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Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.

Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.

Practice Implications

CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.

Castonguay, L., Barkham, M., Lutz, W., & McAleavey, A. (2013). Practice-oriented research: Approaches and applications. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 85-133). New York: Wiley.

In this chapter of the Handbook, Castonguay and colleagues (2013) review research methods and results associated with practice research networks (PRN). There is substantial evidence to show that psychotherapists often are not influenced by research findings when they prepare their case formulations and conduct interventions. As a result, clients may not be benefiting fully from nearly 60 years of research in psychotherapy methods and processes. There may be several explanations for this divide. Clinicians may perceive psychotherapy research, especially the emphasis on empirically supported treatments, as limited in its clinical relevance. Researchers may pay limited attention to concerns of clinicians when developing research strategies and treatment manuals. The end result is that clinicians feel disenfranchised from the research field, and therefore unaffected by the findings. Clinicians may pay more attention to psychotherapy research if they were more involved and “owned” the research and findings. One solution is to develop PRN based on a partnership of practitioners and researchers in which they collaborate on all aspects of a study; i.e., generation of ideas, implementation, and publication. Castonguay and colleagues (2013) report on the research generated by several PRNs in the U.S. The American Psychiatric Institute for Research and Education’s PRN (APIRE-PRN) conducted several studies including: one study that found that compared to White patients, African Americans were less likely to be prescribed second generation antipsychotic medications, which are considered to be the treatment of choice by psychiatrists; and a second study that reported that presence of a personality disorder, low Global Assessment of Functioning scores, and seeing a psychiatrist at a discounted fee was associated with treatment non-compliance. The Pennsylvania Psychological Association PRN (PPA-PRN) conducted several studies, including one study that found that better patient outcomes were associated with: higher expectancy for change among clients, lower client interpersonal problems, greater number of therapy sessions, and lower therapist case load. A second PPA-PRN study that I reported in my August 2013 Blog found that therapist efforts to foster client awareness of their emotions, thoughts, and behaviors were perceived as particularly helpful by both clients and therapists. Finally, the National Drug Abuse Treatment Clinical Trials Network (CTN) conducted several studies with the intent of bringing drug abuse researchers into the real world and creating opportunities for clinicians to participate in research. This network completed over 50 trials. For example, in one trial, researchers found evidence for better retention, treatment engagement, and family functioning for brief strategic family therapy compared to treatment as usual.

Practice Implications

A qualitative study reported by Castonguay and colleagues (2010) indicated that clinician involvement in PRN research fostered new learning as well as a sense of community with other professionals with shared goals. Therapists also indicated that their clients perceived their research participation as intrinsically meaningful and an opportunity to contribute to scientific knowledge. However, participating in a PRN had its challenges as well. Clinicians had to remember detailed procedures, at times practitioners had to depart from their clinical routine, and clinicians had to find time to complete questionnaires and other procedures. Castonguay and colleagues (2010) recommended that practice based research procedures in a PRN remain simple and clear, that clinicians have to have ready access to research staff for consultations, and that incentives have to be built in for clients and clinicians to participate. Studies in which research goals and clinical goals are indistinguishable are most likely to succeed.

Hill, C. & Knox, S. (2013). Training and supervision in psychotherapy. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 775-811). New York: Wiley.

Research on training and supervision in psychotherapy has proven to be very difficult to conduct. Part of the difficulty with the research is that the process under study is highly complex with many interacting variables. Therapists and supervisors have different personal qualities, patients have different levels of problems, training programs differ, supervision styles differ, and therapists and supervisors differ in terms of experience, case load, knowledge, and training background. Nevertheless there exists a moderately large literature on training, supervision, and continuing education in psychotherapy. However, the findings so far have been mixed and somewhat disappointing. In their chapter in the Handbook, Hill and Knox (2013) tackle the difficult task of summarizing this literature and giving some coherence to the findings. Is training and supervision effective? Hill and Knox tentatively conclude that the answer is “yes”. They provide some evidence that novice therapists can be trained in helping skills, that trainees improve over the course of training, that supervision enhances trainees’ awareness of self and others and improves their autonomy, and that experienced therapists, including those in the community can be trained to use manuals. Despite these positive findings, the existing literature also provided some sobering results. These less supportive findings include: that nonsupervised therapists did not differ from supervised therapists on therapy alliance and patient outcomes, that supervision sometimes has negative effects on trainees and their patients, that therapist experience may not be related to better patient outcomes, and that some highly facilitative non-professionals can be just as effective as trained therapists. What contributes to making training and supervision effective? The research in psychotherapy training and medical education is clear on this question: hands-on experience is key to learning a practice-based skill such as psychotherapy. Practice is the most helpful component of skills training. In medical education research, systematic reviews have shown that traditional didactic learning (i.e., classroom style lectures) had no significant impact on physician behaviors or patient outcomes. However, interactive programs (especially supervised rehearsal of skills) did have a significant positive impact on physician behaviors and patient outcomes. Furthermore, psychotherapy supervisees reported that supervisors who were open, empathic, and who provided supportive nurturance in the context of a good supervisory alliance were most helpful to trainees to develop and improve their clinical skills.

Practice Implications

Practicing clinicians who want to get the most out of continuing education should look for opportunities in which they get hands-on experience and continuous supervision in providing the psychotherapy intervention. Other than acquiring a limited amount of knowledge, didactic training alone without practice will likely have little impact on practice. The research also indicates that supervisors and trainees who are able to develop a good supervisory alliance, and supervisors who are open and empathic are more likely to result in improved psychotherapy skills in trainees and better outcomes in patients. Binder and Henry (2010) describe the importance of “deliberate practice” in psychotherapy training and continuing education that includes: performing a task at an appropriate level of difficulty, receiving immediate and informative feedback from a supervisor, and having the opportunity to repeat the skill and correct errors.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

This month I consider the section in Crits-Christoph and colleagues’ chapter on the process of psychodynamic therapy (PDT). There are a number of PDT models, but they each share some fundamental aspects of treatment or purported mechanisms. One is insight or self understanding, in which patients learn about themselves and their relationships through interventions like interpretations. Self understanding is expected to help patients reduce symptoms by increasing adaptive responses in their important relationships. Transference interpretations may help patients understand their patterns within the therapy relationship, address or change these patterns, and generalize the changes to relationships outside of therapy. Another mechanism might be changes in defensive functioning. Defense mechanisms may be expressions and means of coping with unconscious conflict, needs, and motivations. Change in defensive functioning from less adaptive (e.g. acting out, passive aggression) to more adaptive (e.g., altruism, self observation) may be necessary to achieve improvement in symptoms. Crits-Christoph and colleagues addressed four questions in their review of research on the process of PDT. (1) Are the uses of PDT techniques like transference interpretations related to treatment outcomes?  A number of studies have associated the use of PDT interventions and outcomes, and the average effect size is moderate. In general, transference interpretations were associated with better treatment outcomes. However the findings for transference interpretations are complicated. For example, the use of too many transference interpretations may not be therapeutic and may result in poorer outcomes. A small number of studies looked at the quality or accuracy of transference interpretations and found a moderate relationship between accurate interpretations and good outcomes. Most of these studies did not control for previous improvement in outcomes, so an alternate explanation might be that patients whose symptoms improve facilitate therapists to provide more effective transference interpretations. (2) Is patient self-understanding or insight associated with positive outcomes in PDT? Crits-Christoph and colleagues concluded from their review that changes in self-understanding is an important part of the therapeutic process of PDT. The relationship between insight and outcomes were not evident in CBT or medication interventions, thus suggesting that self-understanding is a specific mechanism of PDT. (3) Is change in defensive functioning related to outcomes in PDT? Only four studies have looked at this question. The studies suggest that improved defensive functioning is related to good outcomes especially for those with more severe problems. However, it remains unclear whether change in defensive functioning causes change in symptoms or the other way around. (4) Is therapist competence in PDT related to treatment outcomes? There is some evidence that competence and adherence in delivering PDT were related to good patient outcomes. Some research also showed that competence and adherence to PDT protocols preceded or caused good outcomes.

Practice Implications

There is good evidence that transference interpretations are related to outcomes, but therapists need to use these judiciously. The research suggests that too many transference interpretations in those with lower levels of functioning, or inaccurate interpretations in general, can reduce outcomes or be related to poorer outcomes. There is also good evidence that patient self understanding of relationship patterns will result in positive outcomes. Self understanding or insight may be a specific mechanism by which PDT works that sets it apart from CBT and the effects of medications. The research also indicates some evidence for the positive effects of changes in defensive functioning, but it is not clear whether change in defenses is a cause of or caused by positive symptom outcomes. Therapist competence and adherence in delivering PDT is also related to good patient outcomes. This highlights the need for training and supervision in evidence based PDT interventions.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In this section of their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research on: (1) specific techniques of cognitive behavioural therapy (CBT), and (2) change mechanisms of CBT for depression. Research on techniques and mechanisms of change tests the specific or unique effects of a treatment and the rationale for its use. The first issue addresses whether therapist adherence and competence in using CBT techniques produce desired outcomes in patients. CBT techniques include: following an agenda, reviewing homework, asking about specific beliefs, practicing rational responses with patients, and asking patients to keep thought records. Crits-Christoph and colleagues (2013) report that the research findings on the association between using specific CBT techniques and depression outcomes are mixed. The strongest evidence is for concrete techniques such as setting agendas, reviewing homework, and practicing rational responses. However the number of studies that control for prior symptom change and other factors like therapeutic alliance is small, and so the evidence for the specific effects of CBT techniques remains meagre. The second issue addresses whether targeting depressogenic cognitions with CBT results in positive outcomes. Generally, CBT theory argues that the mechanisms by which CBT works is to focus on core depressogenic schemas (i.e., less consciously long held negative beliefs about the self), conscious negative automatic thoughts, and dysfunctional attitudes (i.e., patterns of automatic thoughts) that lead to or maintain depression. Theoretically, addressing these cognitions in CBT should reduce depressive symptoms. Overall, the research shows that both CBT and medication treatment for depression reduce self-reported negative thinking; that is, the effects on negative thinking were not specific to CBT. Few studies show that changes in cognitions precede changes in depressive symptoms, which is a key CBT tenet. The most promising findings suggest that learning compensatory skills (i.e., finding alternative explanations for negative events and thoughts, and problems solving) may be part of the mechanism by which CBT works, but again this mechanism may not be specific to CBT.

Practice Implications

CBT is an effective treatment for depression. CBT theory suggests that the reason for its effectiveness is the use of specific techniques (i.e., reviewing homework, asking for specific beliefs, practicing rational responses with patients, and asking patients to keep thought records) that target the purported causes of depression (i.e., depressogenic shemas, negative thoughts, and dysfunctional attitudes). Currently there is little research evidence that supports the specificity of CBT techniques or that supports the notion that specific changes in cognitions as a result of CBT reduce depression. Nevertheless, in general, concrete techniques (i.e., setting agendas, reviewing homework, and practicing rational responses) are clinically useful for depressed patients, as is learning compensatory skills like problem solving.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.