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.
This month...
…I blog about client perspectives on psychotherapy failure, therapeutic alliance, and alliance ruptures and resolutions and symptom severity.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
July 2016
Long-Term Efficacy of Psychological Therapies for Irritable Bowel Syndrome
Laird, K.T., Tanner-Smith, E.E., Russell, A.C., Hollon, S.D., & Walker, L.S. (2016). Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology.
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that affects 5% to 16% of the population. People with IBS have reduced quality of life similar to those with heart disease, heart failure, and diabetes. Previous meta analyses indicated that psychological therapies are just as effective as antidepressant medications immediately after treatment for improving symptoms of IBS. However, whether psychological therapies have longer lasting effects is unknown. It is important to patients and providers to know the longer term effects of psychological treatments for IBS because the disorder has a fluctuating course, and so symptoms may reappear after treatment is completed. In their meta analysis, Laird and colleagues reviewed 41 studies that recruited almost 2,300 adult patients. [A note about meta analysis: Meta analysis combines the standardized effect sizes (d) across many studies to estimate an average effect size. This means that meta analyses are much more reliable than any single study, and when possible they should be the basis for practice recommendations]. Psychological therapies for IBS often included cognitive behavioral therapy (CBT), but also included relaxation therapy, mindfulness, hypnosis, behavioral treatment, and psychodynamic therapies. Control conditions often were: supportive therapy, education, fake treatment for biofeedback or hypnosis, online discussion groups, treatment as usual, or wait-list controls. Psychological therapies were more effective than control conditions immediately post-treatment in improving GI symptoms, and the effects were moderately large (d = .69). Psychological therapies remained more effective than control conditions up to 6 months post-treatment (d = .76), and from 6 months to 1 year post-treatment (d = .73). CBT and other treatments (e.g., relaxation, hypnosis) were equally effective; and individual and group delivered treatments were no different in their efficacy. The number of sessions, duration of sessions, and frequency of sessions did not impact the efficacy of psychological interventions.
Practice Implications
Determining the longer term efficacy of psychological treatment for IBS is important because the symptoms tend to be recurrent and sometimes are chronic. Psychological treatments reduce GI symptoms in adults with IBS, and the effects appear to be long lasting – at least up to 1 year post-treatment. The average individual who received psychotherapy was better off than 75% of control condition participants.
Direct Psychological Interventions Reduce Suicide and Suicide Attempts
Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S., & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry.
The World Health Organization reports that more than 800,000 people die of suicide per year around the world. However suicide prevention efforts over the past decade have fallen short of targets. In fact, the prevalence rates of suicide in the US have risen steadily since 2000 to about 1.3% of the population in 2014. Many who kill themselves have a mental disorder like depression, anxiety disorders, substance abuse, psychoses, or personality disorders. Best practices suggest that directly addressing suicidal thoughts and behaviors during treatment, rather than only addressing symptoms like depression and hopelessness, are most effective in reducing suicide. However, there are no meta analyses of randomized controlled trials that specifically assess the relative utility of direct versus indirect psychological interventions. In their meta analysis, Meerwijk and colleagues looked at psychosocial interventions aimed to prevent suicide or to treat mental illness associated with suicide. They included 31 studies representing over 13,000 participants. Interventions included cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), case management, social skills training, and supportive telephone calls. Depending on the target problem, the interventions either directly addressed suicidal behavior or they indirectly addressed suicidal behavior. Mean duration of treatment was over 11 months. Studies that looked at direct or indirect interventions were each compared to control groups that received some form of usual care in the community, or psychiatric management, or general practitioner care. Individuals who received usual care were 1.5 times more likely to die of or attempt suicide compared to those receiving direct or indirect psychological interventions. There was a 35% lower odds of suicide and attempts with direct interventions compared to usual care; and an 18% lower odds of suicide and attempts with indirect interventions compared to usual care. The difference between the effectiveness of direct versus indirect interventions was large (d = .77), suggesting that direct interventions were more effective than indirect interventions at reducing suicide and suicide attempts.
Practice Implications
This is the largest meta analysis of its kind. Most direct interventions to prevent suicide and suicidal behaviors were based on CBT and DBT. Indirectly addressing suicide by focusing on depressive symptoms, anxiety, and hopelessness was somewhat effective compared to usual care. However, direct interventions that included talking about the patient’s suicidal thoughts and behaviors and how best to cope were most effective.
June 2016
Therapist Interpersonal Skills Account for Patient Outcomes
Schottke, H., Fluckiger, C., Goldberg, S.B., Eversmann, & Lange, J. (2016). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research, DOI: 0.1080/10503307.2015.1125546
Therapist effects, or differences between therapists, account for an important amount of patient outcomes (i.e., 5% to 7%). Two therapist characteristics most consistently proposed as predictors of patient outcomes are: therapist competence/adherence to a treatment manual, and therapist interpersonal skills. A recent meta analysis found that therapist adherence or competence were not significantly related to patient outcomes. However, there has been very little research on therapists’ interpersonal capacities. These capacities might include factors like: empathy, warmth, ability to respond well to patient hostility, sensitivity to interpersonal process in therapy, and ability to address alliance ruptures. In this paper, Schottke and colleagues (2016) conducted a five year study with 41 therapists and 264 patients in which they assessed the impact of therapist interpersonal skills on patient outcomes. The therapists were all post-graduate trainees and who practiced a manual oriented cognitive behavioral therapy (CBT) or psychodynamic therapy (PDT). The patients were adults mainly treated for depression, and many had co-morbid problems. What was unique about the study is that the therapist interpersonal skill was rated before they received formal training, and the rating were done by trained reliable judges. The judges rated the therapist trainees on interpersonal skills including: clear and positive communication, empathy, warmth, managing criticism, and willingness to cooperate. Patients were assessed pre- and post-treatment on general symptom outcomes. Higher therapist interpersonal skills were reliably associated with better patient outcomes, even after controlling for symptoms severity and number of comorbid diagnoses. In this study, therapist interpersonal capacities measured before receiving formal training and supervision was a significant predictor of patient outcomes after training was initiated.
Practice Implications
The findings of this study indicate that therapists’ talent should in part be characterized by interpersonal competencies that include clear communication, empathy, respectful management of criticism, warmth, and willingness to cooperate. It could be that therapist trainees with high interpersonal skills engage in an extensive degree of deliberate practice that may account for better patient outcomes.
March 2016
Does Clinician Confidence Lead to Accurate Clinical Judgement?
Miller, D.J., Spengler, E.S., & Spengler, P.M. (2015). A meta-analysis of confidence and judgement accuracy in clinical decision making. Journal of Counseling Psychology, 62, 553-567.
People can make errors in judgements based on decision making rules that are biased. Clinicians also may be prone to making such errors. In their Nobel Prize winning work, Kahneman and Tversky outlined a number of heuristics (i.e., mental shortcuts) that lead to cognitive biases, which in turn affect accuracy of decisions. For example, when making a differential diagnosis clinicians may: rely too heavily on only one piece of information which may be the most available (e.g., “I vividly remember a patient with conversion disorder who had the same history”); or ignore that a particular event (e.g., conversion disorder) is very rare; or seek confirming rather than disconfirming evidence (e.g., the patient has PTSD symptoms that can explain some symptoms). Complicating these biases is the tendency for clinicians to be over-confident. For example, in one study the average psychotherapist rated their performance as better than 80% of their peers, and no therapist rated him or herself in the lower 50th percentile among peers. In their meta analysis, Miller and colleagues reviewed 36 studies of the relationship between clinician confidence ratings and accuracy of decisions among 1,485 clinicians. The authors were particularly interested in the overconfidence bias, which occurs when individuals report higher confidence in their judgments than is warranted by their actual accuracy. For example, studies have assessed the impact of clinician confidence on clinical accuracy in: detecting random responding on a psychological test, diagnosing a brain disorder verified by medical test using neuropsychological test data, predicting future violence and recidivism in offenders, and patient progress in psychotherapy. Most studies find that clinicians are quite confident in their judgments. But, is this confidence warranted? Miller and colleagues’ meta analysis found a significant but small (r = .15) association between confidence and accuracy. This suggests that clinician confidence is only slightly indicative of decision-making accuracy. The effect was a little larger for more experienced clinicians (r = .25), indicating that more experience and training resulted in somewhat more consistency between a clinician’s confidence and their clinical accuracy. Further, higher confidence leads to poorer accuracy when clinicians have to make repeated decisions without feedback, when feedback is not written, and when an event is rare.
Practice Implications
Clinicians, like everyone else, are sometimes subject to making errors when they only look at confirming evidence, when they rely only on their own memory rather than objective data, and when they are over-confident. Accuracy can be increased when clinicians use decision-making aids that provide quality corrective feedback. Aids to help in decision making might include the use of: objective standardized test data, repeated measurements with feedback to assess patient progress in psychotherapy, and actively looking for disconfirming evidence before making a clinical judgement. As the authors conclude, confidence is not a good substitute for accuracy.
Psychotherapists Matter When Evaluating Treatment Outcomes
Owen, J., Drinane, J. M., Idigo, K. C., & Valentine, J. C. (2015). Psychotherapist effects in meta-analyses: How accurate are treatment effects? Psychotherapy, 52(3), 321-328.
One of the ongoing debates in the psychotherapy research literature has to do with the relative efficacy of psychotherapies. Is psychotherapy brand A (CBT, for example) more effective than psychotherapy brand B (psychodynamic therapy, for example)? The most common way to test this question is with randomized controlled trials (RCTs), in which clients are randomly assigned to treatment condition (brand A or B). This study design controls for systematic bias in the results that may be caused by differences between clients. But what about therapists? We know for example that therapist effects (i.e., differences between therapists) account for approximately 5% to 10% of client outcomes. Therapist effects are often larger than the effect of the empirically supported treatment that is being offered. Yet it is almost unheard of for therapists to be randomized to treatments, so therapist effects are not controlled in most psychotherapy trials. As a result the effects of the differences between therapists get statistically rolled into the treatment effects. As Owen and colleagues point out, the impact of not controlling for therapist effects is that some differences between treatments in an RCT will appear statistically significant when in fact they are not. One can control for the effect of therapist differences, thus providing a more accurate estimate of treatment effects, but this is rarely done in published RCTs. So, when these RCTs are summarized in a meta analysis, the meta analysis results are also affected by ignoring therapist effects. In their study, Owen colleagues did something very clever. They took data from 17 recent meta analyses of RCTs that found differences between two interventions. These included meta analyses of studies comparing: CBT vs alternative treatments, bona fide treatments vs non-bona fide treatments, culturally adapted treatments vs those that were not adapted, etc. There are many other meta analyses that show no differences between treatments, but the authors wanted to focus specifically on the 17 that did show differences. Owen and colleagues statistically estimated what would happen to the original study findings of significant differences between treatments if therapist effects on patient outcomes were controlled. They controlled for three different sizes of therapist effects that accounted for: 5% (small), 10% (medium), or 20% (large) of patient outcomes. Even small therapist effects (5%) reduced the number of significant differences between treatments from 100% to 80%. When psychotherapist effects were estimated to be medium (10% - which is the best estimate based on research), the number of significant differences between treatments dropped to 65%. For large therapist effects (20%), the number of significant treatment differences was only 35%.
Practice Implications
I have argued previously that the psychotherapist matters. Placing more time and effort in developing good reflective practice based on quality information and developing therapist skills like empathy, progress monitoring, and identifying and repairing alliance ruptures will result in better patient outcomes. As Owen and colleagues note, when reading an RCT that claims to find significant differences between psychotherapies, ask yourself if they took into account the effects of differences between therapists.
January 2016
Attrition from Cognitive Behavioral Therapy
Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015, August 24). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of Consulting and Clinical Psychology. Advance online publication.
“Dropping out” refers to clients who discontinue therapy prematurely and against professional advice. In contrast, “refusing” refers to clients who do not start a therapy that is made available to them. Together, both dropping out and refusing are referred to as “attrition” from therapy. Attrition is a problem for clinicians because of loss of revenue and time, and a problem for clients because their mental health needs remain unmet. In a previous meta analysis that included 669 studies, Swift and Greenberg (2012) reported that the average drop out rate across all therapies was 19.7%. In this meta analysis, Fernandez and colleagues looked specifically at drop outs and refusers in cognitive behavioral therapy (CBT). The authors reviewed 115 studies that reported drop outs, 36 of which also reported on the number of participants who refused treatment before starting. The average percent of patients who refused CBT prior to starting treatment was 15.9%, and the average percent of patients who dropped out after starting CBT was 26.2%. So the total average attrition rate was 42.1%. Compared to any other disorder, patients with depression were significantly more likely to refuse CBT (21.6%) or to drop out (36.4%). It is possible that depressed patients have a harder time summoning the energy to participate in therapy, and experience lower hope, greater social withdrawal, and lower motivation once they initiate CBT. For those receiving e-therapies (e.g., internet, phone, and CD-based treatments), pre-treatment refusal rates were 10% to 15% higher than individual or group CBT, and drop outs from e-therapies were 10% higher compared to individual or group CBT. Those offered e-therapy might be ambivalent about its utility, the therapeutic alliance might be limited, and they might have a lower sense of engagement in the therapeutic process. Finally, a greater number of planned therapy sessions was related to lower attrition rates. Perhaps the promise of more sessions raised clients’ hopes of achieving better outcomes.
Practice Implications
These findings suggest that engaging and encouraging clients to participate in the therapy may have to start even before therapy begins. This may involve enhancing readiness by means of motivational interviewing, for example. Clients who are depressed are particularly likely to refuse treatment or drop out, and so clinicians must pay particular attention to the level of motivation and engagement of depressed clients. Although e-therapies are promising in that they may allow a therapist or agency to reach more people including those who live in remote areas, the attrition rate of e-therapies may be unacceptably high. Attrition may lead to demoralization and lowered expectations for treatment among these patients, which may negatively impact future treatment. Perhaps e-therapies should not be considered as a first-line treatment for those who can easily access individual or group therapy. Alternatively, the high attrition rates of e-therapies may be reduced by supplementing the intervention with some in-person therapy sessions to enhance engagement and a therapeutic alliance.