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 transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
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
Mindfulness-Based Interventions Among People of Color
Sun, S., Goldberg, S.B., Loucks, E.B., & Brewer, J.A. (2021). Mindfulness-based interventions among people of color: A systematic review and meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2021.1937369.
In the United States, people of color (POC) are disproportionately affected by structural inequalities related to racism such as high rates of incarceration, poor housing, and economic difficulties. Racial disparities also exist in health care such that POC are less likely to use health services thus resulting in more persistent health problems. Research has shown that mindfulness-based interventions (MBIs) may be effective in improving health outcomes of conditions that are prevalent among POC like psychiatric symptoms and cardiovascular disease. Some argue that MBIs are especially culturally relevant to POC because of the focus on overall well-being, the emphasis on resilience, and communally delivered formats. In this meta-analysis, Sun and colleagues systematically reviewed 24 randomized controlled trials with a total of over 2000 participants in which MBI was compared to no treatment or to an active control (a control group that was meant to be therapeutic). Only trials in which the study sample was predominantly (>75%) POC were included. At post-treatment, MBIs showed small but statistically significant outcomes compared to active controls (k = 16, g = 0.11, 95% CI = [0.04, 0.18], p = .002) and to no treatment (k=8, g = 0.26, 95%CI = [0.07, 0.45], p = .007). These are smaller effects than reported in other populations. Drop-out rates for POC receiving MBI was about 22%, which is similar to what is reported in the general psychotherapy outcome literature.
The results suggest a modest effect of MBI for POC, and that the effects may be smaller than reported in studies with other populations. Only two of the studies reported culturally adapting MBI for POC. Psychotherapists might consider cultural adaptation of MBI or providing MBI from a multi-cultural orientation framework that includes therapists’ cultural humility, making the best of cultural opportunities in therapy, and developing cultural comfort and competence.
What Proportion of Patients Benefit from Short-Term Psychotherapy?
Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Hisashi, N., &Furukawa, T.A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 10.1111/acps.13335. Advance online publication.
Many meta-analyses report that psychological therapies are effective to treat depression, that there are no differences between types or orientations of therapy in their outcomes, and that psychotherapy is as effective as medications in the short term and perhaps more effective in the longer term. But what do these findings mean for everyday practice? Many meta-analyses report a standardized mean effect size between treatment and control conditions. However, the effect size is an abstraction that may be difficult to interpret unless you understand the statistic. Clinicians may ask a more practical question: what is the proportion of patients that improve (have meaningful reductions in depression scores) and recover (improved and no longer are depressed)? This meta-analysis by Cuijpers and colleagues of 228 studies representing over 23,000 adult patients looked at the proportion of patients who improved and recovered after psychotherapy relative to those in control conditions (no treatment, care as usual, pill placebo). The psychotherapies were short term manualized treatments like CBT, behavioral activation, interpersonal psychotherapy delivered in individual, group, and self-help formats. About 41% of patients improved with psychotherapy for depression compared to 17% that improved with usual care and 31% for pill placebo. However, after statistically controlling for publication bias (i.e., the likelihood that some unflattering studies were never published), the improvement rate for psychotherapy was 38%. Recovery rates for psychotherapy ranged from 26% to 34%, and recovery in the control conditions ranged from 9% to 17%. There were no differences between therapy orientations. Highest rates of recovery or improvement were achieved by individual therapy and the lowest rates were seen in guided self-help. Deterioration rates were just below 5% in psychotherapy and about 7% to 13% in control conditions.
The effects of time-limited manualized psychotherapies tested in randomized controlled trials were modest. About 40% of patients improved and about 30% recovered. On the positive side, psychotherapies resulted in only about 5% of patients getting worse. The authors argued that clinicians must consider more effective strategies beyond these approaches to improve outcomes for depression. Some have focused on improving psychotherapist effectiveness, rather than on specific interventions. Methods like progress monitoring, managing countertransference, and repairing therapeutic alliance ruptures are means of improving psychotherapists’ effectiveness.
Psychotherapy for Sub-Clinical Depression in Children and Adolescents
Cuijpers, P., Pineda, B.S., Ng, M.Y, Weisz, J.R., Muñoz, R.F., Gentili, C., Quero, S., Karyotaki, E. (2021). A meta-analytic review: Psychological treatment of subthreshold depression in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, Online first publication.
Depression occurs in 2.6% of children and adolescents, with as many as 14% of adolescents meeting criteria for a depressive disorder before the age of 18. Depression in youths is related to a number of impairments, negative health outcomes, and to increased risk of depression as an adult. Subthreshold depression represents clinically important depressive symptoms that does not meet diagnostic criteria for major depression or dysthymia. Like major depression, subthreshold depression is related to impairment and increased mortality. Subthreshold depression in adolescents is related to increased risk for developing other disorders including future depressive disorders in adulthood. In this meta analysis, Cuijpers and colleagues present a review of direct comparison randomized controlled trials of psychological interventions for children and adolescents with subthreshold depression. The meta-analysis included 12 trials representing over 1500 children and adolescents. Eight studies tested CBT, and the others tested IPT or supportive therapy. The pooled effect size of the difference between the psychological interventions and control conditions at post treatment was g = 0.38 (95% CI: 0.14 to 0.63), indicating a small to moderate effect of psychological therapies to reduce subthreshold depression in children and adolescents. The authors found some evidence of publication bias (i.e., the likelihood that some studies were conducted but never published) and after adjusting for this bias, the effect size dropped to g = .24 (95% CI: -0.06 to 0.54) which was not statistically significant. There were only two studies of the treatment of children which showed small non-significant effects, g = 0.01 (95% CI: -1.16 to 1.18), however the effects of treatment for adolescents were considerably better, g = .44 (95% CI: 0.16 to 0.71). Longer term follow-up data (6 to 18 months) did not show sustained effects of treatment. Children and adolescents had a 48% lower chance of developing a depressive disorder if they received treatment, although this was not statistically significant.
The small number of studies limits what one can say about the effects of psychological treatment for subthreshold depression in children and adolescents. The effects were small to moderate at post treatment, but the effects were statistically significant only for adolescents and not for children. Longer term effects of treatments were non-significant, and there was no significant effect on the incidence of depressive disorders at follow up. Despite the disappointing findings, the authors concluded that interventions for subthreshold depression may have positive immediate effects at post treatment for adolescents.
Psychotherapies for Depression
Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.
Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.
Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.
Does Mindfulness Lead to Greater Empathy Among Psychotherapists?
Cooper, D., Yap, K., O’Brien, M. et al. (2020). Mindfulness and empathy among counseling and psychotherapy professionals: A systematic review and meta-analysis. Mindfulness, 11, 2243–2257.
Just about every theoretical model of psychotherapy recognizes that therapist empathy is a necessary and fundamental component of treatment. A meta-analysis showed that higher therapist empathy as rated by patients was a moderately strong predictor of outcomes. Despite its importance, training programs in counseling, clinical psychology, and psychotherapy have not found effective ways of increasing empathy among trainees. Some might argue that more mindful therapists might be more attentive and accepting of aversive emotions and therefore more open to entering a client’s world or experiences. Rogers defined empathy as the capacity to enter into the private perceptual world of the other, and it involves taking another’s perspective and being emotionally moved. Measures of empathy assess dimensions such as personal distress, empathic concern, fantasy, and perspective taking. Mindfulness, on the other hand is defined by some as an open and receptive attention and awareness to one’s own present experiences. The theory is that having this receptive mindful attitude is necessary to develop empathy for others. If this is the case, then mindfulness training might foster a greater empathic attitude among psychotherapists and trainees. In this study, Cooper and colleagues (2020) conducted a meta-analysis to examine the relationship between dimensions of mindfulness and empathy among psychotherapy trainees. They also looked at studies that examined if training in mindfulness was associated with greater empathy among trainees. The results from up to 10 studies showed that greater levels of mindfulness were associated with less personal distress, r = − .42, 95% CI [− .55, − .27], and greater perspective taking, r = .28, 95% CI [.15, .40]. However, there was no significant relationship between mindfulness and empathic concern or fantasy. When aggregating the findings of the six studies that examined the effect of mindfulness training on increasing trainee therapist empathy, there were no significant effects on any of the empathy scales.
This is not a well-developed research area because of the few studies and small sample sizes, and so results should be taken with a grain of salt. Meta-analyses clearly show that therapist empathy is important to patients and their outcomes. Higher levels of mindfulness were associated with greater perspective taking and lower personal distress. Mindfulness might help therapists to disengage from internal experiences and free up resources to be empathic to patients’ distress. However, the existing research does not support the use of mindfulness training to improve therapist empathy.
How Useful Are Smartphone Apps for Mental Health?
Weisel, K.K., Fuhrmann, L.M., Berking, M., Baumeister, H., Cuijpers, P., & Ebert, D.D. (2019). Stand alone smartphone apps for mental health: A systematic review and meta-analysis. NPJ Digital Medicine, 2, 118. https://doi.org/10.1038/s41746-019-0188-8
Mental health and lifestyle apps are very popular. There are more than 318,000 health related mobile apps on the market, 490 of which are specifically about mental health. Most of the apps do not provide information about their effectiveness, and only 11% appear valid on the face of it. Apps are potentially useful to increase access to mental health treatments since smartphones are ubiquitous in the population. However, past reports show that the drop-out rates of unguided internet interventions for mental health are very high, only 17% of clients actually complete all the modules, the average client only completes about 16% to 25% of modules, and any positive effects often disappeared when assessed in the longer term. In this meta-analysis, Weisel and colleagues assess if standalone psychological interventions delivered by smartphone apps are efficacious for mental disorders. Their systematic review found 19 randomized controlled trials that directly compared a smartphone app to a control group (e.g., no treatment) for a variety of disorders (depression, anxiety, PTSD, sleep problems, substance use, suicidal behavior). Almost half of the interventions were CBT-based. Only 1 of the 19 studies had a low risk of bias – that is only 5% of studies were high quality in terms of sampling, randomization, data analysis, and so on. More than half of studies were very low quality. The pooled effect size from six comparisons for depression showed a positive effect of smartphone apps at post-treatment to reduce depressive symptoms (g = 0.33; 95% CI: 0.10–0.57, p = .005). Similar positive findings were found for smoking cessation. These effects are considered small by most standards. However, the findings from four comparisons for anxiety disorders were not significant (g = 0.30, 95% CI: −0.1 to 0.7, p = 0.145). Similar non-significant results were found for most other disorders as well. There were not enough studies to assess the longer-term effects of apps beyond immediately post-treatment.
The main problem with this research area is that the quality of the studies generally is very low. Researchers have known for some time that lower quality studies tend to result in inflated treatment effects. So even if the meta-analysis found small significant effects of mental health apps for depression and smoking cessation, these findings are not likely reliable. Further, there is almost no research on the longer-term outcomes to assess if any positive effects are lasting. The research does not support the use of apps and computerized interventions as standalone treatments. They may be useful as an adjunct to traditional therapy or when they are provided with sufficient guidance by a therapist.