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.

August 2018

The Partners for Change Outcome Monitoring System

Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS): Revisiting the client’s frame of reference. Psychotherapy, 52(4), 391-401.

Generally, psychotherapy is effective for a wide variety of disorders, but regardless, many clients do not benefit. Further, the research shows that some therapists are more effective than others, but therapists tend to grossly over-estimate their effectiveness. In one large survey, therapists reported that their outcomes were better than 75% of their peers, no therapist rated themselves as below average, and therapists tended to over-estimate their effectiveness and under-estimate client deterioration. One way to evaluate patient outcomes and processes is to engage in progress monitoring and feedback. This involves repeated brief assessments of client outcomes followed by real-time feedback to therapists to gauge client progress and signal potential problems. Several such systems exist including the Outcome Questionnaire-45.2 and the Partners for Change Outcome Management System (PCOMS). The PCOMS is made up of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). The ORS measures distress in 3 atheoretical domains (personal, family, social) not based on diagnosis. The SRS is a measure of therapeutic alliance. Both the ORS and SRS are very short 4-item scales that can be administered before (ORS) and after (SRS) each session of therapy. In this paper, Duncan and Reese review the research supporting the use of the PCOMS. A meta analysis found that clients whose therapists received feedback with the PCOMS were 3.5 times more likely to experience reliable change and had less than half the chance of experiencing deterioration. Five randomized controlled trials demonstrated the advantage of the PCOMS over treatment as usual, including by reducing drop outs and achieving reliable change in fewer sessions.

Practice Implications

A lot of research has demonstrated that most therapists over-estimate their effectiveness and that many are not able to identify clients who are getting worse. It is time for therapists to acknowledge this positive bias of their effectiveness and their need for quality information in order to make good clinical decisions. Progress monitoring and feedback systems are one means by which therapists can receive quality information. The repeated use of the PCOMS for example, can help to identify when clients begin to deteriorate and/or when problems emerge with the therapeutic alliance. Being able to identify these issues early may allow therapists to act quickly to avert client deterioration or drop out.
Why Therapists Tend Not To Use Progress Monitoring

Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457.

Progress monitoring is the process of repeatedly assessing client functioning with validated measures and providing feedback to therapists. The feedback is designed to identify problems with the therapeutic relationship or with client deterioration by comparing client progress to similar clients. This allows therapists to change what they are doing, renegotiate aspects of therapy, or directly address the issues. Research is clear that progress monitoring significantly increases the proportion of clients who improve, reduces drop outs by a third, shortens the length of therapy, and reduces costs. Yet the research also indicates that only 12% of psychologists are using progress monitoring in their practice. If progress monitoring is so useful, then why aren`t more therapists using it? In this review, Miller and colleagues discuss some of the barriers and problems with using or adopting progress monitoring in clinical practice. They describe that even in the most favorable circumstances, it takes about two decades for new treatments to be integrated into routine care. Another issue is that recent surveys indicate that only about 33% of psychologists and 66% of training directors are aware of progress monitoring. Even for those who are aware, a common barrier might be cost and time to implement the procedures. Despite the brevity and low cost of the tools, like the PCOMS, they all place an additional burden on clinicians’ busy schedule. There is also the issue of staff turnover. As staff come and go, organizations may lose those who lead, train, and support the use of progress monitoring. Probably the biggest barrier is skepticism on the part of clinicians who might see the tools as too superficial, or who might be concerned that repeated measurement may somehow negatively affect the therapeutic relationship. However, research indicates that clients generally report positive experiences – they like being a more integral part of the assessment process, and they appreciate the ability to track their own progress. Finally, whereas clinicians may use progress monitoring to improve clinical decision-making, administrators may see it as a means of conducting performance reviews.

Practice Implications

In most health care fields, it can take 20 years for an innovation to make it into routine practice. That might be the case for progress monitoring. More clinicians need to know about it, be trained in its use, and see for themselves that the information is valid, of high quality, and that it can supplement their work in identifying clients who are not doing well. In particular, progress monitoring may be a means of enhancing the therapeutic alliance as it provides therapists and clients a vehicle to discuss how the therapy is going, what needs focus, and what to do if things go awry. Organizations need to treat progress monitoring as a means of helping therapists to improve their skills, and not as a means of auditing performance. Therapists need quality information upon which to make sound clinical decisions, and progress monitoring is one way of receiving this information.

July 2018

Placebo Response in Transcranial Magnetic Stimulation for Depression

Razza, L. B., Moffa, A. H., Moreno, M. L., Carvalho, A. F., Padberg, F., Fregni, F., & Brunoni, A. R. (2018). A systematic review and meta-analysis on placebo response to repetitive transcranial magnetic stimulation for depression trials. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 81, 105-113.

Transcranial magnetic stimulation (TMS) is a new treatment for depression thought to modulate brain activity through electromagnetic pulses delivered by a coil placed over the patient’s scalp. A meta analysis shows that TMS may be effective in treating depressive disorders when compared to a placebo control, although only 18.6% of those receiving TMS were no longer depressed at the end of treatment. The placebo control condition usually involves a sham version of TMS in which the coil is placed over the scalp but no magnetic stimulation is applied. In antidepressant trials, the placebo response is quite high such that approximately 40% of patients respond to the placebo condition (in antidepressant trials, the placebo condition includes an identical pill that is inert). In this meta analysis, Razza and colleagues assess the placebo response in TMS. They included only double blind randomized controlled trials (i.e., trials in which both the patient and physician were not aware if the treatment was real or a sham). The authors estimated the placebo response based on pre- to post-sham TMS scores of common measures of depression. The meta analysis included 61 studies of over 1300 patients. The main result showed that sham response was large (g = 0.80; 95%CI = 0.65–0.95). Trials including patients with only one episode of depression or who were not treatment resistant (g =0.67, 95%CI = 0.06–1.28, p= 0.03) had higher placebo responses than those trials in which patients previously had two or more failed antidepressant treatments (g = 0.5, 95%CI = 0.03–0.99, p = 0.048).

Practice Implications

The results of this meta analysis demonstrates a high placebo response in trials testing TMS. This is similar to the high level of placebo response commonly seen in patients in antidepressant medication trials. It appears that psychological factors like attention, instillation of hope, patient expectations of receiving benefit, and perhaps working alliance may account for an important portion of why pharmacological and other medical interventions appear to work for those with depressive disorders. This is particularly true for patients who are receiving treatment for the first time or for whom previous medical treatment was successful.
Are E-Health Interventions Useful for Weight Loss?

Podina, I. R., & Fodor, L. A. (2018). Critical review and meta-analysis of multicomponent behavioral e-health interventions for weight loss. Health Psychology, 37(6), 501-515.

Over 35% of Americans are overweight or obese, and this poses significant health-related challenges. Obesity likely contributes to heart disease, Type II diabetes, and some forms of cancer. Also, obesity is often co-morbid with mental health conditions including depression and binge-eating disorder. Practice guidelines list multicomponent behavioural interventions as state of the art treatment for weight loss. These include dietary counselling, increased physical activity, and behavioural methods to support behaviour change. However, such interventions often require direct in-person contact with a health or mental health professional, which can be expensive and create a barrier to accessing treatment for some. An option to increase access is to deliver the multicomponent behavioural intervention by internet or by another electronic format such as DVD. In this meta analysis, Podina and Fodor reviewed 47 randomized controlled studies representing over 1500 participants in which e-health interventions for weight loss in overweight or obese individuals were tested against in-person treatment or a control condition (no treatment or treatment as usual). E-health interventions were more effective than control conditions for weight loss outcomes at post-treatment, g = 0.34 (95% CI [0.24 to 0.44]). Similar results were found at follow-up. However, e-health interventions were significantly less effective than active in-person treatments, g = -0.31 (95% CI [-0.43 to -0.20]) for weight loss in overweight or obese individuals.

Practice Implications

E-health interventions (mostly internet delivered treatment) of multicomponent behavioral treatment for weight loss was more effective than no treatment or treatment as usual. However, e-health was significantly less effective than traditional face to face behavioral interventions to help people reduce their body weight. The authors raised concerns about the use of e-health interventions for weight loss as the first line treatment as the effects were small and the approach was less effective than in-person interventions.

February 2018

Therapeutic Relationship Predicts Pharmacological Treatment Outcomes

Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.

There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.

Practice Implications

Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.

July 2017

Are the Effects of Psychotherapy Inflated?

Driessen, E., Hollon, S.D., Bockting, C.L.H., Cuijpers, P., Turner, E.H. (2015). Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US National Institutes of Health-funded trials. PLoS ONE 10(9): e0137864. doi:10.1371/journal.pone.0137864.

In 2008 Turner published a well-known study in which he found that almost 50% of antidepressant trials registered with the Food and Drug Administration in the US were never published or were positively “spun” (i.e., essentially negative findings were interpreted to be positive). Almost all of the unpublished trials showed unfavorable results for the antidepressants’ effects. By contrast, the published studies were almost always were positive. This is evidence of publication bias caused by selective publication of some data and suppression of other data. As you can imagine, this has important implications for treatment of depression as the published record appeared to over-inflate effects of antidepressants by 25% (the mean effect size decreased from g = .41 [CI_95% 0.36~0.45] to 0.31 [0.27~0.35] when unpublished studies were included). Has the same type of publication bias occurred in the published record of psychotherapy’s efficacy? In this study by Driessen and colleagues, the authors reviewed all psychotherapy studies for depression funded by the National Institutes of Mental Health in the US between 1972 and 2008. They wanted to determine which ones were published, which were never published, and what the impact of nonpublication was on the mean effect size. Of the 55 grants that were funded, 13 (26.3%) were never published, and the authors were able to obtain data from 11 of those unpublished studies. The overall mean effect size (psychological treatment versus a control condition) of unpublished studies was g = 0.20 (CI_95% -0.11~0.51) indicating a small non-significant effect. The overall mean effect size for published studies was g = 0.52 (CI_95%0.37~0.68) indicating a medium significant effect. Adding the unpublished studies to published studies resulted in a 25% decrease in effect size estimate to g = 0.39 (0.08~0.70), indicating a small but significant effect of psychotherapy.

Practice Implications

This study indicated that psychotherapy is effective but that the effects are likely smaller than indicated in the published record. As in the case of antidepressant medication research, a minority of researchers may not publish findings that are not in line with their preconceived expectations or wished-for results. Regardless, there is certainly room for psychotherapy to improve. After decades of focusing largely on the efficacy of specific psychotherapies like CBT, psychodynamic therapies, and interpersonal therapy, perhaps it is time to shift to studying how and why therapies work, and which patients benefit from specific interventions. There are promising avenues such as research on: repairing therapeutic alliance tensions, enhancing therapist expertise, progress monitoring and feedback, client factors, and managing countertransference.

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August 2018

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July 2018

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February 2018

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July 2017

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