Blog

Hewison, D., Casey, P., & Mwamba, N. (2016). The effectiveness of couple therapy: Clinical outcomes in a naturalistic United Kingdom setting. Psychotherapy, 53, 377-387.

Current randomized controlled trials (RCTs) of couple therapy indicate that about 60% to 70% of couples improve to some degree, and that about 35% to 50% are no longer distressed by the end of therapy. But RCTs have been criticized for being somewhat artificial because their design is based on how pharmacological treatments are tested. Psychotherapy may be more complex than pharmacotherapy in its implementation, and compared to pharmacotherapy, psychotherapy relies more heavily on the qualities of the therapist and therapeutic relationship in order to achieve good outcomes. In an RCT, individuals often have to have a specific disorder to be included in the study, and those with co-morbid disorders may be excluded. This may limit what the findings have to say about real world applications of a particular treatment. Further, therapists in RCTs may receive unusual levels of supervision and support that is seldom seen in regular clinical practice. In this large study of over 435 couples, Hewison and colleagues assessed the effectiveness of a psychodynamically-oriented couple therapy as practiced in a large not-for-profit centre that provides psychological treatment (i.e., the Tavistock clinic in the United Kingdom). All participants received couple treatment and none were randomly assigned to a control group. The couple therapy focused on insight and emotional connection and expression within the context of a therapeutic relationship. The couple relationship rather than the individual partners were the object of the therapy. The unconscious meaning of couple communication was often discussed, and therapist countertransference was seen as a source of information about the couple. Most couples in the study identified as White (77.0%), heterosexual (93.9%), and married or living in a civil partnership (58.4%). More than half of the couples were in the relationship for over 5 years and had children. Therapists were qualified couple therapists or Masters level trainees, had a mean age of 50 (range: 26 – 71), tended to be White women (60%), and were all trained at the clinic. The average number of sessions that a couple attended was 23.3 (SD = 23.5), but with a wide range (2 to 150 sessions) as might be typical in a clinical setting. Overall, individual clients reported a large significant decrease in individual psychological distress (d = -1.04), and a moderate significant decrease in marital distress (d = -0.58). Half of individuals showed a reliable reduction in their individual distress, and over a quarter of couples reported a reliable decline in their couple distress.

Practice Implications

This is the largest study of couple therapy in a naturalistic setting. The psychodynamic couple therapy was effective in reducing individual distress for almost half of the participants although reliable change in couple distress was lower. The results of this field trial indicate that couple therapy that is offered in a functioning real-world clinic setting produces results similar to what is seen in highly controlled randomized trials.

Goldberg, S.B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W.T., Whipple, J.L., Miller, S.D., & Wampold, B.E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53, 367-375.

There is a lot of evidence that psychotherapy is effective – a result that has been demonstrated in randomized trials and in naturalistic setting. As I have noted numerous times in this Blog, psychotherapy is as effective as medications but without the side effects and with longer lasting results. However, there is room for improvement, especially in the effectiveness of individual therapists. Health care organizations are increasingly interested in quality improvement, which refers to efforts to make changes in practice that will lead to better patient outcomes, better care, and better professional development. One approach to quality improvement in medicine has been through audit and feedback – which involves measuring a clinician’s practice, comparing the clinician’s outcomes to professional standards, and giving the clinician feedback. In psychotherapy, the analogue is routine outcome monitoring in which patient progress is monitored with standardized measures throughout therapy, and therapists receive ongoing feedback on each patient’s progress relative to the average patient with that disorder. We know that therapists tend not to improve in terms of patient outcomes with experience alone, and some authors argue that one of the things that therapists are missing is good quality information about their clients’ progress. What would happen if an agency or organization decided to make it a priority to provide therapists with quality information about client progress? This paper by Goldberg and colleagues is a case study in which an agency deliberately created a culture of quality feedback and professional development to improve therapist expertise, therapist intentional practice, and client outcomes. The case study is of a community mental health agency in Alberta. Over 5,000 clients were seen by 153 therapists over a 7 year period (2008 to 2015) as part of the study. Clients received at least three sessions of therapy (mean = 6.53 sessions, SD = 5.02), and had a range of disorders typically seen in a mental health clinic. Therapists included 49.7% licensed or provisionally licensed professionals at the masters or doctoral level from different professions (e.g., social work, psychology, pastoral counselling), and 50.3% practicum students. Throughout the 7 years of the study, therapists saw an average of 33.52 clients (SD = 26.24). In 2008, the agency required the staff to collect outcome measures of all clients before each session (although patient scores were not tied to staff performance evaluations). This policy change caused a 40% turnover in clinical staff within 4 months (clearly a large minority of therapists did not want to participate in this new clinic directive)! These staff positions were replaced and staffing was stable after that point. In addition to requiring clinicians to provide measures on all patients (although patients could decline to participate), the agency provided monthly clinical consultations with an external consultant as a means of professional development. During these consultation, clinicians were encouraged to bring cases that were not progressing well in order to get feedback on their most challenging patients. Discussions were organized around therapeutic alliance, i.e., clarifying goals and preferences, and ways of facilitating engagement. The overall results showed a significant decline in distress among patients over the course of treatment. Of most interest was that therapists on average showed a significant improvement in their outcomes over time. That is, contrary to research showing that therapists do not improve over time when left to their own devices, therapists in this agency that received feedback and professional education around difficult cases did improve significantly.

Practice Implications

The findings of this study indicate that psychotherapists can improve over time if they receive quality information about client progress, and if they receive professional development that is tied to this information (i.e., concrete suggestions for ways of working with difficult clients). In other words, it is possible for therapist to develop expertise over time under some conditions. A significant challenge in this case study was that a number of therapists left the agency due to the quality improvement efforts. Some therapists are sensitive to or feel threatened by outcome monitoring. However, therapists who remained or who were subsequently hired by the agency showed a reliable increase in their expertise and client outcomes as a result of deliberate intentional practice, quality feedback about client progress, and concrete professional development focused on the therapeutic alliance.

Leichsenring, F. Abbass, A., Hilsenroth, M.J., Leweke, F., Luyten, P., ….Steinert, C. (2016). Bias in research: Risk factors for non-replicability in psychotherapy and pharmacotherapy research. Psychological Medicine, doi:10.1017/S003329171600324X.

An important feature of research is that it should be replicable. That is, another researcher should be able to obtain the same finding as the original study as a pre-requisite for the validity of the conclusions. A recent estimate for cognitive and social psychology research is that only about 36% to 47% of studies are successfully replicated. Another study showed similar low replicability of psychotherapy and pharmacotherapy research. Results that are neither replicable nor valid can lead to improper treatment recommendations. Leichsenring and colleagues review several research biases that affect the replicability of findings in psychotherapy and pharmacotherapy research, and they discuss how to limit these biases. Psychotherapy trials often involve an established treatment approach that is pit against a comparison treatment in a head to head contest. Below I list some of the biases detailed by Leichsenring and colleagues that may affect the validity of psychotherapy trials. First, in psychotherapy trials a large proportion of the differences in outcomes between a treatment and a comparison may be due to the researcher’s allegiance to a particular therapy modality. This may be expressed unconsciously by selecting outcome measures that are more sensitive to the effects of one type of treatment versus another. For example the Beck Depression Inventory (BDI) is particularly sensitive to changes in cognitions, whereas the Hamilton Depression Rating Scale (HDRS) is particularly sensitive to physiological side effects related to antidepressant medications. One way to deal with researcher allegiance effects is to include researchers and therapists who have an allegiance to both of the treatments that are under study. Second, the integrity of the comparison treatment may be impaired. That is the comparison treatment may not be carried out exactly as originally intended. This could occur in pharmacological trials in which doses do not match clinical practice, or in psychotherapy trials in which therapists in the comparison treatment may be told to ignore key symptoms. Properly training and supervising therapists and not constraining them by the study protocol is important to avoid this type of bias. Third, some studies make a lot of noise about small effects that are statistically significant. When two bona-fide psychotherapies are compared the differences tend to be small – this is a common finding. Small differences, even if statistically significant, often turn out to be random, unimportant, and of little clinical significance. Concurrent with this problem is that sometimes researchers will use multiple outcome measures, find significant differences only with some, and report these as meaningful. This refers to selectively emphasizing a small number of findings among a larger number of analyses, which are likely due to chance variation and therefore not replicable.

Practice Implications

What should a clinician do when reading a comparative outcome study of psychotherapy? There are some technical red flags for research bias that require specialized knowledge (e.g., small sample sizes and their effect on reliability, over-interpreting statistical significance in the context of small effects, and non-registration of a trial). But there are a few less technical things to look for. First, I suggest that clinicians focus primarily on meta-analyses and not on single research studies. Although not perfect, meta-analyses review a whole body of literature, and are more likely to give a reliable estimate of the state of the research in a particular area. Second, clinicians should ask some important questions about the particular study: (a) are the results unusual (i.e., when comparing 2 bona-fide treatments, is one “significantly” better; or are the results spectacular); (b) does the research team represent only one treatment orientation; and (c) do the researchers reduce the integrity of the comparison treatment in some way (e.g., by not training and supervising therapists properly, by unreasonably limiting what therapists can do)?  

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the chapter on efficacy, Wampold and Imel provide convincing evidence from numerous reviews of meta analyses that the average effect size of psychotherapy across diverse treatments and patients is about d = .80. This is a reliable figure and is considered a “large” effect by commonly accepted standards. Put another way, the average psychotherapy patient is better off than 79% of untreated clients, psychotherapy accounts for 14% of the outcome variance, and for every 3 patients who receive psychotherapy, one will have a better outcome than had they not received psychotherapy. In other words, psychotherapy is remarkably efficacious. These effect size estimates are mostly drawn from randomized clinical trials that are highly controlled (i.e., therapists are highly trained and supervised, patients are sometimes selected to have no co-morbid problems, treatment fidelity to a manual is closely monitored, etc.). Some argue that the context of these trials renders them artificial, and that findings from these trials reveal little about psychotherapy practiced in the real world with complex patients. How do findings from controlled clinical trials compare to everyday clinical practice? Wampold and Imel review the evidence from three areas of research: clinical representativeness, benchmarking, and comparisons to treatment as usual. With regard to clinical representativeness, a meta analysis (k > 1,000 studies) coded the studies for type of treatment setting, therapist characteristics, referral sources, use of manuals, client heterogeneity, etc. The meta analysis found that therapies that were most representative of typical practice had similar effects to what is observed in highly controlled studies. With regard to benchmarking, a large study (N > 5,700 patients) compared treatment effects observed in naturalistic settings to clinical trial benchmarks. Benchmarks were defined as scores on an outcome (e.g., on a depression scale) that are within 10% of scores reported in clinical trial research. Treatment effects in naturalistic settings were equivalent to and sometimes better than those achieved using clinical trial benchmarks. Further, therapists in practice settings achieved the same outcomes in fewer sessions than in clinical trials. With regard to comparisons to treatment as usual, a meta analysis (k = 30 studies) for personality disorders looked at studies that compared evidence-based treatments tested in clinical trials to treatment as usual. The meta analysis found that evidence-based treatments were significantly more effective than treatment as usual with moderate effects. These results suggest that when it comes to personality disorders, special training and supervision, which are common in clinical trials, might be beneficial.

Practice Implications

Wampold and Imel argue that psychotherapy as tested in clinical trials is remarkably effective such that the average treated patient is better off than 79% of untreated controls. The evidence also suggests that psychotherapy practiced in clinical settings is effective and probably as effective as psychotherapy tested in controlled clinical trials. It is possible that therapists who treat those with personality disorders may benefit from additional training and supervision to improve patient outcomes in everyday practice.

Erlangsen, A., Lind, B. D., Stuart, E. A., Qin, P., Stenager, E., Larsen, K. J., ... & Nordentoft, M. (2014). Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: A register-based, nationwide multicentre study using propensity score matching. The Lancet Psychiatry. Early Online Publication: doi:10.1016/S2215-0366(14)00083-2.

Between 9 million and 35 million suicide attempts occur yearly in the world, and suicide accounts for over 800,000 deaths every year worldwide. Suicide attempts are associated with future attempts and with mortality. Within the first year, 16% of people attempt suicide again. Despite the occurrence of suicide attempts and its effects, there has been inconclusive evidence of the effectiveness of interventions to reduce future attempts and death. That is why this Danish nationwide study by Erlangsen is so important. Another impressive aspect of this study is its size and scope. Since 1992, psychological therapies have been offered to people at risk of suicide in specialized clinics throughout Denmark. The aim of Erlangsen and colleagues’ study was to assess if those who received these psychological interventions had a reduced risk of suicidal behavior and mortality compared to people who did not receive the interventions. The authors collected data from 1992 to 2010 from Danish national health registries. This procedure was possible in Denmark because the health system is nationally coordinated and each individual has a traceable national health ID. In order to be included in the study, those who were offered specialized psychological interventions had to receive at least one session of treatment. Therapy included cognitive behavioral therapy, problem solving therapy, dialectical behavior therapy, psychodynamic therapy, systemic therapy and others. The interventions consisted of up to 8 to 10 individual outpatient sessions. The comparison group received “standard care” that consisted of admission to hospital, referral to a general practitioner, or discharge with no referral. The primary outcomes were: repeated self-harm, death by suicide, and death by any other cause. Of the people receiving psychotherapy, 5,678 had useable data. The “standard care” sample was much larger and consisted of 58,281 individuals who were matched to the psychological intervention group on many variables including sex, age, education, antidepressant medications, and psychiatric diagnosis. For those receiving psychotherapy, the rate of repeated suicide attempts in the first year was 6.7% and 15.5% at 10 years. For those receiving standard care, rate of repeated suicide attempts in the first year was 9.0% and 18.4% at 10 years. The odds of another suicide attempt one year post treatment was 73% lower among those receiving psychotherapy. Death by any other cause at the 10 year mark was also significantly lower in the psychological therapy group (5.3%) versus the no-therapy group (7.9%). The authors estimated that over the 20 year span of their data, psychological therapy: prevented repeated suicide attempts in 145 people, prevented deaths by any other cause in 153 people, and prevented 30 suicide deaths. Psychosocial interventions were associated with fewer repeated suicide attempts in women but not in men, and adolescents and young adults benefited most from psychological therapies.

Practice Implications

This is the largest long term follow up study ever of psychological interventions after a suicide attempt. Psychotherapy was associated with reduced risk of self-harm and mortality in the short and long term. This was especially true for women and in adolescents and young adults. Those receiving psychotherapy might have been a select group resulting in biased results. However, the extensive matching of the psychotherapy group to the no-therapy control group reduced the likelihood that factors other than psychotherapy influenced the findings. The study indicates strong support for providing psychological interventions to people at risk of suicide.

Kraus, D. R., Castonguay, L., Boswell, J. F., Nordberg, S. S., & Hayes, J. A. (2011). Therapist effectiveness: Implications for accountability and patient care. Psychotherapy Research, 21, 267-276.

Some patients benefit from psychotherapy, some do not, and a few get worse. Research has indicated that patient motivation, client-therapist match, and client characteristics might be associated with better or worse client outcomes. What about the contribution of the therapist? Do some therapists consistently have patients with better outcomes or with worse outcomes? Are consistently effective therapists effective for most patient problem areas or only some? Answers to these questions have important public health, funding, continuing education, and training implications. In a large study conducted in the U.S., Kraus and colleagues assessed 12 patient domains (sexual functioning, work functioning, violence, social functioning, anxiety, substance abuse, psychosis, quality of life, sleep, suicidality, depression, and mania) with a standardized reliable measure (the Treatment Outcome Package). The measure was used in a variety of public and private clinics and practices. Almost 700 therapists were sampled (including social workers 43%, mental health counsellors 35%, psychologists 10%, others 12%), with an average of 11 years experience. Ten cases were selected from each therapist caseload, so almost 7000 patients were included that received at least 16 sessions of therapy (16 sessions is an adequate dose for 50% of patients to improve – see my August, 2013 blog). The patients were, for the most part, representative of a typical caseload with regard to age, sex, and problem area as compared to previous national (U.S.) research. The authors used a reliable change index to classify patients as reliably improved, unchanged, or reliably worsened. The reliable change index is a way of assessing if change from session 1 to 16 on average exceeded the scale’s measurement error so that the change was considered reliable (i.e., not due to error). Reliable change for each therapist’s 10 patients was calculated so that a therapist could be classified as “effective” (i.e., on average their patients reliably improved), “ineffective” (i.e., on average their patients did not change), or “harmful” (i.e., on average their patients reliably worsened). The frequency of effective therapists ranged from a low of 29% in treating symptoms of sexual dysfunction to a high of 67% in treating symptoms of depression. Harmful therapists ranged from a low of 3% in treating depressive symptoms to a high of 16% in treating symptoms of substance abuse and violence. When looking at competency areas (i.e., areas of reliable effectiveness), the median number of areas of therapist competence was 5 out of 12 problem areas. Only 1 therapist of the approximately 700 therapists was competent in 11 of 12 domains, and none were competent in all 12 domains. Being effective in one domain was not correlated with effectiveness in another domain. So, one cannot infer that if a therapist was effective in treating depression he or she would also be effective in treating social dysfunction, for example.

Practice Implications

There was tremendous variability in therapist skill and areas of competence in this very large sample of therapists. Between 3% and 16% of therapists were classified as reliably harmful to their patients, and between 29% and 67% were reliably effective depending on the problem area they were treating. Therapists who were effective in one domain could be harmful in another. Most therapists had some areas in which they were consistently effective, usually around 5. However, as indicated by previous research, without routine measurement, therapists may not be aware of clients for whom they are consistently helpful or harmful. Routine monitoring of outcomes could guide the matching of client problems to therapists, and could direct therapists to areas for continuing education, training, or personal therapy.

Author email: dkraus@bhealthlabs.com