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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.

September 2019

How Good is the Evidence for Empirically Supported Treatments?

Sakaluk, J. K., Williams, A. J., Kilshaw, R. E., & Rhyner, K. T. (2019). Evaluating the evidential value of empirically supported psychological treatments (ESTs): A meta-scientific review. Journal of Abnormal Psychology, 128(6), 500-509.

In the 1990s the Clinical Division of the American Psychological Association commissioned a Task Force to identify “Empirically Supported Treatments” (EST). The Task Force decided that psychotherapies that repeatedly showed statistically significant improvements over no treatment, placebos, or another treatment would be designated as “Strongly” supported. They also designated some treatments as “Modestly” supported or with “Controversial” support. The EST movement continues to have a great impact on the practice, research, and funding of psychotherapy. Time-limited, diagnosis-focused therapies, tested in randomized controlled trials became the “gold standard”. Clinicians are expected to practice these ESTs, research agencies focus funding on these models, and some governments and insurance companies provide reimbursements only for these types of therapy. The Empirically Supported Treatments (EST) movement redefined the practice of psychotherapy as short-term, symptom-focused, technically-oriented, and mostly cognitive-behavioral. In this meta-scientific review Sakaluk and colleagues asked: how good is the evidence for the ESTs? The authors were particularly concerned with the quality of the studies from a methodological and statistical point of view: how likely was it that these findings could be replicated, or how reliable were the findings? The good news is that there were few instances (about 10%) of research supporting ESTs in which researchers mis-reported the statistics (i.e., error in the reporting of statistical findings). This is quite a bit lower than previously identified mis-reporting rates (about 50%) in psychological research in general. However, only about 19% of ESTs were supported consistently by high quality studies. Over half of ESTs were supported consistently by poor quality studies. Most of the studies supporting ESTs were not sufficiently powered to detect differences between treatments or conditions. That is, often the sample sizes of patients in the studies were too small, and so the significant results were not likely reliable or perhaps not plausible. Also, those therapies that the EST list defined as having “Strong” support were not backed by more higher quality research compared to therapies considered to have “Moderate” support. In other words, the decision to designate treatments as “Strongly” or “Moderately” supported appears to have almost no relationship with the quality of the research.

Practice Implications

Embedded in this dense methodological paper are some troubling findings and important practice implications. The authors suggested that there are a number treatments on the EST list that have dubious research support because the studies of those treatments may not stand up to replication (a critical test in scientific research). It is not clear that ESTs are any more effective than other bona-fide psychotherapies that are not on the list. (Bona-fide psychotherapies are those that are based on a psychological theory, delivered by trained therapists, and in which the patient and therapist develop a relationship). The findings question whether dissemination of and training in ESTs to the exclusion of other psychotherapies can be justified given the quality of the evidence. In other words, it is possible that other bona-fide psychotherapies that are not on the EST list may be just as effective. This does not imply that psychotherapy is not effective or that anything goes when it comes to the practice of psychotherapy. Evidence-based practice in psychotherapy should guide psychotherapists’ clinical choices. However, the EST list is not the final word on what constitutes “evidence-based” practice in psychotherapy, or on what treatments should be researched and funded.
A Critical Look at Some Meta-Analyses of Cognitive-Behavioral Therapy

Wampold, B.E., Flückiger, C., Del Re, A.C., Yulish, N.E., Frost, N.D., …Hilsenroth, M. (2017) In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy, Psychotherapy Research, 27, 14-32.

The vast majority of meta-analyses of studies that compare different brands of psychotherapy for any particular disorder indicate that differences between treatments are quite small and clinically trivial. Meta-analyses are an important way of aggregating effect sizes across studies and of providing reliable estimates of the state of a research field. But meta-analyses are not perfect - they rely on judgements made by the researchers that may bias findings. Despite a large body of evidence to the contrary, three meta-analyses in particular have purported to demonstrate that cognitive-behavioral therapy (CBT) is superior to other therapies for some specific disorders. In this paper, Wampold and colleagues critically review these three meta analyses to see if in fact CBT is superior to other psychotherapies. A meta-analysis by Tolin that reported that CBT was more efficacious than other therapies for anxiety and depression was surprising given that it contradicted 5 previous meta-analyses. It turns out that Tolin misclassified some treatments as CBT (including eye movement desensitization and reprocessing [EMDR] and present-centred therapy [PCT]). Further, Tolin made a critical computational error with one of the studies that when corrected wiped out any superiority for CBT. A second meta-analysis by Marcus and colleagues reported small differences in favor of CBT for primary (i.e., target symptoms) outcomes at post-treatment but not at follow up. Wampold and colleagues reported that the small difference at post-treatment was unduly affected by one study in the meta-analysis that showed unusually large effect in favor of CBT (i.e., the study was likely unreliable because its results were so much out of line with all other studies). Further, the purported superiority of CBT disappeared in the longer term. Finally, a meta-analysis by Mayo-Wilson and colleagues published in the prestigious journal Lancet Psychiatry used a network meta-analysis to compare treatments, and reported that CBT was more effective than other psychotherapies. Network meta-analysis relies heavily on indirect comparisons rather than including only studies that directly compared two therapy modalities. For example, if there are only a few studies that compare treatment A to treatment B (AB), one could look at studies of treatment A versus treatment C (AC), and studies of treatment B versus treatment C (BC), and then use the transitive property (remember high school math?) to estimate the effect of AB indirectly from the studies of AC and BC. It turns out that this practice in the context of meta-analysis is unreliable and can grossly over-estimate differences between treatments.

Practice Implication

The vast majority of meta-analyses show that bona-fide psychotherapies are effective, and one therapeutic orientation does not seem to be superior to another. The three meta-analyses that run counter to this conclusion are deeply flawed. To claim that one treatment is more effective than another will limit patients’ access to other treatments. This is concerning, since most time-limited treatments result in about half of patients recovering from their mental health problems. And so many patients and their therapists need more therapeutic options to draw upon. Falsely claiming that one treatment is more effective than others may lead insurance companies and government policy makers to make erroneous decisions to fund only one type of therapy.
Therapeutic Alliance and Outcomes in Couple and Family Therapy

Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance–outcome relation in couple and family therapy. Psychotherapy, 55(4), 356-371.

In individual psychotherapy the therapist’s tasks include to develop an alliance with one patient. Goals and tasks of therapy need to be collaboratively negotiated, and therapists need to develop an emotional bond with the patient. The alliance also has to be nurtured continuously throughout treatment. This process is more complicated in couple and family therapy. Only in couple and family therapy (and in group therapy) does a therapist have to develop an alliance with multiple people simultaneously. The challenge is greater when family members are in conflict, or when the therapist’s alliance is stronger with one member than another. Such “split” alliances can be problematic especially when family members view their experiences of the therapist differently. To complicate things more, therapists have to be aware of the alliance within the family or couple system. That is, are the family members allied with each other – do they agree on therapy goals and tasks, and are they able to maintain an emotional connection to each other? In addition, just as therapeutic alliance ruptures can occur in individual therapy, so can they occur in couple and family therapy. An alliance rupture may occur when a there is a “split” alliance or when a patient responds to the therapist or other family members with confrontation or withdrawal behaviors. In this meta-analysis of therapeutic alliance in couple and family therapy, Friedlander and colleagues included 48 studies with a total of 2,568 families and 1,545 couples. The correlation between quality of the alliance and outcome was significant (r = .297, 95% CI [0.223, 0.351], p < .001), indicating that a stronger alliance was related to better outcomes. There was some evidence of publication bias suggesting that this estimate may be over-inflated, but even after adjusting for publication bias the correlation was still significant. The correlation between split alliances and outcome was also significant (r = .316, 95% CI [0.157, 0.458], p < .001), indicating that more split alliances contributed to poorer outcomes. The correlations were similar in strength both in couple and in family therapy, and the alliance was important in all therapeutic orientations. However, correlations were larger when the targeted child in the family was younger, and when families were seeking help and not mandated.

Practice Implications

Like in individual therapy, the therapeutic alliance in couple and family therapy is important to improve the outcomes of patients. Regardless of therapeutic orientation, therapists must spend time and effort developing therapeutic alliances with each member of the system, and must try to maintain relatively equal alliances with each family member to avoid splits in the alliance. Therapists should be particularly aware of any confrontation and withdrawal behaviors towards the therapist or within the family or couple as these may indicate an alliance rupture. In such instances, therapists should emphasize shared goals and feelings, validate the common struggle among family members, and focus on the emotional bond with the disaffected patient. Each person’s alliance matters, and family member alliances are not interchangeable. Assessing the alliance with each member throughout therapy will identify potential problems and facilitate better outcomes.

August 2019

Whose Anxiety Are We Treating?

Nehrig, N., Prout, T.A., & Aafjes-van Doorn, K. (2019). Whose anxiety are we treating, anyway? Journal of Clinical Psychology. Online first publication.

Evidence-based practice (EBP) in psychotherapy is defined by the American Psychological Association as the deliberate integration of: (1) the research evidence, (2) clinician expertise in making treatment decisions, and (3) client characteristics, preferences, and culture. The EBP statement was meant to supplant an older model of prescriptive psychotherapy practice that resulted in the creation of lists of empirically-supported treatments (EST). The ESTs were defined as: (1) manualized therapies, (2) shown to be efficacious in randomized controlled trials, (3) for patients with a specific diagnosed mental disorder. However, manualized therapies are not necessarily more effective than non-manualized treatments, and patients in randomized controlled trials may not represent those typically seen by therapists in everyday practice. Although EBPs are the current standard by which psychotherapists should practice, many therapists and organizations focus almost exclusively on the first of the EBP criteria (the research evidence of ESTs) to the exclusion of the second and third criteria (clinician expertise, and patient characteristics, preferences, and culture). In this review article, Nehrig and colleagues speculated about why this is the case by asking: “whose anxiety are we treating?” They argued that manualized therapies identified as ESTs reduce therapists’ anxiety caused by: uncertainty about treatment outcomes, the emotional toll of providing psychotherapy to people who are suffering, and the negative emotions (anxiety, despair, cynicism) that sometimes arises in therapists from the work. Nehrig and colleagues argued that ESTs provide therapists with a sense of control and certainty, while limiting therapists’ attention on relational challenges in the work of therapy. However, this emphasis on ESTs comes at a cost for therapists and patients. Therapists may not focus on developing skills to manage the relational challenges inherent in providing psychotherapy, greater certainty may reduce therapists’ engagement in sufficient self-reflection, and therapists may attend only to patients’ symptoms and not to the patient as a whole person. Nehrig and colleagues also discuss the preference for ESTs among institutions, insurance companies, and government funders of psychotherapy. ESTs reduce anxiety in these contexts because ESTs are seen by managers as methods to enhance accountability and standardization of treatment, to uphold standards of care, and to reduce potential liability. The short-term nature of most ESTs also assuages economic concerns for institutions and funders who wish to manage costs. However, this emphasis on short term manualized treatment also reduces psychotherapy from a complex interpersonal process with inherent uncertainty to one that resembles a clear-cut medical procedure that encourages top-down decision-making about clinical practice.

Practice Implications

Anxiety about the complexity of psychotherapy can cause therapists, institutional managers, and government funders to place greater value on ESTs rather than on clinical expertise of the therapist and patient characteristics. Patient characteristics, preferences, and culture are related to developing the therapeutic alliance and to patient outcomes. Astute therapists can learn to adjust their interventions to these patient characteristics, which may mean using clinical judgement to alter or deviate from a prescriptive manual. An EBP approach that integrates research, clinical expertise, and patient characteristics allows therapists to take into account transtheoretical factors known to affect outcomes like the therapeutic alliance, repairing alliance ruptures, empathy, and to use their clinical expertise to adjust their interpersonal stances to relevant patient characteristics, preferences, and culture.
An Historical Review of Interpersonal Psychotherapy

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.
Therapeutic Alliance in Child and Adolescent Psychotherapy

Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341-355.

Over the past decades there has been increasing research on the efficacy of psychotherapy for children and adolescents, but outcomes have not always been positive. Treatment of children and adolescents comes with challenges that are unique from those experienced in therapy of adults. For example, unlike most adults, children and adolescents may not be the ones to choose to attend therapy - that decision is often made by adults in their lives. Furthermore, psychotherapists must also develop and maintain a collaborative relationship with parents, on whom the therapist and child/adolescent rely in order to be able to engage in treatment. Because of the unique characteristics of working with children and adolescents, negotiating, developing, maintaining, and repairing the therapeutic alliance is potentially complex. The therapeutic alliance is defined as an agreement on tasks of therapy, an agreement on goals of therapy, and the relational bond between therapist and client. In this meta-analysis, Karver and colleagues reviewed 28 studies of psychotherapy with children and adolescents. The mean age was about 12 years, most children/adolescents had internalizing problems, but others had problems with externalizing behaviors, and substance abuse. Almost two thirds of the studies involved a version of behavior or cognitive behavioral therapy. The therapeutic alliance was measured from the perspective of the client, therapist, and/or the parent. The overall mean effect size of the alliance-outcome relationship was small to moderate: r = .19 (p < .01, 95% confidence interval [CI] [0.13, 0.25]). Larger effect sizes were seen in those therapies of children and adolescents with internalizing disorders (r = .19), and when the therapist – parent alliance was measured and correlated with outcomes (r = .30). In other words, a positive alliance was most important for internalizing disorders, and for the relationship between therapist and parent.

Practice Implications

The findings of this meta-analysis indicate that the therapeutic alliance, especially with the parent, is important to the outcomes of children and adolescents in psychotherapy. Clinicians should not only develop an alliance with the youth, but also with the parent/caregiver. Therapists should also consider measuring the alliance regularly during therapy as a means of heading off any ruptures (with the youth or the parent) that might endanger the therapy. The authors recommended using the Therapeutic Alliance Scale for Children – Revised with children/adolescents, and the Working Alliance Inventory with parents.

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