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.

August 2017

What Characterizes Effective Therapists?

Wampold, B. E., Baldwin, S. A., Holtforth, M. G., & Imel, Z. E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.

Practice Implications

Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.
Efficacy of Group Psychotherapy for Panic Disorder

Schwartze, D., Barkowski, S., Strauss, B., Burlingame, G., Barth, J., & Rosendahl, J. (2017). Efficacy of group therapy for panic disorder: Meta-analysis of randomized controlled trials. Group Dynamics, 21, 77-93.

Panic disorder (PD) is characterized by recurrent episodes of intense fear or discomfort accompanied by physical and cognitive symptoms that may include sweating, trembling, or fear of dying. The panic attacks can lead to avoidant behavior that results in isolation, impaired functioning and lower quality of life. Often, those with PD also experience agoraphobia or an intense fear of having a panic attack in public, open spaces, or in a crowd. PD has a lifetime prevalence of 5% among adults in the US. Patients with PD use health care services at a higher rate than the general population, and those with PD may not receive adequate treatment. An evidence-based treatment for PD is cognitive behavioral therapy (CBT). Practice guidelines for PD recommend pharmacotherapy and psychotherapy with CBT. However, these practice guidelines do not take into account group therapy for PD. In this meta analysis, Schwartze and colleagues included group treatment studies of PD that were randomized controlled trials (RCT) and in which direct comparisons of group therapy to other treatments were conducted. RCTs of direct comparisons provide the best quality evidence of the efficacy of a treatment approach. The authors included 15 studies (14 of which were of group CBT for panic) that had 864 patients. There was a large significant effect on panic and agoraphobic symptoms favoring group over no-treatment controls (k = 9; g = 1.08; 95% CI [0.82, 1.34]; p = .001). Similar results were found for depressive symptoms and general anxiety symptoms. There was no significant difference between group and alternative PD treatments (pharmacotherapy, individual therapy) on the primary outcomes (k = 6; g = 0.18; 95% CI [-0.14, 0.49]; p = .264). Again similar results were found for depression and anxiety symptoms. In total 78% of patients with PD were symptom-free after group psychotherapy, compared with 33% in no-treatment control groups, and 71% in alternative treatment.

Practice Implications

The number of studies were small, but the results of this meta analysis indicate that group therapy is an effective treatment for PD and perhaps as effective as typical alternatives like pharmacotherapy and individual therapy. Group CBT protocols usually involve multiple components such as (a) education regarding the etiology and maintenance of PD, (b) cognitive restructuring (identifying and modifying panic-related cognitions), (c) exposure to external situations (in vivo exposure) or internal bodily sensations (interoceptive exposure), (d) relaxation training and/or breathing retraining. Group therapy may also provide a lower cost, more accessible, and possibly as effective treatment alternative than individual therapy for PD.
Interventions for PTSD for Survivors of Mass Violence

Morina, N., Malek, M., Nickerson, A., & Bryant, R.A. (2017). Meta-analysis of interventions for posttraumatic stress disorder and depression in adult survivors of mass violence in low- and middle-income countries. Depression and Anxiety, DOI: 10.1002/da.22618

There is a high prevalence of post-traumatic stress disorder (PTSD) in countries that have experienced civil war and mass violence, and given the number of open conflict, the prevalence is likely increasing. Most people affected are from low- to middle-income countries. Both PTSD and depression confer a large personal, social, health, and economic burden especially when untreated. Research in Western countries show that psychological treatment of PTSD is effective, but there are practical barriers to transporting and adapting these interventions to low- and middle-income countries. In this meta-analysis, Morina and colleagues do a systematic review of psychological interventions for PTSD conducted of adult survivors of war in low- and middle-income countries. Treatments included trauma-focused cognitive-behavioral therapy, interpersonal psychotherapy, eye movement desensitization and reprocessing and several others. In total, 2,124 treated participants and 934 participants in the waitlist condition were included in the analyses. In the 18 trials that were included, symptoms of PTSD and depression were measured. The average drop-out rate was 11.5%. Across all active interventions (k = 16), a large pre–post effect size was found, g = 1.29; 95% CI = [0.99; 1.59] for PTSD. The average between-group effect size comparing active treatments versus control conditions at post-treatment was small to medium, g = 0.39; 95% CI = [0.249; 0.55], and at follow-up was large, g = 0.93; 95% CI = [0.56; 1.31], k = 10. Pre-post effect size for depression was equally large g = 1.28; 95% CI = [0.96; 1.61]. The effect size comparing active treatments versus control conditions for depression at posttreatment (k = 11) was large, g = 0.86; 95% CI = [0.54; 1.18], and at follow-up was medium to large, g = 0.90; 95% CI = [0.49; 1.33], k = 5.

Practice Implications

Evidence-based psychological treatments developed in high-income countries are also effective in reducing symptoms of PTSD and depression in adults who experienced war-time conditions in low- and middle-income countries. Although not directly tested, the evidence suggests that different evidence-based treatments were equally effective. Even if drop-out rates were low, practical barriers still existed, including the number of sessions of these treatments (average was 10 sessions), the need for trained personnel, and the need for face to face meetings. The authors suggested that collaborative care models should be evaluated and tested which aim to enhance the reach of efficacious treatments within primary care to optimize the number of patients who can benefit from these interventions.

July 2017

Cost-effectiveness of Short-term Versus Long-term Psychotherapy

Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., et al. (2016). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of Affective Disorders, 190, 254-263.

There is substantial evidence that short-term psychotherapy is effective for depressive and anxiety disorders, including at follow-up. There are also a few meta-analyses showing the effectiveness of longer term therapy. Although there is research indicating the cost-effectiveness of short-term treatments, less research has evaluated the cost-effectiveness of longer term therapy, and even less research at long term follow-ups. In this study from the Helsinki Psychotherapy Study Group, the authors evaluated the cost-effectiveness of short-term therapy (solution-focused therapy [12 sessions] or short-term dynamic therapy [20 sessions]) versus long term dynamic psychotherapy (2-3 sessions weekly for up to 3 years). Participants (N = 326) with anxiety or mood disorders were randomized to one of the three therapies. Symptoms and work ability were assessed at pre-treatment, post-treatment, and several times during a 5 year follow-up period. A previous publication with this sample showed that long-term treatment resulted in greater recovery with regard to symptoms and work ability (recovery for both outcomes exceeding 60%) compared to short-term treatment (50% recovered). For this study the authors asked: is long-term treatment cost-effective – in other words, is the better outcome from long-term treatment justified by greater cost? Both direct costs (health care utilization) and indirect costs (lost productivity) were calculated in this study using standard econometrics. Long-term therapy cost 3 times as much as short-term treatments. This amount was smaller than expected because those who received short-term treatments had higher auxiliary costs (i.e., the need for other treatments after the short term therapy ended). Shorter therapies were equally cost-effective, but both were more cost-effective than the longer treatment. That is, despite being more effective and requiring less auxiliary treatment, the longer-term therapy was more costly per unit of improvement with regard to symptoms and productivity compared to the shorter treatments.

Practice Implications

From an economic point of view, short-term treatments make the most sense. However, given that many patients needed other treatments after the end of short-term therapy, and given that on average the longer-term therapy was more effective in the long run, a clinician may want to weigh the economics with the specific needs and preferences of each patient.
Is Psychodynamic Therapy as Efficacious as Other Empirically Supported Treatments?

Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry (AJP In Advance)

Mental disorders are an important health concern that confer high levels of personal and economic burden. Up to 45% of primary care patients have at least one mental disorder. Many practice guidelines indicate that cognitive behavioral therapy (CBT), interpersonal therapy (IPT) , and specific pharmacotherapy interventions as empirically supported for common mental disorders. However, many psychotherapists practice psychodynamic therapy (PDT), and a number of reviews have provided evidence for the efficacy of short-term PDT compared to wait-lists, treatment as usual, and other forms of psychotherapy for depression and anxiety disorders. However, there also have been inconsistent findings with regard to the efficacy of PDT. A particularly strict test of efficacy of a therapy involves a comparison of the treatment to a rival intervention that has established efficacy. Such comparisons in which no differences are expected are referred to as equivalence trials. The problem is that no single study in psychotherapy so far is large enough to test for equivalence (technically, this refers to studies being statistically underpowered to detect a small effect), but a meta-analysis that combines samples from many studies can represent a large enough sample and be adequately powered. In this study, Steinert and colleagues conducted a meta-analysis of randomized controlled trials in which PDT was compared to a treatment established in efficacy. Outcomes included target symptoms (anxiety, depression, etc.) measured with reliable instruments. The authors found 21 randomized controlled trials with 2,751 patients, and all of the comparisons included CBT. Based on predetermined accepted standards, the authors decided that an effect size of g = -0.25 to +0.25 would indicate equivalence (i.e., a small and clinically not meaningful difference). Post-treatment differences between PDT and comparison treatments was g = -0.153 (90%CI: -0.227 to -0.079), and similar results were found at follow-up. In other words there were small, non-significant, and clinically not meaningful differences between PDT and other established treatments with accepted efficacy. The studies were rated as high in quality, there was no effect of diagnosis on the results, and there was no evidence of publication bias.

Practice Implications

This meta-analysis found PDT to be as efficacious as other treatments with established efficacy (i.e., CBT). The finding suggest that established practice guidelines may need to be revisited to include PDT. Response rates for anxiety disorders and depressive disorders (around 50%) for those receiving CBT, and even lower remission rates, indicate that there is room for improvement. Having other treatment options may be particularly important for patients who do not respond to one form of therapy and who may need to be switched to another type of intervention.
Are the Effects of Psychotherapy Inflated?

Driessen, E., Hollon, S.D., Bockting, C.L.H., Cuijpers, P., Turner, E.H. (2015). Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US National Institutes of Health-funded trials. PLoS ONE 10(9): e0137864. doi:10.1371/journal.pone.0137864.

In 2008 Turner published a well-known study in which he found that almost 50% of antidepressant trials registered with the Food and Drug Administration in the US were never published or were positively “spun” (i.e., essentially negative findings were interpreted to be positive). Almost all of the unpublished trials showed unfavorable results for the antidepressants’ effects. By contrast, the published studies were almost always were positive. This is evidence of publication bias caused by selective publication of some data and suppression of other data. As you can imagine, this has important implications for treatment of depression as the published record appeared to over-inflate effects of antidepressants by 25% (the mean effect size decreased from g = .41 [CI_95% 0.36~0.45] to 0.31 [0.27~0.35] when unpublished studies were included). Has the same type of publication bias occurred in the published record of psychotherapy’s efficacy? In this study by Driessen and colleagues, the authors reviewed all psychotherapy studies for depression funded by the National Institutes of Mental Health in the US between 1972 and 2008. They wanted to determine which ones were published, which were never published, and what the impact of nonpublication was on the mean effect size. Of the 55 grants that were funded, 13 (26.3%) were never published, and the authors were able to obtain data from 11 of those unpublished studies. The overall mean effect size (psychological treatment versus a control condition) of unpublished studies was g = 0.20 (CI_95% -0.11~0.51) indicating a small non-significant effect. The overall mean effect size for published studies was g = 0.52 (CI_95%0.37~0.68) indicating a medium significant effect. Adding the unpublished studies to published studies resulted in a 25% decrease in effect size estimate to g = 0.39 (0.08~0.70), indicating a small but significant effect of psychotherapy.

Practice Implications

This study indicated that psychotherapy is effective but that the effects are likely smaller than indicated in the published record. As in the case of antidepressant medication research, a minority of researchers may not publish findings that are not in line with their preconceived expectations or wished-for results. Regardless, there is certainly room for psychotherapy to improve. After decades of focusing largely on the efficacy of specific psychotherapies like CBT, psychodynamic therapies, and interpersonal therapy, perhaps it is time to shift to studying how and why therapies work, and which patients benefit from specific interventions. There are promising avenues such as research on: repairing therapeutic alliance tensions, enhancing therapist expertise, progress monitoring and feedback, client factors, and managing countertransference.

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August 2017

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July 2017

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Psychotherapy Practice Research Network (PPRNet)