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.

June 2017

Costs and Benefits of Funding Psychological Services as Part of Medicare in Canada

Vasiliadis, H-M., Dezetter, A., Latimer, A., Drapeau, M., & Lesage, A. (2017). Assessing costs and benefits of insuring psychological services as part of Medicare for depression in Canada. Psychiatric Services in Advance.

About 20% of the population have a mental disorder like depression during their lifetime, and depression is associated with a number of negative health outcomes like mortality, health system costs, and low quality of life. Most patients prefer psychotherapy over medications, but there are significant barriers to accessing psychotherapy, with cost as the biggest barrier. Recently in the United Kingdom, a cost-benefit analysis was used to argue that the development of the Improving Access to Psychological Therapies (IAPT) program would pay for itself in five years. The IAPT is a system of reimbursing psychological therapies through the publicly funded National Health Service in the UK. Similar models are in place in France and Australia. Vasiliadis and colleagues also conducted an economic study in Canada to evaluate the cost-effectiveness of providing psychological services as part of Canada`s Medicare system. They did so by using economic modeling of incidences of depression among patients over a 40-year period, and assessing the relative costs and outcomes of increasing publicly funded access to psychotherapy compared with the status quo. They used known incidence rates for depression in the adult population (2.9%), and estimated health service use from the Canadian Community Health Survey (CHS), and estimated costs (hospitalizations, GP visits, specialist visits, seeing a psychologist or counsellor, antidepressant prescriptions) from provincial health billing manuals. They also used the existing research literature to estimate the average effects of psychotherapy for depression on various outcomes (quality of life, suicide and attempts, health service use, etc.). Adequate mental health services for depression was defined as either 8 sessions of psychotherapy or use of antidepressants. They found that 36.7% of Canadians with depression did not use mental health services, and only 67.4% of those who did access treatment received adequate care. In the economic models that were tested, increasing access to care resulted in a projected decrease in depression, suicidality, health system and societal costs. Increasing access would cost an additional $123 million per year, but savings to society in terms of reduced health system costs and increased productivity was $246 million per year. In other words, for every $1 spent by Medicare on psychotherapy, Canada would recoup $2 in reduced costs and increased productivity.

Practice Implications

The findings of this Canadian study echo those of similar economic studies done in the UK, France, and Australia. Increasing access to psychotherapy for depression through Medicare is more effective and less costly than the status quo. In fact this Canadian study may underestimate potential gains because it did not account for the increased use of the health system by depressed people with chronic medical conditions. Currently, public expenditures for mental health and addictions in Canada account for only 7.2% of the total health budget. An increase of 0.07% of the total health budget to cover psychological services would result in health care cost savings, improved mental health, reductions in disability, and increased productivity among Canadians.
Is the Alliance Really Therapeutic?

Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325.

The therapeutic alliance is often defined as the agreement between the client and therapist on the goals and tasks of treatment within the context of an affective bond. The alliance is associated with good treatment outcomes regardless of how it is measured, who measures it, when it is measured, and what type of therapy is offered. But researchers and theorists debate the causal role of the alliance in therapy. Is the therapeutic alliance simply a byproduct of an effective treatment (i.e. people begin feel better in therapy and therefore experience a better alliance)? Or is the alliance a client trait which is a necessary factor that enables effective treatments to work (i.e., some clients are better at developing an alliance which is required for therapeutic interventions to take hold). Or is the alliance a state-like factor that fluctuates over time and is therapeutic in and of itself (i.e., the growth in the alliance by itself is sufficient to induce symptom change). In this review of recent advanced methods to research the alliance, Zilcha-Mano provides an overview of statistics that model the session to session dynamic fluctuations and impacts of growth in the therapeutic alliance. She argues convincingly that for the most part, the alliance is not a byproduct of symptom improvement. Using this advanced methodology research indicates that session by session change in symptoms do not precede change in the alliance. The research supporting trait-like aspects of the alliance indicates that some clients are more adept than others at developing an alliance with their therapists. Therefore an early alliance in therapy indicates a client trait that provides a necessary context for effective therapies to do their work. However, research also shows that the alliance changes dynamically over the course of treatment, and that change in the alliance from a preceding session predicts change in symptoms in subsequent sessions. This indicates that alliance also has state-like elements that dynamically fluctuate and influence outcomes, which provides evidence that this aspect of the alliance is therapeutic in and of itself.

Practice Implications

The accumulating research evidence indicate that the therapeutic alliance is a key aspect of successful therapies. New research is showing how to best manage the alliance, like how to repair alliance ruptures. The research also indicates that the role of the alliance may differ according to client characteristics. Those clients who arrive for treatment with better trait-like characteristics (more adaptive representations of self, more adaptive relationships with others) may be better able to create a strong alliance early. For these clients, the alliance may not be highly therapeutic in itself, but rather set the context for therapy interventions to work. However, some clients find it difficult to maintain satisfying relationships with others including the therapist. For these clients, state-like changes in the alliance may be essential for treatment – that is, developing a strong alliance over the course of treatment may be therapeutic in itself to improve their interpersonal relationships outside of therapy.
Specific and Non-Specific Effects in Psychotherapy

Palpacuer, C., Gallet, L., Drapier, D., Reymann, J-M., Falissard, B., & Naudet, Florian (2016). Specific and non-specific effects of psychotherapeutic interventions for depression: Results from a meta-analysis of 84 studies. Journal of Psychiatric Research.

Specific effect in psychotherapy refer to those technical interventions that are based on a treatment model that are specific to a particular modality. For example, the effects on symptoms caused by transference interpretations, cognitive restructuring, or exposure might all be considered specific effects. Non-specific effects is a very broad term that sometimes refers to effects on symptoms caused by common factors across all psychotherapies like therapist empathy, therapeutic alliance, or positive regard. Non-specific effects has also been used to refer to any extra-therapeutic effects that are more peripherally related to treatments, like type of control groups used in a study, researcher allegiance, number of treatment sessions, or length of follow-up. In this meta-analysis of 84 studies of over 6000 participants, Palpacuer and colleagues examined the association between non-specific factors (defined as intervention format [group or individual], client demographics, number of treatment sessions, length of follow up, and researcher allegiance to one of the treatment modalities) and treatment outcomes for depression. First, they looked at whether the specific type of intervention (cognitive behavioral, psychodynamic, interpersonal, problem solving, and others) was associated with reductions in depressive symptoms. Second, they assessed if the non-specific factors added to the prediction of improved depressive symptoms and accounted for some of the effects of specific types of interventions. Similar to previous findings, all psychotherapies were significantly more effective than waiting-list controls. However, the effects of the specific intervention approaches became non-significant when the non-specific factors were included in the analysis. That is, non-specific factors seemed to account for some of the effects of the specific treatments. In particular, if the study was conducted in North America vs Europe (β = 0.55, 95% CI: 0.22; 0.90), if the researcher had an allegiance to a particular therapeutic approach (β = 0.29, 95% CI: 0.07; 0.52), or if the number of sessions was higher (β = 0.03, 95% CI: 0.01; 0.04) then depressive outcomes were better.

Practice Implications

This meta analysis of over 87 studies suggests that although various psychotherapies are effective, there remain questions about how and why they work. For example, the findings suggest that North American patients may have different expectations and higher responses to treatment, that a researcher's belief in the effectiveness of their favored intervention actually improves patients' outcomes, and that a higher number of sessions may also result in better outcomes. These factors appear to account for an important proportion of the specific effects of each type of psychotherapy.

May 2017

Lying in Psychotherapy: What Clients Don’t Tell Their Therapist

Blanchard, M. & Farber, B.A. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship, Counselling Psychology Quarterly, 29, 90-112.

Clients’ disclosure of their thoughts and feelings are key aspects of psychotherapy, and trust is at the heart of the therapeutic relationship. However clients are not always honest with their therapist. Clients may keep secrets, hide negative reactions to interventions, minimize, spin, or tell outright lies. In this study, Blanchard and Farber asked: “what do clients lie about in therapy and why”. The authors used a broad definition of dishonesty that included: consciously twisting the facts, minimizing, exaggerating, omitting, and pretending to agree with the therapist. The authors excluded delusions, repression, denial, and other forms of unconscious deception. Blanchard and Farber were particularly interested in client dishonesty about therapy itself and about the therapist. The authors conducted an online survey of psychotherapy clients recruited from a community sample in a U.S. city, and 547 adult clients responded. The sample was surprisingly similar to a therapy-using population reported in the National Survey on Drug Use and Health. Most clients were women (78%), White (80%), saw a female therapist (71%), received CBT (35.4%) or psychodynamic therapy (18%), and were treated for depression (64%) and/or anxiety (49%) disorders. The survey asked about a wide range of possible topics for dishonesty such as use of drugs or alcohol, desire for revenge, pretending to agree with the therapist, etc. With this broad definition of conscious dishonesty, 93% of clients reported lying to their therapist, in which the average number of topics lied about per client was 8.4 (SD = 6.6). Those who lied more often also reported a general tendency in their lives to conceal negative personal information (r = .45). Only 6.8% of clients reported having told zero lies in therapy. Some topics were highly endorsed by clients – for example, 54% endorsed lying about “how badly I really feel – I minimized”, 25% did not disclose “my thoughts about suicide” and “my use of drugs or alcohol”. Other topics (endorsed by 5% to 25% of clients) included lies about eating habits, self-harm, infidelity, violent fantasies, experiences of physical or sexual abuse, and religious beliefs. About 72.6% of clients lied about at least one therapy-related topic, including: “pretending to like my therapist’s comments or suggestions” (29%), “reason for missing an appointment” (29%), “pretending to find therapy more effective than I do” (28%), “pretending to do the homework” (26%), “my real opinion of the therapist (19%), “not saying I want to end therapy (16%), and “my therapist makes me feel uncomfortable” (13%). Other items were relatively rare in the sample including “my romantic or sexual feeling about my therapist” (5%). Survey respondents were then asked why they were dishonest. Reasons why clients were dishonest included: “wanting to be polite”, “I didn’t want my therapist to feel he was bad at his job”, “I didn’t want to look bad or feel embarrassed”, “I would feel bad if I told her it really didn’t help me”, “wanting to avoid my therapist’s disapproval”, and “wanting to avoid upsetting my therapist”.

Practice Implications

Using a broad definition of dishonesty, this study found that 93% of clients did not tell the truth in one way or another to their therapist. Concern about self-judgments (i.e., embarrassment) or external judgments (i.e., avoiding therapist’s disapproval) may lead most clients to be less than honest at some times. Over 70% of clients reported lying about an aspect of therapy itself or of the therapeutic relationship. Clients appear to be particularly sensitive to upsetting or disappointing their therapist. This suggests the importance of therapists monitoring the level of emotional safety, trust, and alliance in the therapeutic relationship. Therapists may have to accept a certain level of dissimulation by clients in the therapy. Engaging in empathy, positive regard, and a focused attention on the therapeutic relationship may be important for therapists in order to overcome a level of fear or distrust among some clients about their self-judgement or the therapist`s judgment. These findings suggest that clients may benefit from therapists who receive training in identifying and resolving therapeutic alliance ruptures.
What is the Therapist’s Contribution to Patient Drop-out?

Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2028.

Sometimes patients experience negative outcomes in psychotherapy. For example, some patients drop out of therapy (i.e., they unilaterally decide to leave therapy before making any progress or before the endpoint planned with the therapist). In a previous meta-analysis of 669 studies, dropout rates ranged from 17% to 26% in psychotherapy trials. In this study, Saxon and colleagues were interested in the therapist effect on drop out. In other words, what is the impact of the individual therapist on negative outcomes like patients unilaterally terminating treatment? To examine the therapist effect one can look at differences between therapists in the average number of patients who drop out within their caseload. The authors looked at over 10,000 patients seen by 85 therapists from 14 sites in the United Kingdom initiative for Improving Access to Psychological Therapies. Therapists were selected if they saw more than 30 patients, and patients were included if they attended more than one session of therapy. Patient mean age was 40.3 (SD = 13.0), 71.2% were women, most were White (95%) and employed (76%). Of all the patients, 76.8% had some level of depression and 82.7% had some level of anxiety. Over 90% of the patients scored in the clinical range for symptom severity at pre-treatment. Patient symptom severity seen by a particular therapist was controlled in this study so that therapists who tended to treat severe cases were not penalized (i.e., case mix was controlled). Patients who dropped out represented 33.8% of the sample, with over half of these patients unilaterally terminating before the third session. The mean number of sessions for treatment completers was 6.1 (SD = 2.68). Therapist differences (i.e., the therapist effect) accounted for 12.6% (CI = 9.1, 17.4) of the patient drop out variance. In other words, about a quarter of therapists had a significantly greater number of drop outs compared to the average therapist. The mean dropout rate for the average therapist was 29.7% (SD = 6.4), the mean dropout rate for the above average therapist was 12.0% (SD = 7.3), whereas the mean dropout rate for the below average therapist was 49.0% (SD = 10.4).

Practice Implications

Who a patient gets as a therapist appears to have an important impact on whether the patient remains in therapy. Almost half of clients dropped out if they saw a poorly performing therapist (and nearly a quarter of therapists were poorly performing). By contrast, highly performing therapists only had a 12% drop out rate. Therapist variables that are known to be related to negative outcomes like dropping out include: lack of empathy, negative countertransference, and disagreements with patients about the therapy process. Previous research showed that therapeutic orientation is not related to negative outcomes. Therapists who are perform below average on when it comes to patient dropout might be able to use progress monitoring or some other means of measuring their patients’ outcomes to their advantage. These therapists may require more support, supervision, or training to improve their patients’ outcomes.
Effectiveness of Psychodynamic Couple Therapy in a Naturalistic Setting

Hewison, D., Casey, P., & Mwamba, N. (2016). The effectiveness of couple therapy: Clinical outcomes in a naturalistic United Kingdom setting. Psychotherapy, 53, 377-387.

Current randomized controlled trials (RCTs) of couple therapy indicate that about 60% to 70% of couples improve to some degree, and that about 35% to 50% are no longer distressed by the end of therapy. But RCTs have been criticized for being somewhat artificial because their design is based on how pharmacological treatments are tested. Psychotherapy may be more complex than pharmacotherapy in its implementation, and compared to pharmacotherapy, psychotherapy relies more heavily on the qualities of the therapist and therapeutic relationship in order to achieve good outcomes. In an RCT, individuals often have to have a specific disorder to be included in the study, and those with co-morbid disorders may be excluded. This may limit what the findings have to say about real world applications of a particular treatment. Further, therapists in RCTs may receive unusual levels of supervision and support that is seldom seen in regular clinical practice. In this large study of over 435 couples, Hewison and colleagues assessed the effectiveness of a psychodynamically-oriented couple therapy as practiced in a large not-for-profit centre that provides psychological treatment (i.e., the Tavistock clinic in the United Kingdom). All participants received couple treatment and none were randomly assigned to a control group. The couple therapy focused on insight and emotional connection and expression within the context of a therapeutic relationship. The couple relationship rather than the individual partners were the object of the therapy. The unconscious meaning of couple communication was often discussed, and therapist countertransference was seen as a source of information about the couple. Most couples in the study identified as White (77.0%), heterosexual (93.9%), and married or living in a civil partnership (58.4%). More than half of the couples were in the relationship for over 5 years and had children. Therapists were qualified couple therapists or Masters level trainees, had a mean age of 50 (range: 26 – 71), tended to be White women (60%), and were all trained at the clinic. The average number of sessions that a couple attended was 23.3 (SD = 23.5), but with a wide range (2 to 150 sessions) as might be typical in a clinical setting. Overall, individual clients reported a large significant decrease in individual psychological distress (d = -1.04), and a moderate significant decrease in marital distress (d = -0.58). Half of individuals showed a reliable reduction in their individual distress, and over a quarter of couples reported a reliable decline in their couple distress.

Practice Implications

This is the largest study of couple therapy in a naturalistic setting. The psychodynamic couple therapy was effective in reducing individual distress for almost half of the participants although reliable change in couple distress was lower. The results of this field trial indicate that couple therapy that is offered in a functioning real-world clinic setting produces results similar to what is seen in highly controlled randomized trials.

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June 2017

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Psychotherapy Practice Research Network (PPRNet)