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 psychotherapy for adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
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 2023
Therapist Qualities That Lead to Treatment Failure or Termination
Alfonsson, S., Fagernäs, S., Sjöstrand, G., & Tyrberg, M. J. (2023). Psychotherapist variables that may lead to treatment failure or termination—A qualitative analysis of patients’ perspectives. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000503
Research indicates that about 14% of patients terminated psychotherapy because it did not help them, and 7% because they were not comfortable with their therapist. Psychotherapists have difficulty identifying when patients are at risk of terminating the treatment, and many therapists do not identify when a patient is getting worse. In other words, therapists may not be a good source of understanding when and why patients do not improve and leave therapy. When researchers ask therapists to speculate about why a patient terminated prematurely, the therapists often focus on patient-related factors and not therapist-related factors. In this study, Alfonsson and colleagues interviewed 24 adult patients who had a negative experience in therapy or who terminated prematurely within the past year. Alfonsson and colleagues’ goal was to gather patient perspectives on what went wrong to begin to understand the phenomenon and to guide future training and practice of therapists. Qualitative analysis of the interview transcripts yielded four main categories of therapist variables as perceived by the patient that led to negative outcomes. The first main category was the Therapist's Negative Traits. This included therapist inflexibility/rigidity regarding their assessment of the patient and treatment plan, unengaged therapists who were not paying attention during sessions, unempathetic therapists who did not express warmth or caring for the patient’s situation, and insecure therapists who were too uncertain or oversensitive. The second main category was Therapist Unprofessionalism. This included therapists who were too superficial and avoided difficult topics, therapists who were informal such that they acted too familiar, or they were too affected by their own moods, therapists who were perceived to break confidentiality, and therapists who were nontransparent and seemed to withhold information. The third main category was Therapist Incompetence. This included therapists who were unstructured in their treatment and lacked focus, therapists who had a poor understanding of the patient’s problems by missing important issues or not understanding the patient’s situation, therapists with poor knowledge and lacked competence in a particular treatment model, and therapists who were too passive by not providing active treatment. The fourth category was Therapist Mismatch in which patients did not feel that they connected with the therapist.
Practice Implications
Some of the therapist factors are practical in nature such as those in the Therapist Incompetence category and parts of the Therapist Unprofessionalism category. For such issues, therapists may need more training that focuses on ethical practice, gaining better knowledge of psychopathology and treatment, and applying such knowledge to therapy with various patients. However, other factors like Therapist Negative Traits and parts of the Therapist Unprofessionalism category may be more challenging. These refer to personal traits of the therapist such as a perceived lack of empathy, personal insecurity, rigidity, and a tendency to remain superficial. Changing these traits may require therapists to engage in ongoing supervision and personal therapy. Therapists can also engage in routine outcome and process monitoring to get session-to-session feedback about patient experiences, symptoms, and the therapeutic alliance to help identify when things are not going well in the therapy before the patient drops out.
Different Aspects of the Therapeutic Relationship Are Associated with Different Outcomes
Finsrud, I., Nissen-Lie, H. A., Ulvenes, P. G., Vrabel, K., Melsom, L., & Wampold, B. (2023). Emotional and cognitive processes in psychotherapy are associated with different aspects of the therapeutic relationship. Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000853
One can understand the therapeutic relationship as having an emotional component and a cognitive component. Researchers have found that these two components of the therapeutic relationship can be conceptualized as two factors: a patient’s Confidence in the Therapist (a patient who perceives their therapist as warm, empathic, competent, and trustworthy), and a patient’s Confidence in the Treatment (a patient’s experience of the treatment as viable and as providing a meaningful way to accomplish change). These factors align with the therapeutic alliance in that Confidence in the Therapist is akin to the bond aspect of the alliance, and Confidence in the Treatment is like the collaborative agreement on the tasks and goals aspects of the alliance. In this large naturalistic study, Finsrund and colleagues assessed if Confidence in the Therapist and Confidence in the Treatment are related to different types of outcomes (change in emotional clarity vs change in rumination), and to different types of therapy (CBT vs psychodynamic). The study had 631 adult patients with anxiety or depressive disorders and 54 therapists who conducted either CBT or psychodynamic therapy. Therapists treated the patients in a hospital setting in Norway and patients completed measures of Confidence in the Therapist, Confidence in the Treatment, symptom outcomes, rumination, and emotional clarity on a weekly basis for up to 12 weeks of treatment. Patients were highly symptomatic and more than 89% had more than one clinical diagnosis. As expected, higher Confidence in the Therapist predicted emotional change (higher emotional clarity) and higher Confidence in the Treatment predicted cognitive change (lower rumination). However, higher Confidence in the Therapist predicted better emotional clarity only in the patients receiving psychodynamic therapy, whereas higher Confidence in the Treatment predicted less rumination in both CBT and psychodynamic therapy (although the effect appeared larger in CBT).
Practice Implications
The results are in line with the notion that different aspects of the therapeutic relationship play different roles depending on the outcomes that patients and therapists desire. In cognitively oriented therapies, therapists rely more heavily on providing a viable explanation of the symptoms, a treatment rationale that is consistent with the explanation, and tasks of therapy (homework, self-monitoring, behavioural experiments) that are consistent with the treatment rationale. In psychodynamically-oriented therapies, therapists focus on emotional and relational changes in which therapists and patients work through aspects of the therapeutic relationship that deal with their affective bond and their interpersonal work together. Effective therapists likely do both with patients – i.e., they come to an agreement on the tasks and goals of therapy (the rationale for treatment) and they repair ruptures in the therapeutic alliance as a means of achieving interpersonal learning and emotional change.
Psychological Therapies Improve Patient Quality of Life
Kolovos, S., Kleiboer, A., & Cuijpers, P. (2016). Effects of psychotherapy for depression on quality of life: Meta-analysis. British Journal of Psychiatry, 209, 460-468. https://doi.org/10.1192/bjp.bp.115.175059.
It is well-documented that depression is the most common mental disorder among adults and is associated with substantial impairments in quality of life. Quality of life refers to a range of life domains including social relationships, physical abilities, mental health functioning, role functioning, and engagement in daily activities. Several meta-analyses exist demonstrating that a range of different psychotherapies are effective in reducing depressive symptoms. Until this study by Kolovos, there wasn’t a meta-analysis looking at the effects of psychotherapies for depression on patients’ quality of life. In this study, the authors meta-analyzed 44 studies that included over 5000 adult patients with depressive symptoms. The psychotherapies varied from CBT to acceptance and commitment therapy, to interpersonal psychotherapy that were compared to a control group in a randomized controlled trial. Quality of life was measured pre- and post-treatment. Typically, quality of life was assessed in two domains – mental health quality of life was defined as personal satisfaction with the current psychological state, and physical health quality of life referred to perceived competence to perform and function in everyday activities. Global quality of life refers to an overall assessment of the mental health and physical health domains. The mean effect size of psychotherapy for global quality of life after adjusting for publication bias was g = 0.30 (95% CI 0.21–0.40) indicating a small but significant effect. For the mental health domain, after adjustment for publication bias, the mean effect size was g = 0.37 (95% CI 0.28–0.47) indicating a small to moderate effect of psychotherapy. For the physical health domain, after adjusting for publication bias the mean effect size was g = 0.13 (95% CI 0.01–0.25) indicating a small significant effect. For both the global measure of quality of life and the mental health domain, the effects of psychotherapy were larger when patients had more severe symptoms.
Practice Implications
Overall, the authors concluded that psychotherapy for depression has a positive impact on various domains of patients’ quality of life like their mental functioning, social and work relationships, and engagement in everyday activities. These findings are especially large for those patients with more severe symptoms who received psychotherapy. It is possible that as depressive symptoms lift, patients begin to have the energy, self-esteem, and concentration necessary to engage in everyday life activities.
October 2023
Psychotherapies for borderline personality disorder reduce suicide risk by half.
Setkowski, K., Palantza, C., van Ballegooijen, W., Gilissen, R., … Cuijpers, P. (2023). Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis. Psychological Medicine, 1–20. https://doi.org/10.1017/S0033291723000685
Borderline personality disorder (BPD) is characterized by severe functional impairments, high levels of distress, and a high risk of suicide. The prevalence rate of suicide attempts is very high ranging from 55% to 85%. As many as 85% of patients with BPD achieve remission (no longer diagnosed with BPD) within 10 years. Treatment guidelines consider psychological therapies as the first-line therapies for BPD. Several previous meta-analyses of these therapies have resulted in varying results – with some showing that specific treatments are effective but other studies not reporting the same results. Some of the inconsistencies across meta-analyses can be explained by the fact that there are as many as 10 tested bona fide therapies with relatively few trials assessing each one to a control condition. In this study, Setkowski and colleagues used what is known as network meta-analysis which allows one to compare relative treatment effects even if some treatments were not compared to each other in the same study. There are pros and cons to this approach that are too technical to get into here, but suffice it to say that the network meta-analysis methodology has sparked debate. In this network meta-analysis, the authors reviewed a total of 43 randomized controlled trials of psychological therapy for adults with BPD compared to a treatment-as-usual (TAU) control condition. The main outcomes were BPD symptom severity, suicidal behaviours, and dropping out of treatment (as an index of acceptability of the treatment). The authors found that dialectical behaviour therapy (DBT), Schema Therapy (ST), and Mentalization-Based Therapy (MBT) were more effective than TAU and generic treatments (i.e., therapy not specifically for BPD) for reducing symptoms of BPD. There was some evidence that Schema Therapy was the most effective treatment, but this was based on very few studies and so the authors did not consider this to be a reliable finding. When comparing psychological treatments with each other, no one treatment was more effective relative to another psychotherapy. Regarding suicide risk, no psychotherapy was significantly superior to treatment as usual. However, several treatments reduced the risk of suicidal behaviour by almost 50%. Schema Therapy and Transference Focused Therapy (TFP) both had the lowest dropout rates thus indicating high acceptability of these treatments for patients, but again these findings were based on very few studies.
Practice Implications
Although this study adds to the discussion of which therapy is best for BPD, the results are muddied by the small number of studies for each treatment approach. And, unfortunately, the network meta-analysis approach did not clarify the issues. The authors’ decision to split up therapies of the same orientation (e.g., psychodynamic, transference-focused, mentalization-based) into separate sub-categories made it even more difficult to draw conclusions because the number of studies of each sub-category is small. The authors concluded that there is not strong enough evidence to answer the question of which treatment is most effective for BPD. On the positive side, psychological therapies in general reduced the risk of suicide attempts by half.
How Reliable is the Research on CBT Plus ERP for Obsessive-Compulsive Disorder?
Reid, J.E., Laws, K.R., Drummond, L., Vismara, M. Grancini, B., Mpavaenda, D., Fineberg, N.A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.
Cognitive-behavioural therapy (CBT) combined with exposure and response prevention (ERP) is considered by many the treatment of choice for obsessive-compulsive disorder (OCD). However, questions remain about the size of its effects, the reliability of the research, and the relative efficacy of CBT plus ERP compared to other psychological treatments. Reid and colleagues conducted a systematic review and meta-analysis of randomized controlled trials of CBT with ERP in patients of all ages with OCD. They included 36 studies with 2000 patients (537 children/adolescents and 1483 adults) receiving treatment and 1015 in control conditions. When compared against all control conditions, CBT with ERP showed a significant and large effect (g = 0.74: 95% CI = 0.51 to 0.97 k =36). While CBT with ERP was more effective than a “psychological placebo” (e.g., progressive relaxation; g = 1.13: 95% CI 0.71 to 1.55, k = 10) and no treatment control conditions (g = 1.27: 95% CI 0.79 to 1.75), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI −0.27 to 0.16, k = 8). When compared to pharmacological treatment with an adequate dosage of selective serotonin reuptake inhibitors, CBT with ERP was marginally better with a small effect (g = 0.32: 95% CI -0.00 to 0.64, p = 0.05). Researcher allegiance or bias had a big impact on the effects of CBT with ERP. Researcher allegiance refers to studies conducted by researchers who prefer, favour, or have a vested interest in the treatment they are testing. In the studies identified as having researcher allegiance, a large favourable effect for CBT with ERP emerged (g = 0.95: 95% CI 0.69 to 1.2). By contrast, in trials where the authors did not identify researcher allegiance (k= 8), CBT with ERP showed no significant effects (g = 0.02: 95% CI−0.29 to 0.33). This difference was statistically significant (Q = 20.33, p < 0.005). There was no evidence of publication bias, but 28 of the 36 studies had a high risk of bias (in which there were deficiencies in the research design, procedures, or data analyses).
Practice Implications
At this point, CBT plus ERP is the most studied treatment for OCD, and it appears to be effective in reducing symptoms post-treatment. However, this meta-analysis raises more questions than it answers about the reliability of the research. Other active treatments (e.g., CBT without ERP) appear just as effective, which suggests that ERP may not be necessary to treat OCD. Researchers who favor or have a vested interest in CBT plus ERP produce much larger effects for their preferred treatment, and the quality of most of the research is low. Such findings lower one’s confidence in the conclusions drawn from the research.
Hope and Expectancy Factors
Constantino, M.J., Muir, H.J., Gaines, A.N., & Ouimette, K. (2023). Hope and expectancy factors. In The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness, (pp.131 – 153), S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors). American Psychological Association. https://doi.org/10.1037/0000358-007
In the early days of psychotherapy research, Jerome Frank wrote cogently about hope and persuasion as the bedrock of psychotherapy’s effectiveness. These days, researchers refer to hope as outcome expectations – or the prognostic belief that a given course of treatment will be helpful. One might consider outcome expectations to be a factor behind the placebo effect – or positive outcomes in the absence of a specific therapeutic ingredient. Whereas pharmacological researchers try to control or reduce the placebo effect, psychotherapists often cultivate and take advantage of outcome expectations to improve client outcomes. In this chapter, Constantino and colleagues review the research on outcome expectations. A meta-analysis showed a small but significant positive effect on outcomes, with outcome expectations explaining approximately 3% of clients’ post-treatment outcomes. This is not a large effect by any means, but significant enough for clinicians to consider how to make the best use of these expectations. One of the mechanisms by which outcome expectations might affect patient outcomes is through the development and maintenance of a therapeutic alliance. In another meta-analysis, early outcome expectations predicted better client-rated alliance during treatment, which in turn predicted better post-treatment outcomes. That is, the client’s outcome expectations could facilitate a collaborative bond with the therapist, which in turn is associated with good client outcomes.
Practice Implications
As a therapist, one should be realistic about the potential effects of therapy for a client while at the same time taking advantage of the potential benefits of a client’s outcome expectations. It might be useful for therapists to gauge the client’s early treatment expectations and to prioritize promoting hopefulness when a client’s expectations are unrealistically low. This might involve collaboratively developing achievable treatment goals and coming to an agreement with the client on how therapy will proceed to meet these goals. That is, to develop a therapeutic alliance as a means of promoting a client’s hope that the agreed-upon treatment plan is credible and will be helpful.