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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Progress Feedback Narrow the Gap Between More and Less Effective Therapists
Delgadillo, J., Deisenhofer, A.-K., Probst, T., Shimokawa, K., Lambert, M. J., & Kleinstäuber, M. (2022). Progress feedback narrows the gap between more and less effective therapists: A therapist effects meta-analysis of clinical trials. Journal of Consulting and Clinical Psychology, 90, 559–567.
Some therapists are more effective than others. This is often referred to as the therapist effect. Somewhere between 1% and 29% of patient outcomes can be attributed to which therapist the patient receives. In general, therapists with high facilitative interpersonal skills, high humility, and an ability to withstand difficulties in practice (i.e., ruptures, burnout) may be more clinically effective. To improve outcomes in therapy, some have suggested using routine outcome monitoring and progress feedback. This involves regularly measuring and tracking patient progress with standardized self-report scales throughout treatment and providing the clinician with this information during therapy. Progress feedback allows the therapist to compare their patient’s progress against norms and against the patient’s own progress in preceding sessions. If the patient is not progressing or is deteriorating, then the therapist is alerted to address the issue. Research indicates that progress feedback makes therapy more effective. Less is known about how progress feedback leads to better outcomes. In this meta-analysis, Delgadillo and colleagues assessed the impact of progress feedback on the therapist effect – that is, does progress feedback improve the outcomes of less effective therapists? The meta-analysis was of six clinical trials with data from 4,549 patients and 131 therapists who were randomly assigned to a progress feedback condition or to a control condition without progress feedback. The variability between therapists (ICC = .011) suggested that 1.1% of the overall variance in patient outcomes was due to therapist effects. However, feedback was associated with a significant reduction in the therapist effect (ICC = .009) by 18.2%. A closer look at the data indicated that progress feedback narrowed the gap between more and less effective therapists, such that patients of less effective therapists benefitted the most from their therapist receiving feedback.
In this meta-analysis conducted on data from controlled studies, there were few under-performing therapists. However, implementing progress feedback was clinically important to achieve better outcomes among some of these therapists. That is, even a single underperforming therapist could attain relatively poor outcomes with dozens or even hundreds of patients. Who the therapist is matters – and some therapists (and their patients) can benefit from supplementing clinical judgement with reliable feedback about patient progress throughout the course of psychotherapy.
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
Cuijpers, P., Karyotaki, E., Eckshtain, D., Ng, M.Y., Corteselli, K.A…. Weisz, J.R. (2020). Psychotherapy for depression across different age groups: A systematic review and meta-analysis. JAMA Psychiatry, 77, 694-702. doi:10.1001/jamapsychiatry.2020.0164
There are now hundreds of controlled studies showing the efficacy of psychotherapy for depression. Most of these studies have focused on specific age groups, so that psychotherapies were tested for children, adolescents, adults, and older adults separately. Few studies have looked at whether psychotherapy has different effects across age groups. This information might be important because it may indicate that some therapies might have to be altered or specifically designed for the age group. In this meta-analysis, Cuijpers and colleagues collected all randomized controlled trials of psychotherapy vs no treatment, usual care, or some other control group for depression across age groups. They found 366 studies representing over 36,000 patients. The studies included those of children, adolescents, young adults, middle-aged adults, older adults, and older old adults. The overall effect size across all age groups was g = 0.75 (95% CI, 0.67-0.82) suggesting a moderate effect of psychotherapy for depressive symptoms at post-treatment. The effect size for children was the lowest (g = 0.35, 95% CI: 0.15-0.55, k = 15), and the effect size for adolescents (g = 0.55, 95% CI: 0.34-0.75, k = 28) was also low. Effects for middle-aged adults (g = 0.77, 95% CI: 0.67-0.87, k = 304), older adults (g = 0.66, 95% CI: 0.51-0.82, k = 69), and older old adults (g = 0.97, 95% CI: 0.42-1.52, k = 10) were not significantly different. Young adults consistently had significantly better outcomes (g = 0.98, 95% CI: 0.79-1.16) than the other age groups except when compared to older old adults.
It is possible that psychotherapies for depression as currently tested in the research literature are less effective for children and youth. This may be because the treatments that are most often used with children and adolescents are age adapted versions of therapy originally designed for adults. Psychotherapy for children and adolescents are affected by parental and family characteristics, and that these contexts may not be adequately accounted for by the therapies as currently tested and practiced. In any case, this meta-analysis suggests that current therapies for childhood and adolescent depression may need to be reconsidered given their relatively lower effects.
Multicultural Competence and Orientation
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Therapist multicultural competence is a commitment to increasing one’s knowledge of patient’s cultural background, tailoring interventions to a patient’s culture, and understanding the impact of one’s own cultural background. Multicultural competence research has looked at its impact on clinical interactions. In a meta-analysis of 15 studies, therapist multicultural competence was associated with lower levels of patient drop-out from therapy (r = 0.26) and with greater patient improvement (r = 0.24). An interesting finding of these meta-analyses is that whereas patient ratings of a therapist’s multicultural competence was significantly associated with better patient outcomes (r = 0.38), therapist ratings of their own multicultural competence was not significantly associated with outcomes (r = 0.06). In other words, if one is interested in a therapist’s multicultural competence then one should ask the patient, not the therapist. A related but broader concept is multicultural orientation. The multicultural orientation framework is not so much a theoretical approach but a “way of being” for a therapist. The three aspects of multicultural orientation include cultural humility (in which a therapist takes an open and curious stance towards the patient’s identities), cultural opportunities (in which the therapist actively explores a patient’s cultural beliefs and values), and cultural comfort (or the extent to which a therapist feels at ease working with cultural dynamics). A systematic review of multicultural orientation theory identified 9 articles that found that therapist cultural humility was associated with better therapeutic alliances, fewer in-session microaggressions, and greater patient improvement.
The research on multicultural competence suggest that therapists should regularly assess a patient’s cultural identities for adapting the therapeutic approach. This assessment should focus on the patient’s, not the therapist’s, evaluation of the therapist’s multicultural competence. It is also important for therapists to build their knowledge of specific cultural groups when tailoring their treatments. Regarding a multicultural orientation, it appears that a therapist’s cultural humility is critically important. That is a therapist who is open, non-defensive, and curious regarding a patient’s identities will be most helpful to patients of various cultures.
Psychological Therapies for Culturally Diverse Populations
Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 5.
Psychological therapies are culturally bound practices with certain values built into them. For example, common therapies prize independence in patients and rapport in the therapeutic relationship. However, some cultures may value community rather than independence, and respect rather than rapport. In this part of the chapter, Barkham and Lambert ask: what is the effect of a conventional psychotherapy that is based on the values of a dominant culture when applied to a different ethnic or racial group? In one small meta-analysis of 9 and 16 studies, culturally adapted interventions were significantly more effective than unadapted interventions g = 0.52 (95% CI [0.15, 0.90]) and resulted in close to 5 times greater odds of remission. Adaptation usually refers to incorporating some cultural practices into the therapy, adapting the language of the therapist, or providing a therapist who is from the same culture as the patient. Similarly, there is research on the effects of a multicultural competency and multicultural orientation of the therapist. These competencies refer to therapists who learn about a patient’s culture, use culturally relevant treatment strategies, and are aware of their own assumptions and biases regarding the patient’s culture. A meta-analysis of 18 studies reviewed the impact of a therapist’s multicultural competence on various aspect of therapy. Therapist multicultural competence accounted for 37% of the working alliance, 52% of patient satisfaction, 38% of a patient’s perception of therapist competence, and 34% of depth of the session. However, therapist multicultural competence accounted for only 8% of patient outcomes. More recently, some authors have discussed the importance of multicultural orientation, which refers to a therapist’s cultural humility as an attitude towards the patient’s culture, a therapist’s willingness to explore the patient’s racial and cultural identities, and the therapist’s comfort with cultural diversity.
The research on the impact of psychotherapy on diverse patient populations is still rather small, but some practice implications can be gleaned. Adapting therapies to the patient’s culture and identity likely will improve patient mental health outcomes. The adaptation might include incorporating cultural practices, metaphors, and values into the therapy, and providing therapy in the language of the patient, or finding a therapist from the same cultural background as the patient. Similarly, there is evidence that therapists who are multiculturally competent (learn about the patient’s culture and checks their own biases) can provide a deeper therapeutic experience for their patients. Emerging research on therapist multicultural orientation suggests that a therapist’s cultural humility, willingness to engage in cultural conversations, and comfort with diverse cultures may lead to better experiences of therapy for their patients.
Routine Outcome Monitoring
Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 4.
Routine outcome monitoring is also known as progress monitoring and feedback. This involves regularly assessing patients with a psychometrically reliable scale before a therapy session and providing the therapist with feedback on the patient’s progress. The feedback includes how the patient is doing relative to the average patient, and how the patient is doing in this session relative to their own scores in previous sessions. By doing this, therapists can get regular and reliable information about their patient’s progress and be alerted to when the patient is not on track to improve or is getting worse. Decisions about patient improvement on a session-to-session basis are complex because they involve knowing how the patient is doing regarding symptoms, quality of life, and relationship functioning relative to other patients and relative to their own functioning in the past. No wonder therapists often mis-judge when a patient is getting worse. Routine outcome monitoring involves decision-making tools to enhance a clinician’s decisions – like the way a physician uses a blood test or x-ray to enhance their clinical observations. In this part of the chapter, Lutz and colleagues review the research over the past 50 years on outcome monitoring and feedback. The effects of psychotherapy with feedback compared to psychotherapy without feedback ranges from small (g = .07) to medium (d = .40) in size. These effects seem small, but the authors remind us that feedback is a relatively simple clinical tool provided in addition to psychotherapy, and so these positive effects occur are over and above the general effectiveness of psychotherapy. Highest effect sizes are achieved for clients who are not on track (likely to get worse) such that feedback compared to no feedback in these not-on-track patients result in effect sizes ranging from 0.36 to 0.53, indicating a moderate to large effect. Further, when feedback was provided, patient dropout was reduced by 20% compared to when feedback was not provided.
Although routine outcome monitoring is relatively easy to use, there are barriers to their implementation. Organizational cultures are difficult to change, and resources must be assigned to implement these strategies. Clinicians must have the technology, some training, and funds to purchase the psychometric scales which may be a challenge for some. And attitudinal barriers are a problem if managers or clinicians do not value outcome measurement. Nevertheless, patient reported outcomes with psychometrically valid scales should be central to ensure good patient-centered care. Psychotherapists can benefit from quality information to help their clinical decision making, especially when it comes to identifying patients who might not be benefitting. Such feedback about patients who are at risk of getting worse may help clinicians to adjusting treatment and their interpersonal stances to these patients.
Psychological Treatments for Panic Disorder
Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148
Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.
The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.