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.

July 2017

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 Almost all of the unpublished trials showed unfavorable results for the antidepressants’ effects.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of antidepressants by 25% (the mean effect size decreased from g = .41 [CI_95% 0.36~0.45] to 0.31 [0.27~0.35] when unpublished studies were included).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55 grants that were funded, 13 (26.3%) were never published, and the authors were able to obtain data from 11 of those unpublished studies. The overall mean effect size (psychological treatment versus a control condition) of unpublished studies was g = 0.20 (CI_95% -0.11~0.51) indicating a small non-significant effect.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.

June 2017

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.

April 2017

Efficacy of Psychotherapies for Borderline Personality Disorder

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

February 2017

The Importance of Psychosocial Factors in Mental Health Treatment

Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.

In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.

Practice Implications

Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.
Has Increased Availability of Treatment Reduced the Prevalence of Mental Disorders?

Jorm, A.F., Patten, S.B., Brugha, T.S., & Mojtabai, R. (2017). Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry, 16, 90-99.

Mental disorders are a major source of disability. However, many individuals remain untreated, such that 36% to 50% of serious cases in industrialized countries went untreated in the previous year. In 2001 the World Health Organization argued for making treatment more accessible and to train more mental health professionals. In this wide-ranging review, Jorm and colleagues look at data from the U.K, the U.S., Canada, and Australia to assess if in fact treatment provision has increased over time, and whether this increase was associated with declines in the prevalence of common mental disorders. In all of the countries surveyed, antidepressant use among those with mental disorders (mainly anxiety and depressive disorders) increased dramatically from 1990 to 2011, such that their use rose by 300% or more during that period. The use of psychotherapy increased in Australia by about 46% among those with a diagnosable disorder. While the rates of psychotherapy-use remained the same in the U.K., they declined dramatically in the U.S. from 71.1% in the late 1980s to 43.1% in 2007 (no data was available from Canada). At the same time however, the prevalence of mental disorders has been increasing or remaining the same in all of the four countries. For example, in England the prevalence of common mental disorders among women went from 18.1% in 1993 to 18.9% in 2007. The authors then speculated as to why the dramatic increase in the use of antidepressants was not followed by a decrease in diagnosed mental disorders. They were able to rule out a number of possibilities like increased reporting of mental illnesses, or an increase in risk factors in the communities involved. The authors did suggest however that antidepressant medications may not be prescribed as intended by primary health care providers. For example, in Australia, only 50% of people prescribed antidepressants receive them as recommended in clinical guidelines. In an Alberta, Canada study, 67.2% of those who reported taking an antidepressant had no active mood or anxiety disorder at the time of the survey. Among those with major depression, only 14.3% reported receiving psychotherapy.

Practice Implications

This large review highlights some findings that are already well known: that antidepressant use is dramatically on the rise, and that psychotherapy use is declining slightly over time. This may be due to the quick and easy availability of antidepressant medications, the direct to consumer advertising done by the pharmaceutical industry in some countries, and to a possible cultural need for easy fixes to complex problems. What is new in this review, is that the rise in available antidepressant medications appears not to have made a dent in the rate of mental illness in four industrialized countries.

December 2016

The Poor State of Psychotherapy Research for Indigenous People

Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.

Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.

Practice Implications

The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.

This month...

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July 2017

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June 2017

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April 2017

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February 2017

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December 2016

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Psychotherapy Practice Research Network (PPRNet)