Blog

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate (2^nd ed.). New York: Routledge.

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books

In the concluding chapter of their book, Wampold and Imel discuss the evidence and strategies that therapists can use to improve patient outcomes. As indicated in previous PPRNet Blogs, Wampold and Imel concluded that the differences between specific treatment approaches is small. In other words, Wampold and Imel argue that there is no good evidence that one bona fide psychotherapy is more effective than another for most disorders. By “bona fide” treatments, they mean psychotherapy that: provides the client with a plausible theory/explanation of the disorder, delivers a structured intervention based on the plausible theory, and is offered by an effective therapist. The authors also found that contextual factors (e.g., therapeutic alliance, therapist empathy, client expectations) accounted for a sizeable proportion of patient outcomes. A key element in this understanding of effective therapy is the role of the therapist. The authors reviewed various studies and meta analyses that showed that therapists differ widely in their outcomes and in their ability to establish a therapeutic alliance. Unfortunately, therapists tend to be overly-optimistic about their clients’ outcomes. Therapists often do not have quality data on their clients’ progress, and the complexities of the therapeutic work makes it difficult for therapists to keep in mind all aspects of the therapy that is helpful or not helpful to clients. For example, some therapists may be good at establishing an alliance, but they may not be so good at providing a viable treatment structure. Other therapists may be highly empathic with clients who have moderately severe symptoms, but the same therapists may not respond as empathically with more difficult clients. Outcome or process monitoring (i.e., providing therapists with reliable information about the ongoing status of patient symptoms or about the quality of the therapeutic relationship) provides an evidence-based aid in helping therapists to improve their clients’ outcomes.

Practice Implications

Regardless of the type of psychotherapy they use, therapists are responsible for achieving good outcomes for their clients. This includes continually developing therapeutic skills over time. There is some evidence that a reflective attitude towards one’s psychotherapy practice is helpful. Unfortunately, therapists may not be continually improving or reflecting on their practice. This is indicated by research showing that trainees and interns appear to be as competent as experienced clinicians. Therapists need quality information about their clients in order to improve their own practice and clients’ outcomes. But psychotherapy practice is complex, the therapeutic relationship is multifaceted, and clients are variable in their presenting issues and life experiences. All of these make it difficult for any therapist to make accurate decisions in therapy. Progress or process monitoring (i.e., continually measuring outcomes and relationship processes with a psychometrically valid instrument), may be one way for therapists to receive high quality feedback about patient progress in order to improve their psychotherapy practice.

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, Tharmanathan, P....White, D. (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): Large scale pragmatic randomised controlled trial. BMJ, 351, h5627. Doi: 10.1136/bmj.h5627.

Depression is one of the most common reasons why people see family physicians for consultation. The personal and economic burden of depression is high, such that depression is the leading cause of disability worldwide. Effective treatments for depression include antidepressant medications and psychotherapy. Cognitive behavioral therapy (CBT) is an effective treatment for depression, but is not always accessible for those who live in remote areas, and for those who cannot easily find or afford a trained psychotherapist. One solution, touted by some is to provide computerized CBT (cCBT) via internet or CD. In fact, the National Institute for Health and Care Excellence (NICE) in the UK recommend cCBT programs as a first step of care for depression. Commercially available cCBT programs include “Beating the Blues”, and freely available programs include “MoodGYM”. Previous research shows a large effect of cCBT for reducing depressive symptoms, but non-adherence (i.e., not completing the modules) and patient dropout rates tend to be high. Another issue is that most of the studies of cCBT were conducted by the developers of the programs, and so there may be researcher allegiance effects that could bias the findings. In this large trial, Gilbody and colleagues asked: “How effective is supported computerized cognitive behavior therapy (cCBT) when it is offered in addition to usual primary care in adults with depression?” The authors recruited 691 depressed patients seen in primary care with a general practitioner (GP) in the UK. All participants had access to a computer and high speed internet. The participants were randomly assigned to receive: (1) usual GP care plus 8 50-minute sessions of Beating the Blues, or (2) usual GP care plus 6 weekly modules of MoodGYM, or (3) only usual GP care. Usual GP care included providing antidepressants, counselling, or brief psychotherapy which are all offered as part of the UK National Health Service. Computerized CBT was supported by weekly telephone calls followed by reminder emails to encourage participants to access, use, and complete the programs. At 4 months after the start of treatment, about half of all participants were no longer depressed, and there were no differences between the three study conditions on any of the outcomes (e.g., depression, quality of life). The results were consistent up to 2 years post treatment. However, only about 17% of those receiving one of the cCBT treatments completed all of the sessions. The average number of sessions completed of cCBT was very low (Beating the Blues = 2 out of 8 sessions; MoodGYM = 1 out of 6 sessions). The authors concluded that there was no significant benefit of adding supported cCBT to usual GP care.

Practice Implications

Adding cCBT to usual GP care did not provide added benefit to depressed patients. Low adherence and low engagement with cCBT likely reduced the utility of computerized delivery of therapy. It is possible that more intensively supported cCBT (i.e., with weekly face to face contacts) might have improved the added value of cCBT, but would also have reduced the practically utility and accessibility of cCBT. Those who are depressed might have difficulty with summoning the energy and concentration necessary to repeatedly log on to computers and engage in computerized or internet based treatment.

Tritt, A., Kelly, J., & Waller, G. (2015). Patients’ experiences of clinicians’ crying during psychotherapy for eating disorders. Psychotherapy, 52(3), 373-380.

Psychotherapy can be an emotionally intensive experience for both patients and therapists. In a large survey, more than 70% of therapists reported having cried in therapy, and 30% cried during the past month. Therapists who cried almost always saw the experience as positive or neutral (99.2%) for the patient and the therapeutic relationship. Do clients feel the same way about therapists who cry? In this study, Tritt and colleagues surveyed 188 adult patients with an eating disorder who were recently in psychotherapy. Of those, 107 (56.9%) reported that their therapist had cried during therapy. There was no association between frequency of therapist crying and therapist age, patient diagnosis, or type of psychotherapy (i.e., manual-based or not). Therapists who cried a moderate amount were seen by clients as having a positive demeanor (i.e., happy, firm, consistent), whereas therapists who cried more extremely were rated by clients as having a more negative demeanor (i.e., anxious, angry, bored). If therapists who cried were generally perceived by clients to have a positive demeanor, then therapist crying had a positive impact on therapy. That is, clients reported a greater respect for the therapist, greater willingness to express emotions, and higher willingness to undertake therapy in the future. However, if therapists who cried were generally perceived by clients to have a negative demeanor, then therapist crying had a negative impact on therapy. That is, clients were less willing to express emotions in therapy and to undertake therapy in the future. Further, if the therapist who cried was rated as having a negative demeanor, the client experienced more self blame, assumed that there was something wrong in the therapist’s life, and that the therapist and client did not share the same perspective on the client’s life and treatment.

Practice Implications

This small but unique and interesting survey sheds some light on clients’ experiences of therapists who cry during therapy. More than half of clients experienced their therapist crying during therapy. In contrast to surveys of therapists who tend to evaluate therapist crying as exclusively positive or neutral, this survey found that many but not all clients experienced therapist crying as positive. It depends on how the client perceives the therapist as a person. Therapists who are seen by clients as happy, firm, and consistent may assume that patients will experience their crying as a positive indicator of the therapeutic relationship. However, therapists who are seen by clients as anxious, bored, or angry cannot assume that clients will see their tears as being positive for therapy.

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Change in dysfunctional attitudes or cognitions is one of the specific mechanisms by which cognitive therapy (CT) is thought to be effective in the treatment of depression. In this part of their book, Wampold and Imel discuss the evidence that addresses the specific change mechanisms for CT. The reason they focus on CT is that CT is by far the most researched psychotherapy approach, and there is a substantial number of CT studies that have addressed this issue of change mechanisms. In an early meta analysis, Oei and Free (1995) found a significant relationship between change in cognitions and CT. However, in the same meta analysis, the authors found that CT and non-cognitive therapies did not differ in terms of their effects on cognitions. That is, most treatments, whether CT or not, appeared to change cognitions. In another study, three different interventions (behavioral activation, CT, and CT plus behavioral activation) all resulted in change in cognitions and improved depression. In other words, cognitive interventions do not seem to be needed to alter cognitions and reduce depression. Wampold and Imel argue that nonspecific processes in CT (and other psychotherapies for that matter) are largely responsible for the effectiveness of psychotherapy. For example, there is evidence to suggest that a number of patients show substantial symptom improvement early in treatment before specific cognitive techniques are introduced. Some have argued that this early favourable response is largely due to the effects of client expectations, reassurance, and remoralization rather than the specific procedures of the therapy. Moreover, patients who experience this remoralization early-on may be better at successfully applying techniques taught in CT. A large review of this literature concluded that there was insufficient evidence to support the notion that challenging thoughts was responsible for the positive effects of CT.

Practice Implications

This line of research appears to indicate that the specific practice of challenging thoughts or dysfunctional attitudes is not primarily responsible for patient change in CT. It may be that for any psychological treatment that has a cogent rationale for the disorder and is administered by an acknowledged expert, client progress may be determined largely by contextual factors. These factors may include a therapeutic alliance, client expectations of benefit, and client remoralization, which may in turn allow clients to benefit from the specific interventions of psychological treatments.

Weitz, E.S., Hollon, S.D., Twisk, J., van Straten, A., Huibers, M.J.H., David, D., …. Cuijpers, P. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: An individual patient data meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1516.

The American Psychiatric Association guidelines for the treatment of depression indicates that although psychotherapy is adequate for mild to moderate depression, anti-depressant medications are indicated for the treatment of severe depression in major depressive disorder. These recommendations are mainly based on the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program that was published in the mid 1990s. Several authors since then have disputed this claim, but no meta-analyses have been done on the studies of head-to-head patient-level comparisons of psychotherapy vs antidepressant medications for the purpose of evaluating their relative efficacy for severity of depression. In this meta analysis, Weitz and colleagues look at medications vs psychotherapy for depression and then evaluate if initial severity of depressive symptoms helped to explain any differences. The authors looked at all studies that compared cognitive behavioral therapy (CBT) against antidepressant medications for depression. They focused on CBT because it was the most often studied of the psychotherapies in this context. A systematic review turned up 24 studies, and they were able to get original patient-level data from the authors of 16 of the 24 studies. This represented over 1,700 participants with major depression. These 16 studies were no different from the 8 studies that did not provide original data. Between 17% and 54% of the 1,700 depressed participants met criteria for severe depression at pre-treatment. There were no significant differences between antidepressant medications and CBT on clinically relevant outcomes in terms of “response” (i.e., improvement) or “remission” (i.e., symptom-free). In total, 63% of patients in the antidepressant medication condition and 58% of patients in the CBT condition responded to treatment, and 51% of patients in the antidepressant medication condition and 47% of patients in the CBT condition met criteria for remission. Most importantly, the effects of CBT and antidepressant medications on response to treatment or remission did not differ based on initial severity of depressive symptoms.

Practice Implications

Patients with severe depression were no more likely to require medication to get better than patients with less severe depression. This meta analysis that included the majority of studies that exist on the topic found no evidence to support the guidelines that severe depression should be treated with antidepressant medications over psychotherapy. The authors conclude that CBT may also be a first-line treatment for severe depression.

Fonagy, P., Rost, F., Carlyle, J., McPherson, S.,… Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock adult depression study (TADS). World Psychiatry, 14, 312-321.

Usually I do not write about individual studies, mainly because meta-analyses and systematic reviews are much more reliable. But occasionally a unique study is published that is important enough to report. This is a rare trial that focuses on “treatment-resistant” depression defined as long-standing depression that has not responded to at least two previous evidence-based interventions. Depression is known to have a relapsing chronic course for about 12% to 20% of patients. And not responding to treatment is highly predictive of non-response to future treatment for depression. Fonagy and colleagues argued that in order to be effective, treatments for chronic and resistant depression need to be longer and more complex than current time-limited evidence-based approaches. Further, they argued that follow ups should be of longer duration. The authors tested a manualized long term psychoanalytic psychotherapy (LTPP). The treatment involved 60 sessions over 18 months provided by 22 trained therapists. In this trial, the “control” condition was treatment as usual (TAU) as defined by the National Institute for Clinical Excellence in the United Kingdom. TAU was made up of short term evidence-based interventions like antidepressant medications or CBT provided by licensed trained professionals. LTPP plus TAU was compared to TAU alone for 129 patients randomly assigned to one of the conditions. At pre-treatment, the majority of patients scored in the severe range on the Beck Depression Inventory (BDI) or the Hamilton Depression Rating Scale (HDRS). The average patient had 4 previous unsuccessful treatments for depression. No differences were found between LTPP and TAU at post treatment, but differences began to emerge after 24 months. Complete remission was infrequent in both conditions after 42 months (14.9% LTPP vs 4.4% TAU). However, partial remission at 42 months was significantly more likely in LTPP (30.0%) than TAU (4.4%). Patients were significantly more likely not to meet DSM-IV criteria for depression at 42 months in LTPP (44%) than in TAU (10%). The differences between conditions in mean BDI and HDRS scores were significant and medium sized indicating greater improvement with LTPP.

Practice Implications

This is the first study of its kind to test a manualized LTPP for treatment resistant depression. Patients in LTPP were more likely to maintain gains whereas those receiving evidence-based TAU were more likely to relapse. Although this is only one study and should be interpreted cautiously, it does suggest that chronic treatment-resistant depression is more likely to respond to longer and more complex treatment, and that outcomes of such treatment tend to be maintained in the longer term.