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Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no

Boswell, J.F., Kraus, D.R., Miller, S.D., & Lambert, M.J. (2015). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25, 6-19.

Routine outcome monitoring (ROM) refers to: (1) systematically assessing patient outcomes at every session, (2) comparing patient scores and progress to a database of similar patients, (3) using algorithms or decision tools to identify patients who are not improving or deteriorating, (4) providing regular and immediate feedback to therapists about the patient, and (5) in some cases providing clinical decision aids to help therapists improve outcomes for patients who are not improving or who are deteriorating. Boswell and colleagues review the research related to ROM. Generally, about 30% to 50% of patients do not respond to treatment, and 8% of patients tend to get worse during treatment. Therapists tend to overestimate their patients’ improvement, and so therapists may not always identify patients who do not respond or get worse. Therapists may need assessment aids to help them make decisions about patient progress and treatment. Boswell and colleagues point out that ROM have a proven ability to predict treatment failure and other negative outcomes. In a meta analysis of over 6,000 patients, the patients at risk of a negative outcome whose therapist received ROM feedback prior to every session were better off than 70% of at-risk patients whose therapist received no feedback. When therapists are provided feedback and suggestions for interventions, their patients had almost four times higher odds of achieving clinically significant improvement. Boswell and colleagues list a number of barriers that psychotherapists and agencies experience to implementing ROM in their practices. Many therapists are not aware of or have no experience with ROM, and so they may not be aware of its benefits to their practice and patients. Time and money are two practical issues that may arise. This type of assessment is not always reimbursed and the average clinician may feel that they do not have enough time to reflect on routine assessment and feedback so as to reconsider their interventions. Agencies may not understand the value of allocating resources to this type of testing (although medically oriented agencies would not hesitate to order a blood test or an x-ray). Finally, some therapists might experience ROM as intrusive, as impeding the therapeutic relationship, and as a means for an agency to control therapist decisions.

Practice Implications

Routine outcome monitoring (ROM) has clear benefits to patients, therapists, and agencies. To overcome barriers, therapists and agencies could implement ROM as part of routine clinical care, and advertise this as an evidence-based practice that will benefit prospective patients. Clients generally appreciate knowing that they will receive the best possible care. ROM can enhance the therapeutic relationship if it is presented to clients as a collaborative endeavor. For example, if a patient is not improving or is deteriorating, therapists can discuss this with patients as well as a plan to alter aspects of the treatment in order to improve the prospects for a better outcome. Therapists can choose from a number of possible ROM options to best tailor the approach to their clients based on cost, time, and relevance. Currently, there are several outcome monitoring systems available to clinicians including: the Partners for Change Outcome Management System (PCOMS), the Treatment Outcome Package (TOPS), the Clinical Outcomes in Routine Evaluation (CORE), and the Outcome Questionnaire (OQ) system.

Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical Psychology, 83, 115-128.

Existential therapies are a group of psychological interventions that address questions about existence, and they assume that by overcoming existential distress, psychological problems may be decreased. Underlying existential therapy is the assumption that: people need a meaning or purpose, individuals have a capacity to choose and actualize this potential, people will do better when they face challenges rather than avoid them, and human experiencing is related to others’ experiences. Vos and colleagues list four main schools of existential therapies: Daseinanalysis which focuses on free expression and greater openness to the world; logo-therapies which are aimed at helping clients establish meaning in their lives through didactics, British existential therapy which encourages clients to explore their experiences, and the existential-humanistic approach which help clients face mortality, freedom, isolation, and meaninglessness. Vos and colleagues review the research literature showing that meaning in life and positive well-being are associated with coping with stressful life events including life threatening illnesses. In this meta-analysis, the authors review the randomized controlled trials of different types of existential therapies to assess the efficacy of the treatments compared to a control condition like social support groups, being on a waiting list, or receiving care as usual. They grouped outcomes into four areas: meaning in life, psychopathology, self-efficacy, and physical well-being. Their meta-analysis included 15 studies of 1,792 participants, 13 of the studies were with medically ill patients, and 10 of those studies were aimed at patients with cancer. Effects of existential therapy versus a control condition on meaning in life tended to be positive and moderate. Effects on psychopathology and self-efficacy were positive and small. The effects of existential therapies versus a control condition on physical well-being were not significant. There were no differences between the types of existential therapy, though the number of studies was small to adequately assess these differences.

Practice Implications

Clients seem to benefit from group therapy interventions focused on meaning compared to social support groups, being on a waiting list, or receiving care as usual. Medically ill patients who received existential therapy found greater meaning in their lives, and the effects were moderate to large. Their psychopathology and self-efficacy also improved significantly but effects were small. The quality and number of studies was not optimal which limits the confidence one can have in these findings. The authors conclude that despite the small number of studies, existential therapies that use structured interventions that incorporate psychoeducation and discussions on meaning in life are a promising treatment for physically ill patients.

Safran , J. D. & Kraus , J. (2014). Alliance ruptures, impasses and enactments: A relational perspective. Psychotherapy, 51, 381-387.

In this clinically oriented review, Safran and Kraus discuss the evidence related to alliance ruptures, repairing alliance ruptures, and methods of training in alliance rupture repair. Safran’s work represents “second generation” research on the therapeutic alliance. The therapeutic alliance refers to the relational bond between client and therapist and their agreement on tasks and goals of therapy. A positive alliance is associated with good client outcomes across a variety of therapeutic approaches. Therapeutic alliance ruptures in psychotherapy are inevitable, such that the alliance is continually being re-negotiated, both implicitly and explicitly, throughout the therapy. Such ruptures might include strains, tensions, or breakdowns that could interfere with the ongoing collaboration between therapist and client. Ruptures are associated with re-enactments of dysfunctional relational patterns, but they also may provide opportunities for change and growth in therapy. Safran’s model of alliance ruptures and repairs sees the processes in the client-therapist relationship as key to understanding the client’s relationship problems. Collaboratively addressing tensions in the alliance allows the client to develop more flexible ways of being in relationships and of experiencing themselves. Research by Safran and Muran (2000) suggest that it is rare not to have some minor strain occurring in the therapeutic alliance. Ruptures may occur in half of therapy cases within the first six sessions. Research indicates that unresolved ruptures are associated with deterioration in the alliance, poor outcome, and patients dropping out. In a meta-analysis, repairing alliance tensions by using evidence-based strategies was associated with improved patient outcomes and the effect was large. Alliance ruptures occur across theoretical orientations. For example, research on cognitive therapy showed an improvement in therapist-client interpersonal processes after therapists were trained in techniques to resolve alliance ruptures.

Practice Implications

Alliance ruptures can range in intensity from minor tensions to major rifts in collaboration. They may occur at any time in treatment, and may be present in single or across multiple sessions. Safran and Kraus describe two general types of ruptures. First, withdrawal ruptures occur when clients deal with ruptures or misunderstandings by falling silent. The resolution may involve the therapist exploring the client’s interpersonal fears, reasons for inhibiting negative feelings, and providing the client with an opportunity to communicate their needs. Second, confrontation ruptures occur when clients directly express anger, resentment or dissatisfaction with the therapist or therapy in a blaming manner. The resolution may involve the therapist empathically engaging with the client to facilitate feelings of disappointment, hurt, and vulnerability. Key to this process is the therapist’s meta-communication or mindfulness abilities. The therapist must be aware of the behavior associated with the rupture, collaboratively explore the rupture experience, help the client overcome avoidance of feelings related to the rupture, and explore the client’s needs and wishes that emerge while working through the rupture.

Puig, A., Yoon, E., Callueng, C., An, S., & Lee, S. M. (2014). Burnout syndrome in psychotherapists: A comparative analysis of five nations. Psychological Services, 11(1), 87-96.

Psychotherapists can experience severe stress when working with some clients. The stress can be the result of work conditions like budget cuts and increased therapy caseloads, and from characteristics of the work itself like remaining compassionate with clients who experience significant emotional pain and trauma. In the May 2014 blog, I reported on research on secondary trauma experienced by therapists as an occupational hazard of working with traumatized patients. Although secondary trauma is distinct from burnout, the accumulation of these experiences by therapists coupled with other demands of the work can lead to burnout. Burnout syndrome is often defined as the failure to perform clinical tasks well because of discouragement, apathy, and the experience of emotional or physical drain. Burnout can affect both the therapist’s well being and patient outcomes. In this study by Puig and colleagues, the Counsellor Burnout Inventory (CBI) was given to therapists in five countries. The CBI measures therapist Exhaustion, sense of Incompetence, Negative Work Environment, and Deterioration in Personal Life. The samples of therapists were from countries that included the United States (n = 750), Korea (n = 382), Japan (n = 257), Philippines (n = 218), and Hong Kong (n = 222). Puig and colleagues argue that countries like the US may be characterized by a more individualistic cultural context, whereas other countries in Asia may have more collectivistic values. These cultural values and differing professional practice contexts may affect the experience of burnout by psychotherapists. The majority of therapists were female (67.3% to 85.3%) with average experience ranging from 5.34 years in Korea to 12.33 years in the US. Puig and colleagues translated the CBI from English and then conducted a confirmatory factor analysis that showed that the CBI is reliable and valid within each of these samples of therapists from different countries. Therapists in Hong Kong and the US had the highest scores on the Exhaustion scale. Puig and colleagues suggested that burnout in Hong Kong and US may be most affected by demands of the work that psychotherapists do in those countries. Psychotherapists from Japan reported highest levels on the Incompetence scale, suggesting that burnout in Japanese therapists might be most affected by a sense of low self efficacy and efficiency. Of all the nations, US therapists perceived their working environments most negatively. Deterioation in Personal Life scores were highest in Korea suggesting that burnout may contribute to low personal quality of life for Korean psychotherapists. All therapists reported low mean scores on the Devaluing Client scale, but those in the US and Philippines had the lowest mean scores. It appears that burnout is least affected by negative relationships with clients for all therapist groups.

Practice Implications

Therapists, policymakers, and administrators need to attend to increased stress related to psychotherapists’ work, the environment, and characteristics of clients who experience trauma. The impact of stress and burnout can be seen in therapists’ performance their personal lives and well-being. In addition, burnout can affect patient outcomes. Puig and colleagues suggest that psychotherapists can participate in professional development activities (e.g., workshops) to enhance their knowledge and skills in managing stress and maintaining a healthy and balanced work and personal life. Organizations should consider restructuring the social and work environment (e.g., workload), and clarifying and reassessing their expectations of therapists in order to prevent conflict and ambiguity. On his web site, Ken Pope provides a list of resources for therapist well-being and preventing burnout, and he discusses the ethics of therapist self-care.

Hoglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171, 1056-1066.

In this overview of patient-therapist relationship factors, Per Hoglend reviews research on transference in psychotherapy. He argues that transference and transference work is a specific technique that focuses on exploring the patient-therapist relationship. Hoglend takes a broad definition of transference as: the patient’s pattern of feelings, thoughts, perceptions, and behaviors that emerge in the therapeutic relationship and reflect the patient’s personality functioning. Hoglend also defines transference work as any therapist intervention that refers to or explains the patient’s experience of the therapist and their interaction. These interventions include the therapist: (1) addressing transactions in the patient-therapist relationship; (2) encouraging exploration of feelings and thoughts about the therapy or therapist; (3) encouraging the patient to discuss how he or she believes the therapist might feel or think about the patient; (4) including him or herself in interpreting the patient’s dynamics; and (5) interpreting repetitive interpersonal dynamics and linking these to the therapy relationship. More than 30 studies have been published on providing empirical evidence for the relationship between transference work in psychotherapy and positive patient interpersonal outcomes. Effect sizes of the association between transference work and patient outcomes tend to be large. Some of the research indicates that low frequency of transference interventions is useful, but that a higher frequency may lead to negative effects on the patient. Research on transference-focused psychotherapy indicates that it is as effective as dialectical behavior therapy and supportive psychotherapy for borderline personality disorder, but that transference-focused therapy produced better outcomes for attachment related functioning like mentalizing. In the First Experimental Study of Transference Work (FEST), Hoglend found that patients with low quality of object relations (i.e. a poorer ability to maintain close relationships and to regulate affect) benefited most from transference focused therapy. However, those with high quality of object relations did not require the transference work to get better. Also, women responded better to transference work than men. There are some studies of therapeutic approaches like cognitive behavior therapy, in which patients with depression had better outcomes when the patient-therapist relationship was explicitly discussed.

Practice Implications

Hoglend argues that transference work in psychotherapy is an active ingredient that can lead to specific change in some patients. Most studies that Hoglend reviewed showed significant and large associations between transference work and interpersonal changes in patients. Exploring the patient-therapist relationship appears to be most useful for female patients, those with difficult interpersonal relationships, and those with more severe personality pathology. Patients with more mature relationships may not benefit as much from transference work. Although generally effective, if transference work is used too frequently in a session it can also lead to negative patient outcomes.