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.

January 2017

Individual versus Group Psychotherapy

Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.

With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.

Practice Implications

When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.

December 2016

Effects of Combining Psychotherapy and Pharmacotherapy on Quality of Life in Depression

Kamenov, K., Twomey, C., Cabello, M., Prina, A.M., & Ayuso-Mateos, J.L. (2016). The efficacy of psychotherapy, pharmacotherapy, and their combination on functioning and quality of life in depression: A meta-analysis. Psychological Medicine, doi: 10.1017/S0033291716002774.

Both psychotherapy and pharmacotherapy are efficacious for reducing symptoms of depression. Some studies suggest that functioning (i.e., the ability to engage in work, school, and social activities) and quality of life (i.e., satisfaction with these activities and perception of one’s health) are just as important to depressed patients as is reducing their symptoms. In fact, many patients place greater priority on improving functioning compared to reducing symptoms. In this meta analysis, Kamenov and colleagues assess the relative efficacy of psychotherapy vs pharmacotherapy in improving functioning and quality of life. They also evaluate if combining psychotherapy and pharmacotherapy is efficacious relative to either treatment alone. The meta analysis included k = 153 studies of over 29,000 participants. Psychotherapies often included CBT and interpersonal psychotherapy. Compared to control groups (k = 37 to 52) both psychotherapy (g = 0.35, 95% CI = 0.24, 0.46) and medications (g = 0.27, 95% CI = 0.21, 0.32) significantly improved functioning. Also, compared to controls both psychotherapy (g = 0.35, 95% CI = 0.26, 0.44) and medications (g = 0.31, 95% CI = 0.24, 0.38) significantly improved quality of life in depressed participants. In studies that directly compared psychotherapy and medications, there were no significant differences when it came to improving functioning, but there was a small significant advantage to psychotherapy over medication for improving quality of life (g = 0.21, 95% CI = 0.01, 0.43). Combined psychotherapy and medications (k = 19) was more effective to improve functioning compared to pharmacotherapy alone (g = 0.34, 95% CI = 0.18, 0.50) and compared to psychotherapy alone (g = 0.32, 95% CI = 0.14, 0.49). Combined treatment was also more efficacious for improved quality of life compared to medications alone (g = 0.36, 95% CI = 0.11, 0.62) and to psychotherapy alone (g = 0.39, 95% CI = 0.19, 0.58).

Practice Implications

Combined treatment of medications and psychotherapy is more effective than either treatment alone for improving functioning and quality of life. However, most patients prefer psychotherapy to medications, and some studies indicate that many patients choose not to get treated at all rather than receive medications. Further, quality of life can be substantially compromised by medication side effects. Clinicians should take these factors into account when considering monotherapy with antidepressant medications or combined treatment of pharmacotherapy and psychotherapy for depression.

November 2016

Cultural Adaptation of Psychotherapy

Hall, G.C.N., Ibarak, A.Y., Huang, E.R., Marti, C.N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy.

Cultural adaptation of psychological interventions involves identifying cultural contexts of behaviors and developing constructs of mental health functioning relevant to the cultural context. Most cultural adaptation of psychotherapies involves taking existing treatments originally developed for those of European ancestry and adapting them for another specific cultural group or context. However, a few efforts exist in which new treatments were developed within a particular culture to address culture-specific concerns. Eight dimensions along which interventions could be culturally adapted include: language, people, metaphors, content, concepts, goals, methods, and context. Some researchers have expressed concern that cultural adaptation could distance an intervention from its evidence-base, and reduce its effectiveness. In this meta analysis by Hall and colleagues, the researchers look closely at the effects all culturally adapted treatments and prevention methods. They reviewed 78 studies that included nearly 14,000 participants. All studies included culturally adapted interventions for individuals of non-European ancestry. For example, these included studies that adapted CBT interventions for various disorders (mainly depression and anxiety disorders), or studies that match therapist to client in terms of ethnicity. Only 5% of studies created a new intervention developed within a particular culture, whereas the vast majority of studies adapted an existing treatment initially developed for clients of European ancestry. The average effect size was g = .67 (confidence intervals not reported), indicating that culturally adapted interventions produced better outcomes than comparison conditions. Culturally adapted interventions were also more likely to result in better outcomes than the same interventions that were not adapted (g = .52). Effect sizes for cultural adaptation in treatment studies (g = .72) were larger than for prevention studies (g = .25), likely because participants in treatment studies had higher levels of initial psychopathology. There was little evidence that matching therapist and client on ethnicity was helpful.

Practice Implications

This meta analysis provides compelling evidence that cultural adaptation of existing treatments can result in more positive outcomes compared to not adapting the same treatment. The effect sizes may even underestimate the true effects of cultural adaptation because the outcome variables like measures of depression were rarely adapted to a specific culture (e.g., depression among Chinese participants may be expressed differently than depression among European participants, and most depression measures were created by and for Europeans).

October 2016

Clients’ Experiential Depth in Therapy Predicts Better Outcomes

Pascual-Leone, A. & Yeryomenko, N. (2016). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process, Psychotherapy Research, DOI: 10.1080/10503307.2016.1152409

A key issue in existential-humanistic psychotherapy is the degree to which therapy encourages clients to explore new feelings and meanings in relation to the self. This is often called ‘experiential depth’ or simply ‘experiencing’. Carl Roger highlighted the need for clients to increase their awareness, accept their feelings, and use their feelings as information to further explore and understand themselves. The notion of ‘depth of experiencing’ refers to the degree to which clients engage and explore their feelings moment by moment in therapy to increase personal meaning-making. One way of assessing experiential depth is with the Client Experiencing Scale. Low scores on the scale indicate unengaged levels of experiencing, in which clients recount events in an emotionally neutral or disengaged manner. High scores indicate more introspection as clients begin to process their experiences and identify feelings that lead to creating new meanings that contribute to resolving their problems. In this meta analysis of the Client Experiencing Scale, Pascual-Leone and Yeryomenko systematically reviewed the research literature and found 10 studies of 406 clients that evaluated the scale`s association with client outcomes. The therapies in the meta analysis included experiential-humanistic approaches, CBT, and interpersonal psychotherapy. Overall, they found a moderate association (r = .25; 95% CI: .16, .33) between higher client experiencing and better treatment outcomes. The association was similar for different therapeutic orientations and stages of therapy. On average, client depth of experiencing tended to increase from the early to later stages of treatment.

Practice Implications

Compared to those who did not engage with their experiences in a meaningful way, clients who were internally focused, engaged in exploration, referred to their emotions, and who reflected on their experiences had better outcomes. Experiential depth allowed clients to create new meanings to resolve personal problems. Therapist interventions that deliberately point the client to a deeper level of experiencing, are likely to result in clients following suit and deepen their own process.
The Quality of Psychotherapy Research Affects The Size of Treatment Effects for CBT

Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M., Huibers, M.J.J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245-258.

You might think that an esoteric topic like study quality should not really be of interest or concern to clinicians – but it is an important topic with practice implications. In this meta analysis Pim Cuijpers and his research group updated the meta analytic evidence for the efficacy of cognitive behavioral therapy (CBT) for a variety of disorders (major depressive disorder [MDD], generalized anxiety disorder [GAD], panic disorder [PAD], and social anxiety disorder [SAD]). The important thing about meta analyses is that the method combines the effect sizes from all relevant studies into a single metric – an average effect size. These average effect sizes are much more reliable than findings from any one single study. In fact, whenever possible, clinical decision-making should be based on a meta analysis and systematic review and not on a single study. Meta analyses also allow one to give more weight to those studies that have larger sample sizes, and that employ better methodologies. Even more, meta analytic techniques allow one to adjust the averaged effect size by taking into account publication bias (i.e., an indication of the effects from studies that might have been completed but were never published, likely because they had unfavorable findings). Usually, average effect sizes are lower when they are adjusted for study quality and publication bias. Cuijpers and colleagues’ meta analyses found that the unadjusted average effects of CBT were large for each of the disorders (ranging from g = .75 to .88 [confidence intervals not reported]). However adjusting for publication bias reduced the effects to medium-sized for MDD (g = .65) and GAD (g = .59). Only 17.4% of the individual studies of CBT were considered to be of “high quality” (i.e., studies that use the best methodology to reduce bias, like random allocation, blinding, using all the available data, etc.). After adjusting for study quality, the effects of CBT for SAD (g = .61) and PAD (g = .76) were also reduced to medium-sized. Not surprisingly, the effects of CBT were largest when the treatment was compared to a wait-list no-treatment control group. The effects were small to moderate when CBT was compared to treatment as usual or to a placebo.

Practice Implications

Even when adjusting for study quality and publication bias, the average effects of CBT were medium-sized for a variety of common disorders compared to control conditions. Unfortunately, the quality of the studies was not high for most trials, reducing the effect sizes and lowering our confidence in the efficacy of the treatment. Nevertheless, the findings of this meta analysis suggest that CBT will likely have moderate effects for the average patient with MDD, SAD, PAD, and GAD.

September 2016

Interpersonal Psychotherapy for Mental Health Problems

Cuijpers, P., Donker, T., Weissman, M.M., Ravitz, P., & Cristea, I.A. (2016). Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. American Journal of Psychiatry, 173, 680-687.

Interpersonal psychotherapy is a structured therapy that was originally developed for the treatment of depression. The therapy focuses on stressful life events like grief, interpersonal disputes, life transitions, social isolation or deficits that may cause symptoms. Interpersonal psychotherapy also helps people to connect with social supports and improve their relationships. The treatment emphasizes developing a therapeutic alliance, psychoeducation, and choosing an interpersonal focus. Recently, several trials have been conducted to assess the efficacy of interpersonal psychotherapy for other mental health problems like addictions, eating and anxiety disorders. In this comprehensive meta analysis, Cuijpers and colleagues looked at all randomized controlled trials of interpersonal psychotherapy for any mental disorder. The review included 90 studies representing over 11,000 patients. Most of the studies targeted depression, but some studies used interpersonal psychotherapy to treat other disorders. The effect size of the difference between interpersonal psychotherapy and control conditions was moderately large (g = 0.60), indicating that interpersonal psychotherapy was efficacious. Interpersonal psychotherapy was as effective as other psychotherapies (g = 0.06), and as effective as antidepressant medications (g = -0.13). Combined interpersonal psychotherapy and medications was more effective than interpersonal psychotherapy alone, but the effect size of the difference was small (g = 0.24). The combination of monthly maintenance interpersonal therapy plus daily pharmacotherapy was significantly more effective in preventing relapse of depression compared to pharmacotherapy alone or interpersonal psychotherapy alone (odds ratios between 0.34 and 0.36 with confidence intervals not crossing 0). The effects of interpersonal psychotherapy for eating disorders was mixed largely because of the small number of studies and lower quality of studies. For anxiety disorders, interpersonal psychotherapy was as effective as other treatments (g = -0.16) and more effective than control conditions (g = 0.82).

Practice Implications

Interpersonal psychotherapy showed moderate to large effects in the treatment of depression and anxiety disorders, and it was as effective as other interventions. Interpersonal psychotherapy may be effective for eating disorders as well, though the evidence is less clear. Patients and providers need to have more treatment options since no one treatment is effective for all patients. The relationship emphasis of interpersonal psychotherapy provides an important alternative to medications or cognitive behavioral therapy for some patients.

This month...

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January 2017

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December 2016

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November 2016

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October 2016

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September 2016

Practice Implications

Psychotherapy Practice Research Network (PPRNet)