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Alexandersson, K., Wågberg, M., Ekeblad, A., Holmqvist, R., & Falkenström, F. (2022) Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression. Psychotherapy Research, DOI: 10.1080/10503307.2022.2025626.

There has been a long-standing debate in psychotherapy about whether a therapist’s capacity to be adherent to treatment manual and to be competent in delivering specific treatment interventions leads to better patient outcomes. Some argue that rigid adherence may lead to worse outcomes, and meta-analytic research suggests that specific treatment adherence or competence has no impact on outcomes. Others argue that facilitative therapist behaviors (empathy, warmth, involvement, support) and the therapeutic alliance plays a more important role in whether patients get better. It is possible that psychotherapy research designs and rudimentary data analytic methods obscure the effects of therapist treatment adherence. In this study, Alexandersson and colleagues collected data from a randomized controlled trial of cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for depression. The researchers rated therapist behaviors (adherence to the treatment manual, facilitative behaviors) from recorded therapy sessions. They also assessed patient ratings of the therapeutic alliance after every session. Alexandersson and colleagues used a statistical modeling procedure that allowed them to look specifically at the effects of therapist adherence in a previous session on a patient’s depressive symptoms in a subsequent session. Their results did not show any effects of therapists’ use of specific CBT or IPT techniques on patient outcomes. Facilitative therapist behaviors in a previous session predicted better patient outcomes in the next session for CBT but not for IPT. The effects of facilitative therapist behaviors on outcomes were partially explained by levels of the therapeutic alliance. That is, facilitative behaviors among CBT therapists led to higher therapeutic alliance ratings by patients, which in turn led to lower patient depression scores in the subsequent session.

Practice Implications

The authors were a little surprised that facilitative therapist behaviors (empathy, warmth, involvement, support) led to better outcomes in CBT but not in IPT. They speculated that therapist relational competence might be especially relevant early in CBT to facilitate a strong alliance, which in turn reduces depressive symptoms among patients. The demanding tasks of CBT (behavioral activation, homework) might mean that therapists’ warmth, support and engagement are important precursors to patients benefitting from the therapy.

Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.

Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.

Practice Implications

Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.

Once-Weekly or Twice-Weekly Sessions of Psychotherapy?

Bruijniks, S., Lemmens, L., Hollon, S.D., Peeters, F.P., ….Huibers, M.J. (2020). The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients. The British Journal of Psychiatry, doi: 10.1192/bjp.2019.265. [Epub ahead of print].

Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.

Practice Implications

This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.

Ravitz, P., Watson, P., Lawson, A., Constantino, M.J., Bernecker, S., Park, J., & Swartz, H.A. (2019). Interpersonal Psychotherapy: A scoping review and historical perspective (1974-2017). Harvard Review of Psychiatry, 27, 165-179.

Interpersonal Psychotherapy (IPT) focuses on relationships and emotions, and emphasizes stressful interpersonal loss, life changes, relationship disputes, and social isolation as the causes and maintenance factors related to depression and other disorders. The IPT is predicated on the importance of relationships for survival and the bidirectional links between depression and problems with relationships and social support. IPT was first manualized in 1974 and used as a comparison condition in studies of pharmacotherapy for depression. Contrary to expectations, IPT did just as well as antidepressant medication in early treatment trials, thus giving rise to an important new psychological treatment. This scoping review by Ravitz and colleagues summarizes the development of IPT over the past 40 years. The review identified over 1000 articles of IPT, 133 of which were randomized controlled trials. Following the initial trials in the 1970s, IPT was included in the Treatment of Depression Collaborative Research Program in the 1980s, funded by the National Institute of Mental Health in the United States. This was the largest trial of its kind whose results indicated that patients with high baseline depression did best with medications followed by IPT, whereas CBT did not show significant advantage over the placebo condition. The 1990s to the mid-2000s saw a precipitous increase in randomized controlled trials of IPT in which IPT was: compared to other therapies, compared to medications, and/or provided in combination with medications. In addition, treatment trials of group IPT were conducted in low- and middle-income countries. These studies led the World Health Organization to publish and disseminate a group IPT manual. More recent research in the past decade has seen IPT offered in different formats (individual, telephone, group, internet), for different populations (adolescents, perinatal women, late-life), and in a variety of low- and high-income countries. Currently, there is good research support for the efficacy of IPT for depression, eating disorders, bipolar disorder, PTSD, and anxiety.

Practice Implications

Relationships play an important role in determining health, disease, vulnerability, recovery, and resilience. Because of the universal importance of relationships, IPT is relevant to mental health care across cultures and populations. Therapists should consider the importance of relationship loss and grief, role transitions throughout the lifespan, persistent conflicts in relationships, and social isolation when treating patients with depression and other mental disorders.

Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk

Levy, K.N., Kivity, Y., Johnson, B.N., & Gooch, C.V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta‐analysis. Journal of Clinical Psychology. Online first publication, DOI: 10.1002/jclp.22685.

Adult attachment refers to characteristic ways people manage their emotions and relationship styles. Securely attached individuals adaptively and flexibly experience emotions and they are able to give and receive love and support to others. Insecure attachment can be sub-categorized as avoidant or anxious attachment. Those who are anxiously attached tend to up-regulate their feelings so that they may feel easily overwhelmed, and they tend to be preoccupied with relationship loss. Those with avoidant attachment styles tend to down-regulate their emotions so that they have difficulty experiencing or expressing feelings, and they might dismiss the importance of relationships as a means of protecting themselves. John Bowlby, the founder of attachment theory, argued that psychotherapy had the potential to serve as a secure base from which individuals might explore themselves and relationships. He also described the therapist as a temporary attachment figure with which the patient might develop an emotional bond to promote change and for a corrective experience. In this meta-analysis, Levy and colleagues looked at whether attachment dimensions can change in psychotherapy and whether they can predict improvement in patient symptoms pre- to post-therapy. (A note on meta analysis. It is a method of systematically reviewing a research literature, combining the effect sizes in that literature, and summarizing these effects. Because meta analyses usually contain many studies, their results are much more reliable than the results of any single study, and so they provide the most solid basis for making practice recommendations). In this meta analysis, Levy and colleagues included 36 studies, totaling 3,158 clients. Higher client attachment security (or lower attachment insecurity) at the start of therapy was associated with better outcomes by post-treatment (r = 0.17, p < 0.001, 95% CI = [0.13, 0.22], k = 32). Also, greater improvement in attachment security (change in attachment security from pre- to post-treatment) predicted better outcomes (r = 0.16, p < 0.001, 95% CI = [0.07, 0.25], k = 15). When looked at separately, higher levels of either attachment anxiety or attachment avoidance were associated with poorer outcomes, and change in either type of attachment insecurity was associated with better outcomes. These effects appeared to be consistent regardless of the type of therapy (non-interpersonal vs interpersonal therapies).

Practice Implications

Although attachment insecurity is associated with poorer outcomes, change in attachment insecurity is possible with psychotherapy and this change is associated with better symptom outcomes. Therapists should expect longer and more challenging treatment with patients who are anxiously attached. Anxiously attached individuals may appear engaged early in therapy, but they are quick to anger, feel rejected, and become overwhelmed. Such individuals may benefit from help to contain their emotional experiences by repeating the treatment frame and increasing structure. They may also benefit from interpersonally-oriented therapy focused on reducing their preoccupation with relationship loss. Avoidantly attached individuals may appear aloof, but they may be easily overwhelmed by demands for closeness. Therapists may have to carefully balance the amount of interpersonal space or demands in treatment with these clients so that they remain in therapy.