Reliable is the Research on CBT Plus ERP for Obsessive-Compulsive Disorder?
Reid, J.E., Laws, K.R., Drummond, L., Vismara, M. Grancini, B., Mpavaenda, D., Fineberg, N.A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.
Cognitive-behavioural therapy (CBT) combined with exposure and response prevention (ERP) is considered by many the treatment of choice for obsessive-compulsive disorder (OCD). However, questions remain about the size of its effects, the reliability of the research, and the relative efficacy of CBT plus ERP compared to other psychological treatments. Reid and colleagues conducted a systematic review and meta-analysis of randomized controlled trials of CBT with ERP in patients of all ages with OCD. They included 36 studies with 2000 patients (537 children/adolescents and 1483 adults) receiving treatment and 1015 in control conditions. When compared against all control conditions, CBT with ERP showed a significant and large effect (g = 0.74: 95% CI = 0.51 to 0.97 k =36). While CBT with ERP was more effective than a “psychological placebo” (e.g., progressive relaxation; g = 1.13: 95% CI 0.71 to 1.55, k = 10) and no treatment control conditions (g = 1.27: 95% CI 0.79 to 1.75), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI −0.27 to 0.16, k = 8). When compared to pharmacological treatment with an adequate dosage of selective serotonin reuptake inhibitors, CBT with ERP was marginally better with a small effect (g = 0.32: 95% CI -0.00 to 0.64, p = 0.05). Researcher allegiance or bias had a big impact on the effects of CBT with ERP. Researcher allegiance refers to studies conducted by researchers who prefer, favour, or have a vested interest in the treatment they are testing. In the studies identified as having researcher allegiance, a large favourable effect for CBT with ERP emerged (g = 0.95: 95% CI 0.69 to 1.2). By contrast, in trials where the authors did not identify researcher allegiance (k= 8), CBT with ERP showed no significant effects (g = 0.02: 95% CI−0.29 to 0.33). This difference was statistically significant (Q = 20.33, p < 0.005). There was no evidence of publication bias, but 28 of the 36 studies had a high risk of bias (in which there were deficiencies in the research design, procedures, or data analyses).
Practice Implications
At this point, CBT plus ERP is the most studied treatment for OCD, and it appears to be effective in reducing symptoms post-treatment. However, this meta-analysis raises more questions than it answers about the reliability of the research. Other active treatments (e.g., CBT without ERP) appear just as effective, which suggests that ERP may not be necessary to treat OCD. Researchers who favor or have a vested interest in CBT plus ERP produce much larger effects for their preferred treatment, and the quality of most of the research is low. Such findings lower one’s confidence in the conclusions drawn from the research.
September 2023
Psychological Treatment of Depression
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C.Y., ….Karyotaki, E. (2023). Psychological treatment of depression: A systematic overview of a ‘Meta-Analytic Research Domain’. Journal of Affective Disorders, 335, 141-151. https://doi.org/10.1016/j.jad.2023.05.011
About 280 million people worldwide suffer from depression, and this has enormous economic consequences for society. The main treatments for depression include pharmacotherapy and psychotherapy, with over 850 randomized controlled trials (RCTs)of psychotherapy assessing outcomes across all age groups. There are over 100 meta-analyses looking at the effects of psychotherapy for depression, but no single review of the entire literature exists. In this “Meta-analytic Research Domain”, Cuijpers and colleagues describe their attempts to develop a “living” systematic review that they updated regularly. In this update, the authors provide an overview of what has been learned from RCTs of psychotherapy in the treatment of depression. To start, they used the American Psychological Association's definition of psychotherapy as “the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviours, cognitions, emotions, and/or personal characteristics…”. The effects of psychotherapy for depression appear to be moderate. The overall response rate (50% reduction in symptoms) was 41% for psychotherapy and 16% for no treatment. Remission from depression (no clinically elevated depressive symptoms) at post-treatment was about 33%, whereas about 10% of patients in control conditions (no treatment or treatment as usual) remitted after therapy. These effects of time-limited psychotherapy are maintained in the longer term. Although CBT is the most studied therapy, there are no differences between different types of psychotherapy in the treatment of depression. Psychotherapy is effective across the lifespan, but the effects for children and adolescents tend to be smaller. Combined treatment of psychotherapy and pharmacotherapy was more effective than psychotherapy alone (RR = 1.27; 95% CI: 1.14-1.29) or pharmacotherapy alone (RR = 1.25; 95% CI: 1.13-1.37). Most patients in these studies had moderate to severe depression. The average response rate (50% reduction in symptoms) was 29% for psychotherapy or pharmacotherapy alone, but combining treatments resulted in 12% to 16% higher response rate. Psychotherapy was more effective than pharmacotherapy at 6 months to 12 months follow-up. One key downside of the research is that Cuijpers and colleagues classified only 31% of studies as having a low risk of bias (i.e., high-quality studies with sufficient sample sizes and other state-of-the-art procedures), and the risk of publication bias (suppression of negative findings) was high. Low-quality studies and publication bias tend to inflate the effects of treatments.
Practice Implications
There is a large and varied research literature on the effects of psychotherapy on depression. The authors noted no differences among the time-limited therapies, so bona fide and tested treatments will be equally effective. Overall, time-limited psychotherapy is modestly to moderately better than no treatment, with about one-third of treated patients no longer being depressed after time-limited psychotherapy. Results in more severely depressed patients are better with combined treatment of pharmacotherapy plus psychotherapy.
August 2023
Client Factors that Predict Outcomes
Swift, J. K., Owen, J., & Miller, S. D. (2023). Client factors. In S. D. Miller, D. Chow, S. Malins, & M. A. Hubble (Eds.), The field guide to better results: Evidence-based exercises to improve therapeutic effectiveness (pp. 47–78). American Psychological Association. https://doi.org/10.1037/0000358-004
Research over 5 decades has demonstrated that client contributions explain the majority of the variance in psychotherapy outcome. That is, patient factors are much more predictive than the type of therapy offered. Effective therapists adjust their interactions and interpersonal stances to relevant patient characteristics. Most demographic variables are not related related to patient outcomes (age, gender, education level, socio-economic status). In this chapter, Swift and colleagues review the research on patient factors that are reliably associated with improvements in psychotherapy. Here I review of few of these factors. Role expectations and preferences refer to patients’ beliefs and preferences about what is likely to happen in therapy – that is, type of therapy, type of therapist, how active or passive the patient or therapist will be, and how long therapy might last. Research indicates that pre-therapy education and preparation results in improved client outcomes (d = .34). Patients’ motivation is also associated with more engagement and better results. Therapists who tailor interventions to patient motivation level result in better outcomes (d = .41). Client attachment style is also associated with patient outcomes such that those with more secure attachments tend to experience greater symptom relief (d = .35), and that reductions in insecure attachment is also related to better outcomes. Finally, reactance or resistance refers to the emotional reaction of patients when they feel stressed or threatened. This may result in rejecting an intervention or therapist. A recent meta-analysis found a large positive effect (d = .79) when therapists of highly resistant patients took a more passive stance and when therapists of less resistant patients took a more active stance in therapy.
Practice Implications
Studies suggest how best to adapt interventions and therapist interpersonal stances for some patients based on their characteristics. Regarding expectations and preferences, therapists might spend time preparing their patients for what will happen in therapy and by collaboratively coming to an agreement on how therapy will proceed. Therapists should also tailor their interventions to the level of their patient’s motivation by focusing on supportive interventions when motivation is low (patients at the pre-contemplation stage of change), or helping the patient to set goals and make plans for changing behaviors when the level of motivation is moderate (patients at the preparation stage of change). For attachment insecurity, therapists who engage in interventions to help clients to experience more attachment security might see greater effects of therapy. These interventions might involve improving the patient’s quality of relationships, emotion regulation, and reflective capacities. The findings also suggest that therapists should be less directive with patients who have high levels of reactance or resistance but more directive for patients who have lower levels of reactance or resistance. These therapist interpersonal stances tailored to level of patient expectations, attachment style, motivation, and resistance have a better chance of engaging the client in therapy.
July 2023
Therapeutic Relationship Factors that Work
Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006
Next to patient factors that affect outcomes in psychotherapy, the therapeutic relationship is the most important predictor or contributor to patient outcomes. The therapeutic relationship is important to in-person therapy and to therapy delivered virtually. There is no scientific doubt of the importance of the therapeutic relationship on patient outcomes. The relationship is managed and cultivated by the therapist’s attitudes and behaviors. And so, it is not surprising that therapists differ in their ability to facilitate the therapeutic relationship. However, it is also possible for therapists to improve their therapeutic relationship skills through training and supervision. The therapeutic relationship is important to all therapeutic orientations. In this part of the chapter, Norcross and Karpiak review the research on relationship factors that work including therapist empathy, positive regard, developing a therapeutic alliance, and repairing alliance ruptures when they occur. Empathy occurs when a patient experiences a therapist who perceives and expresses an accurate understanding of a patient’s feelings, perspectives, and experiences. Empathic responding is one of the strongest predictors of patient outcomes with effect sizes ranging from moderate to large (d = .58), but only when it is rated by the patient. Therapist ratings of their own empathy has a much lower association with patient outcomes. Positive regard is the therapist’s genuine liking and expressed appreciation for the patient as a person. That is, a therapist’s verbal and nonverbal expression that they value, care about, and believe in the patient. The key here is genuineness – that the therapist’s words are consistent with their intentions and feelings. Positive regard expressed in therapy is moderately related to patient outcomes (d = .57). The therapeutic alliance refers to the warm emotional bond between patient and therapist, and their collaborative agreement on the goals of therapy and how they will work towards those goals. More than 300 studies of over 30,000 patients indicate that the alliance is moderately related to patient outcomes (d = .57), and this is a highly reliable finding. Ruptures in the alliance are characterized by patient withdrawal from the therapist or therapy, or by confrontation in which the patient criticizes or is dissatisfied with the therapist or therapy. Therapists’ attempts to repair alliance ruptures is moderately related to positive patient outcomes (d = .62), and this skill is most important for newer therapists and therapists with a CBT orientation.
Practice Implications
A positive therapeutic relationship has a much bigger impact on patient outcomes than the specific type of therapy used by therapists. A therapist who narrowly focuses on the content of what a patient says and rigidly adheres to a treatment manual will reliably have patients who have worse outcomes. Therapists whom patients experience as truly empathic (not just expressing sympathy for a patient), who can genuinely feel and express positive regard for a patient, and who can develop and maintain a therapeutic alliance and repair alliance ruptures reliably will have patients who have better experiences of therapy and better outcomes. These therapist skills and capacities can be learned through deliberate practice, supervision, personal therapy, and by maintaining a stance of flexibility, openness, and humility.
Therapist Factors Related to Patient Outcomes
Nissen-Lie, H.A., Heinonen, E., & Delgadillo, J. (2023). Therapist factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-005.
The thing about therapists that people in the profession do not like to talk about is that some therapists are more effective than others. Meta-analyses indicate that about 5% of patient outcome variance can be explained by differences between therapists. Although this seems small, it accounts for about one-third of the total difference in outcomes among patients. One study found that patient recovery rates for the most effective therapists were twice that achieved by their least effective counterparts. In another study, 15% more patients recovered when they saw an “average” therapist compared to one of the least effective clinicians. One key problem is that therapists consistently over-estimate their own effectiveness, and consistently under-estimate the percentage of their patients who get worse. This makes it difficult for therapists to correct course when necessary or to engage in targeted professional and personal development. In this chapter, Niessen-Lie and colleagues review the research that identifies key therapist qualities that are related to better patient outcomes. It turns out that demographics of the therapist (sex, gender, ethnicity, age), experience level, profession, and education level are all unrelated to patient outcomes. In fact, there is some evidence that more experienced older therapists have slightly poorer outcomes than their younger counterparts. However, some therapist factors are important and known to be related to patient outcomes. For example, therapists who are consistently effective across different types of patients, patient severity, and diagnoses have the best outcomes. Another key therapist factor or attribute is interpersonal skill. This includes therapist empathy, warmth, the capacity to express emotions verbally, the ability to develop a therapeutic alliance with a variety of patients, and the capacity to tolerate and manage strong negative emotions in therapy. A third therapist factor is flexibility. Therapists who can be flexible in using therapeutic techniques within a given treatment tend to have patients with better outcomes. Finally, therapists who can maintain an attitude of humility tend to have better outcomes. Humility refers to an openness to other’s points of view, accepting that there is room for growth, and for pushing beyond one’s current skill level while taking care of oneself. Without this attitude, there is little motivation for continued learning, personal growth, and professional development.
Practice Implications
A therapist’s experience level, profession, experience, and other demographics have no bearing on their patients’ outcomes. However, we do know that being effective with a range of patients, interpersonal skills (empathy, verbal expression of emotions, and ability to tolerate strong emotions), flexibility in applying therapeutic interventions, and professional humility are related to patient outcomes. These therapist skills can be developed and improved during one’s career. Improving these skills require a therapist to be willing to examining when things do not go well in therapy (reviewing when patient outcomes are poor or a patient drops out), to reflect on one’s abilities, and to look for disconfirming evidence by asking “could I be wrong?” First, however, therapists must identify when therapy with a patient was ineffective. And for this, they may need the help of standardized assessments to monitor the state of the therapeutic relationship and patient progress.