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 therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
November 2014
Transference in Psychotherapy: A Review of the Research
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.
October 2014
Are Humanistic-Experiential Therapies Effective? Review and Meta-Analyses
Elliott, R.E., Greenberg, L.S., Watson, J. Timulak, L., & Briere, E. (2013). Research on humanistic-experiential psychotherapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 495-538). New York: Wiley.
Humanistic or experiential psychotherapies (HEP) include: person centred therapy, gestalt therapy, emotion-focused therapy, existential psychotherapy, and others. Elliott and colleagues argue that each of these approaches share the characteristic of valuing the centrality of an empathic and therapeutic relationship. That is, an authentic relationship between patient and therapist provides the client with a new and emotionally validating experience. HEP methods that deepen client emotional experiences occur within an empathic relationship, and interpersonal safety is key to enhancing a client’s attention for self awareness and exploration. Despite the long history of research in HEP, these treatments are often used as “control” conditions in outcome studies of psychotherapies – that is, to control for “non-specific” or relationship factors. Elliott and colleagues conducted meta analyses on the effectiveness of humanistic-experiential therapies. Overall, they included 199 studies of over 14,000 patients. Pre to post treatment effect sizes were large (d = .95), indicating a positive effect HEP across a wide range of clients. (A note on effect sizes: Cohen’s d < .20 represents a negligible effect; d = .20 to .49 is a small effect; d = .50 to .79 is a moderate effect; and d > .80 is a large effect). Compared to a wait-list control (62 studies), the positive effect of HEP was significant with a moderate effect size for the difference (d = .76). There were 135 studies that compared HEP to other active forms of psychotherapy. The difference between HEP and non-HEP therapies were trivial and non significant (d = .01). In the 76 studies that compared HEP to cognitive behavioral therapy (CBT), those who received CBT had better outcomes, but the effects were negligible (d = .13). The authors reported that there is enough evidence to indicate that HEP are efficacious for depressive disorders, substance misuse, and relationship problems; and HEP are probably efficacious for anxiety and psychotic disorders.
Practice Implications
The research on outcomes of humanistic-existential psychotherapies (HEP) provides support for the effectiveness of these therapies for a variety of disorders, and provides further support for the importance of the facilitative and relationship factors that help patients get better. Empathy, genuineness, positive regard each comes with research support to indicate their importance to patient outcomes. Elliot and colleagues conclude that the education of psychotherapists is incomplete without greater emphasis on HEP and its facilitative components.
August 2014
Depression as a Risk Factor for Poor Prognosis Among Patients with Acute Coronary Syndrome
Lichtman, J.H., Froelicher, E.S., Blumenthal, J.A., Carney, R.A., Doering, L.V., et al. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: Systematic review and recommendations: A scientific statement from the American Heart Association. Circulation, 129, 1350-1369.
There are about 15.4 million US adults with coronary heart disease. About 20% of those hospitalized for an acute coronary syndrome (ACS; that includes myocardial infarction or unstable angina) meet diagnostic criteria for major depression. An even larger percentage of those with heart disease show sub-clinical levels of depressive symptoms. As I reported in the June 2014 PPRNet Blog about 4% of the population suffer from depression, and so the rates of depression are substantially higher among those with ACS. There is a large body of research showing a reliable association between depression and increased morbidity and mortality after ACS. The goal of this scientific statement by the American Heart Association is to review current evidence for the role of depression as a risk factor among patients with ACS. The authors were particularly interested in studies looking at: (1) all cause mortality, (2) cardiac mortality, and (3) composite outcomes including mortality and nonfatal events. Fifty three studies, representing tens of thousands of patients were included in the review. Twenty one of 32 published studies indicated that depression is a risk factor for all-cause mortality after ACS. Fewer studies looked at the relationship between depression and cardiac mortality, but 8 of 12 studies suggested that depression is a risk factor for cardiac mortality after ACS. Finally evidence from 17 of 22 studies suggested that depression was a risk factor for combined outcomes of cardiac mortality, all cause mortality, and nonfatal cardiac events. The authors also reported on meta analyses looking at the association between depression and mortality following myocardial infarction. Depression increased the risk in individuals of mortality from 1.6 to 2.3 times. The authors concluded that the American Heart Association should elevate depression to the status of a risk factor for adverse medical events in patients with ACS.
Practice Implications
This scientific statement by the American Heart Association published in a technical journal read by cardiologists is important because it acknowledges a mental health problem as a risk factor for mortality from a common medical disease. The evidence is quite strong that depression increases the risk of death in those with heart disease, especially acute coronary syndrome (ACS). Some of the mechanisms for the risk may include genetic/physiological factors like inflammation, platelet aggregation, and the serotonin system that are associated with both depression and ACS. In addition, depression can result in less physical activity and poorer self care which could exacerbate a number of health problems that increase the risk for cardiac disease. Depression is also associated with increases in high risk health behaviors like smoking, sedentary lifestyle, and non-adherence to medical treatment. Assessing for and treating depression among patients who have a history of or are at risk of heart disease is important. If such a patient is depressed or has elevated depressive symptoms, then the depression should be treated in order to reduce the risk of death due to medical problems. In the July 2014 PPRNet Blog, I reported on a network meta analysis showing the positive effects of 7 psychotherapies for depression.
July 2014
Evidence for Psychodynamic Therapy of Personality Disorders
Barber, J.P., Muran, J.C., McCarthy, K.S., & Keefe, J.R. (2013). Research on dynamic therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 443-494). New York: Wiley.
In this part of their chapter, Barber and colleagues (2013) summarize the research on the efficacy of dynamic therapies for personality disorders. As the authors indicate, dynamic therapies refer to a family of interventions that: focus on the unconscious, affect, cognitions and interpersonal relationships; use interpretations and clarifications; consider transference and countertransference; and use the therapeutic relationship to improve self understanding and self-awareness. Following Magnavity (1997), the authors describe dynamic therapies specifically for personality disorders as identifying maladaptive, recurring patterns of thinking, behaving and emotional responding with the intent of restructuring these through linking current and transference patterns to early attachment and trauma. Barber and colleagues conducted meta analyses of available research on dynamic therapies for personality disorders. They combined several outcomes based on patient and observer reports as an index of general outcome. In seven studies representing 452 patients, dynamic therapies for personality disorders were more effective than control conditions (i.e., treatment as usual, or wait-lists), and the size of the effect was moderate. They found no significant differences between dynamic therapies and other types of therapy for personality disorders. Dynamic therapies had significant advantages over control conditions for general symptomatology, interpersonal problems, personality pathology, and suicidality. These therapeutic effects were maintained to short-term follow up.
Practice Implications
There are now several dynamic therapies for personality disorders that have substantial research evidence for their efficacy. For example, Transference Focused Psychotherapy for borderline personality disorder is considered a “well-established” treatment by the American Psychological Association Division 12. Mentalization-based treatment is also considered to be “probably efficacious”. Other “probably efficacious” dynamic therapies include: McCullough-Vaillant’s short term dynamic psychotherapy (STDP) and brief relational therapy for Cluster C personality disorders (i.e., avoidant, dependent, obsessive-compulsive); and intensive STDP for general personality disorder.
Is There Such a Thing as Expertise in Psychotherapy?
Tracey, T.J.G., Wampold, B.E., Lichtenberg, J.W., & Goodyear, R.K. (2014). Expertise in psychotherapy: An elusive goal? American Psychologist, 69, 218-229.
As I have reported many times in this blog, there is substantial evidence for the efficacy of psychotherapy. However, the quality of psychotherapy differs across therapists – that is, some therapists achieve better client outcomes than others. Tracey and colleagues (2014) ask: is it possible to demonstrate expertise in psychotherapy? They define expertise as “increased quality of performance that is gained with additional experience”. Professions that can demonstrate expertise include: astronomers, test pilots, chess masters, mathematicians, and accountants. But several professions may not demonstrate expertise, including: psychiatrists, college admissions officers, court judges, personnel selectors, and psychotherapists. The difference is that the former group has predictable outcomes and has access to quality feedback. In addition, Tracey and colleagues argue that psychotherapy lacks adequate models for how interventions produce benefits. As a result, adherence to treatment protocols (i.e., manuals) is not reliably associated with better patient outcomes. Further, more experienced therapists are not more effective than less experienced therapists. Experienced therapists might have more complete conceptualizations of client problems, but these conceptualizations may not be accurate. Finally, although therapists affect outcomes, client variables (e.g., motivation, severity of symptoms, expectations) likely explain the largest proportion of outcome variance. Tracey and colleagues argue that part of the problem is that psychotherapists do not engage in “deliberate practice”; that is, practice of a specific task (e.g., identifying a rupture in the alliance), receiving specific feedback (e.g., that a rupture was not identified), opportunity for repetition (e.g., to identify a subsequent rupture in the alliance), and opportunity for improvement afforded by error (e.g., better able to identify a future rupture and repairing that rupture). Generally the practice of psychotherapy provides little feedback about the accuracy of past clinical decisions. In other words there is a lack of quality information to help therapists develop into experts. Further, for a whole host of reasons, psychotherapists are notoriously poor at assessing client progress (i.e., like other humans, therapists engage in a number of biased evaluations of their performance). Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes. However, this may not aid therapists in developing expertise, since progress monitoring provides little information about what therapist behaviors are necessary to improve performance and client outcomes.
Practice Implications
Tracey and colleagues conclude that currently psychotherapy does not provide evidence that it is a profession with expertise. To achieve expertise, therapists need quality information not only about their patients’ outcomes but also about their own average outcomes (i.e. performance) relative to other therapists working with similar clients. And therapists need information on how to manage specific events in psychotherapy. Tracey and colleagues suggest therapists set aside time to generate hypotheses about one’s practice that can be disconfirmed, and then test these hypotheses. For example, if a therapist is experiencing a higher than average number of premature client terminations (which may follow a misunderstanding with the client), the therapist may hypothesize that he or she is not identifying key alliance ruptures. To test this hypothesis, the therapist could repeatedly assess the alliance (with a validated instrument) with some clients, use this information and not clinical judgement alone to identify alliance ruptures (i.e., a week to week severe downward trend in alliance scores), and implement an intervention to repair the alliance with these clients. Do clients with whom a therapist has implemented this procedure drop out at a lower rate? Does this process of deliberately identifying alliance ruptures and repairing them lead to enhanced therapist performance regarding alliance ruptures? This form of deliberate practice (testing disconfirmable hypotheses based on quality information) might lead to greater expertise in identifying alliance ruptures.
June 2014
Cognitive Therapy for Depression
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.