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 client perspectives on psychotherapy failure, therapeutic alliance, and alliance ruptures and resolutions and symptom severity.
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
June 2021
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.
Practice Implications
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.
Practice Implications
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.
April 2021
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.
Practice Implications
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.
December 2020
Psychotherapy for Those Who Do Not Respond to Treatment
Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.
Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).
Practice Implications
The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.
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.
Practice Implications
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.
November 2020
Therapist and Client Emotional Expression: A Meta-Analysis
Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.
Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.
Practice Implications
This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.