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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
What Does a Good Outcome Mean to Patients?
De Smet, M. M., Meganck, R., De Geest, R., Norman, U. A., Truijens, F., & Desmet, M. (2020). What “good outcome” means to patients: Understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective. Journal of Counseling Psychology, 67(1), 25–39.
Many researchers consider the randomized controlled trial (RCT) as the best research design for testing medical and psychological treatments. However, critics of the design point to its limitations. For example, in order to collect homogenous samples of patients, researchers may exclude those with complex comorbidities. As a result, patient samples in RCTs may not represent patients one might see in real clinical practice. Also, researchers, and not patients, tend to define the meaning of what is a “good outcome” in these studies. It is possible that researchers and patients may not share the same definition of what it means to have a good outcome from psychotherapy. One key statistical and measurement method that researchers use to define outcomes is the reliable change index, which calculates the degree of change on a symptom scale from pre-treatment to post-treatment relative to the unreliability of the measurement. Using this method, researchers classify patients as “recovered” (reliably changed and passing a clinical cut-off score), “improved” (reliably changed but remaining in the clinical range), “not improved”, or “deteriorated”. However, this commonly used approach does not indicate whether the changes are actually meaningful to the patients. In this study, De Smet and colleagues interviewed patients from a randomized controlled trial of time-limited psychotherapy (16 sessions of CBT vs psychodynamic therapy) for depression who were classified as “recovered” or “improved” at post-treatment based on the reliable change index of a commonly used depression self-report scale. The authors asked how the patients experienced their depression symptom outcome, and what changes the patients valued since the start of therapy. In the original treatment trial of 100 patients, 28 were categorized as “recovered” and 19 patients were categorized as “improved”. During the post-therapy interview, the “recovered” and “improved” patients typically reported a certain degree of improvement in their symptoms. However, the patients categorized as “improved” reported that their gains were unstable from day to day, some reported having relapsed, and half did not feel that they improved at all. None of the “recovered” patients indicated that they felt “cured” of depression. Patients identified three domains of change that they experienced and valued. First, they felt empowered – that is, they had increased self-confidence, greater independence, and new coping skills. Second, they found a personal balance – that is, they had better relationships with loved ones, felt calmer, and had greater insight into their problems. Third, patients tended to identify ongoing struggles despite positive changes in the other domains – that is, certain key problems remained unresolved. “Improved” patients, and even some in the “recovered” group, indicated that their core difficulties had not been altered by the therapy.
Although measurement of symptom change can give a clinician a general sense of how the patient is doing with regard to their symptoms and whether the patient is on track, such measurement may not capture the complexity of patients’ experiences of the therapy and any broader changes they may value. Patients in this trial, especially those classified as “improved”, had varied experiences. Aside from symptom reduction, clinicians should assess what their patients may value, such as: better relationships, greater self-understanding, more self-confidence, and feeling calmer. Most patients, including some who “recovered”, felt that they were engaged in an ongoing struggle, even after therapy. These findings suggest that addressing some of the core difficulties patients face may require longer term psychotherapy.
Is Short-Term Prolonged Exposure Effective to Treat PTSD in Military Personnel?
Foa, E., McLean, C.P., Zang, Y., Rosenfield, D., Yadin, E… Peterson, A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. Journal of the American Medical Association, 319, 354-364.
Post-traumatic stress disorder (PTSD) can affect 10% to 20% of military personnel returning from combat. PTSD is often chronic and debilitating, and is associated with symptoms that are distressing, that lower quality of life, and that negatively impact family and loved ones. Prolonged exposure therapy (PE) has been tested in the past, and researchers have claimed that it is an efficacious treatment in civilians and veterans. PE is a form of behavior therapy and cognitive behavioral therapy characterized by re-experiencing the most traumatic event through remembering it and engaging with, rather than avoiding reminders of the trauma. In their treatment guidelines, the American Psychological Association (APA) proposed PE as a recommended treatment for PTSD. In this randomized controlled trial, Foa and colleagues assess if providing PE in intensive short time frame (massed exposure; 10 sessions over 2 weeks) was as effective as standard exposure (10 sessions over 8 weeks) for 370 military personnel in the US with PTSD. That is, the authors were interested to see if providing the same amount of therapy based on exposure in a shorter time was just as effective. They also compared the two versions of PE (massed and standard exposure) to two control conditions: present centred therapy (PCT) that is largely supportive therapy that does not rely on exposure to the trauma, and a no treatment control condition. The main outcomes were reductions in level of PTSD symptoms and reductions in PTSD diagnoses at post-treatment and up to 6 months post-treatment. Massed and standard PE were equally effective in reducing symptoms and diagnoses of PTSD compared to no treatment. However, PE was not more effective than PCT in reducing symptoms and diagnoses, and PCT was more effective than no treatment. Overall, reductions in PTSD symptoms and reduction in PTSD diagnoses were modest. Drop out rates were high at about 50% for all conditions.
Drop out rates were high and outcomes were modest for these short-term psychological treatments for PTSD in military personnel, such that over 60% still had a diagnosis of PTSD at 6 months follow up. And PE therapy did no better than a control condition (PCT) that simply provided support with no exposure to the trauma. These findings are similar to other research in this area. Psychotherapy for trauma may require more time to work, and perhaps different models of understanding and treating the disorder. As Shedler recently remarked, it takes at least 20 sessions/weeks before 50% of clients improve. So it may not be surprising that 2 or 8 weeks of therapy had only a small impact on PTSD symptoms.
Can a Unified Protocol Bring Together Diverse Evidence-Based Treatments?
Barlow, D.H., Farchione, T., Bullis, J.R., Gallagher, M.W., Murray-Latin, H.,… Cassiello-Robbins, C. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.2164.
One barrier to disseminating and implementing evidence-based treatments is that therapists have to learn to competently apply many different manualized protocols – at least one for each disorder that they treat (depression, anxiety disorders, eating disorders, and others). Barlow and colleagues argue that it is possible to unify many of these protocols under one umbrella, and so they created a unified protocol for this purpose. The unified protocol is an emotion-focused, cognitive-behavioral intervention that targets temperamental characteristics, particularly neuroticism and emotion dysregulation that underly anxiety, depressive, and related disorders. The unified protocol consists of motivational enhancement followed by 5 treatment modules: (1) mindful emotion awareness, (2) cognitive flexibility, (3) identifying and preventing patterns of emotion avoidance, (4) increasing awareness and tolerance of emotion related physical sensations, and (5) emotion-focused exposure. In this trial, 223 participants with an anxiety disorder (generalized anxiety, obsessive compulsive, panic disorder, or social anxiety disorder) were randomly assigned to the unified protocol, or to the evidence-based treatment specific to the disorder, or to a no-treatment wait-list condition. The sample size was large enough to test a hypothesis of equivalent findings between the two treatment conditions. The differences in changes to symptoms between the unified protocol and the specific interventions for each disorder were small and non-significant at post-treatment and at the follow-up assessments. The treatment conditions were significantly more effective than the wait-list control condition. There were no differences between the treatments in drop-out rates or treatment adherence.
It may be possible for therapists to competently learn to apply a single unified evidence-based treatment for a variety of anxiety disorders that has equivalent outcomes to currently recognized but separate treatment approaches. The unified protocol suggests that the temperamental factors underlying anxiety disorders (emotion dysregulation, emotion avoidance, cognitive inflexibility) can be targeted to treat a wide-range of emotional disorders.
Cognitive Therapy and Dynamic Psychotherapy for Major Depression in a Community Setting
Connolly Gibbons, M.B., Gallop, R., Thompson, D., Luther, D., Crits-Christoph, K., Jacobs, J., Yin, S., & Crits-Christoph, P. (2016). Comparative effectiveness of cognitive therapy and dynamic psychotherapy for major depressive disorder in a community mental health setting: A randomized clinical noninferiority trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.1720.
Dynamic psychotherapy is widely practiced in the community, but there remain very few trials assessing its effectiveness. Dynamic therapy targets individuals’ problematic relationship conflicts. Cognitive therapy on the other hand has been established as effective for major depression in a number of controlled trials. This study by Connolly Gibbons and colleagues was designed to test if dynamic therapy was equivalent (not inferior) to cognitive therapy in treating major depressive disorder in a community setting. There are two important and novel aspects to this research. First, the study takes place with community-based therapists in a community mental health setting. This means that the usual critique that randomized controlled trials do not speak to what therapists do with real patients in everyday practice is addressed in this study. Second, the sample size is large enough and the study is sufficiently powered so that one can make conclusions about non-inferiority (statistics geeks will know that making a hypothesis of non-inferiority, equivalence, or no difference requires enough power and a large enough sample size – something that is quite rare in psychotherapy trials). Twenty therapists who worked in a community mental health center were trained by experts in dynamic therapy or cognitive therapy. The therapists treated 237 adults with major depressive disorder with 16 sessions of dynamic or cognitive therapy. Therapists were followed the treatment manuals and they were judged by independent raters as competent in delivering the treatment. Patients on average got significantly better regarding depressive symptoms (d = .55 to .65), and there were no significant differences in the rate of improvement between dynamic and cognitive therapy patients (d = .11). There were also no differences between treatments on several measures of quality of life. A noteworthy finding was that about 80% of patients continued to have some depressive symptoms by the end of treatment even though they improved.
This study adds to research indicating that short-term dynamic psychotherapy is as effective as short term cognitive therapy for treating major depression. The study also indicates that the treatments under intensive supervision and training can be provided effectively by community therapists in real world settings. That 80% of patients continued to have some depressive symptoms suggests that the short term nature of the therapies may not have represented a large enough dose of treatment for most patients.
Is Exposure Necessary to Treat PTSD?
Markowitz, J.C., Petkova, E., Neria, Y., Van Meter, P.E., Zhao, Y., … Marshall, R.D. (2015). Is exposure necessary? A randomized controlled trial of Interpersonal Psychotherapy for PTSD. American Journal of Psychiatry, 172, 1-11.
Post-traumatic stress disorder (PTSD) is a condition caused by experiencing or witnessing a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. PTSD has a lifetime prevalence of 6.8%, which makes it a highly prevalent disorder. The main technique of empirically validated psychological treatments for PTSD involve exposing patients to safe reminders of the trauma including memories, with the intent of extinguishing the fear responses. This is the basis of cognitive behavioural therapy (CBT) with prolonged exposure, which is a consensus treatment for PTSD. However, not all patients benefit from CBT with prolonged exposure, and such treatment may be too difficult for some patients and therapists to tolerate. Markowitz and colleagues argued that PTSD symptoms reflect interpersonal issues including interpersonal withdrawal, mistrust, and hypervigilence. Interpersonal psychotherapy (IPT) is a time-limited efficacious treatment for depression that was adapted for this study for non-exposure based non-CBT treatment of PTSD. IPT was modified so that the first half of treatment focused on recognizing, naming, and expressing feelings in non-trauma related interpersonal situations. The second half of treatment focused on common IPT themes such as role disputes and role transitions. The authors argued that IPT helps individuals with PTSD gain mastery over social interactions and mobilize social supports. The authors conducted a randomized controlled trial that had a sufficient sample size to test a hypothesis of “non-inferiority”, that is to adequately test if PTSD and exposure based CBT were equally effective. Both treatments were compared to a progressive muscle relaxation (PMR) control condition. In all, 110 participants with chronic PTSD were recruited and randomized to IPT, CBT, or PMR. Most patients reported trauma of 14 years duration from either sexual or physical abuse, and half had a current comorbid depression. All three interventions resulted in large significant reductions in PTSD symptoms. IPT (63%) and CBT (47%) were not significantly different in rates of response (i.e., in which response was defined as 30% improvement in a clinician administered PTSD scale), but IPT had a significantly higher response rate than PMR (38%). Patients with comorbid depression were more likely to drop out of CBT with prolonged exposure than IPT.
The results of the study suggest that IPT and CBT with exposure were equally effective in reducing symptoms of PTSD. It is important to keep in mind that this is one well-conducted trial that needs to be replicated by independent researchers in order to establish if the findings are truly reliable. Nevertheless, the findings contradict the widespread belief that patients with PTSD require exposure-based treatment in order to improve. IPT may be another option for the treatment of PTSD, especially for patients who cannot tolerate the prolonged exposure. Patients with comorbid depression may have the most difficulty tolerating prolonged exposure therapy, and so they may benefit from IPT as an alternative. IPT may help patients gain abilities in social interactions and social support, which may make it easier for them to spontaneously expose themselves to recollections of trauma.
Interpersonal Psychotherapy and Cognitive Therapy for Depression
Lemmens, L.H.J.M., Arntz, A., Peeters, F., Hollon, S.D., Roefs, A., & Huibers, M.J.H. (2015). Clinical effectiveness of cognitive therapy v. interpersonal psychotherapy for depression: Results of a randomized controlled trial. Psychological Medicine, doi:10.1017/S0033291715000033
Generally, I prefer to report on meta analyses rather than individual studies mainly because findings from meta analyses are based on a larger number of studies and so are more reliable (see my November, 2013 blog). However, this study by Lemmens and colleagues represents a large clinical trial of 182 depressed patients who were randomized to cognitive therapy (CT), interpersonal psychotherapy (IPT), or a no-treatment control condition. The size of the trial provided the study with enough statistical power to test a hypothesis of non-inferiority of treatments. (A statistical note: A study finding of “non-inferiority” between treatments is sometimes unreliable because it is easier to detect such a finding with a small or poorly designed study. Studies with larger sample sizes provide greater statistical power, which in part makes a non-inferiority finding more reliable). A previous meta analysis showed both CT and IPT to be equally effective interventions for major depression. However, none of the studies in that meta analysis had sufficiently large sample sizes to reliably detect non-inferiority of interventions, none reported outcomes after post-treatment, and none of the studies used a no-treatment comparison condition. In their study, Lemmens and colleagues provided 16 to 20 sessions of individual therapy (45 minutes in length) to participants who met criteria for major depressive disorder. CT was based on Beck’s model and focused on identifying and altering cognitions, schemas, and attitudes associated with negative affect. IPT seeks to understand the social and interpersonal context of a patient’s depressive symptoms, and helps the patient to solve the interpersonal problem or change their relation to the problem, which may result in a resolution of the depressive symptoms. The study by Lemmens and colleagues was well designed in which: patients were randomized to conditions (CT, IPT, wait-list), 10 licensed therapists were expertly trained (5 CT therapists, 5 IPT therapists), and the therapies were competently delivered. Depressive symptoms significantly decreased for patients in both CT and IPT conditions with large effects, and these findings remained stable to 5 months post treatment. There were no differences between CT and IPT at post treatments and follow up, and both treatments were more effective than the waitlist control condition. Half of the sample had clinical improvements in symptoms, and 37% of patients were without depressive symptoms at 1 year follow up.
CT and IPT did not differ in the treatment of depression in the short (post-treatment) and long term (follow up). The study does not address why two very different treatments led to similar positive outcomes. The authors suggest two possible reasons: (1) different specific treatment pathways led to similar results, or (2) change was driven by factors common to both treatments like motivation and therapeutic alliance.