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 therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
September 2014
Psychotherapeutic Interventions to Promote Forgiveness
Wade, N.G., Hoyt, W.T., Kidwell, J.E., & Worthington, E.L. (2014). Efficacy of psychotherapeutic interventions to promote forgiveness: A meta-analysis. Journal of Consulting and Clinical Psychology, 82, 154-170.
Forgiveness can include reducing vengeful and angry thoughts and feelings, and may be accompanied by positive thoughts, feelings and motives towards the offending person. This does not necessarily include reconciliation with the offending person, nor does it require forgetting, condoning, or excusing the wrongdoing. Promoting forgiveness in psychotherapy includes helping clients move toward more positive and optimal functioning. There are two prominent empirically based models of forgiveness interventions. Enright’s model contains four phases: (1) uncovering negative thoughts about the offense, (2) decision to pursue forgiveness, (3) work toward understanding the offending person, and (4) discovery of unanticipated positive outcomes and empathy for the offending person. Worthington’s model has five steps: (1) recalling the hurt and emotions, (2) empathising with the offender, (3) altruistic view of forgiveness, (4) commitment to forgiveness, and (5) holding on to or maintaining forgiveness. Wade and colleagues conducted a meta analysis: to compare forgiveness outcomes and mental health outcomes of forgiveness interventions in general; to compare of forgiveness interventions to each other; and to compare forgiveness interventions to non-forgiveness psychotherapies or to control conditions. The meta analysis included 53 studies of 2,323 participants. Participants receiving forgiveness interventions reported significantly greater forgiveness compared to those not receiving treatment and compared to those who received alternative treatments that were not specific to forgiveness. Forgiveness interventions also resulted in greater positive changes in depression, anxiety, and hope compared to no-treatment conditions. There were no differences between Enright’s and Worthington’s approaches when duration of treatment and modality (individual vs group) were controlled. However, as an individual treatment, Enright’s model showed better outcomes. Longer duration of treatment was associated with greater forgiveness, and greater severity of the offense was also associated with greater forgiveness.
Practice Implications
Theoretically grounded forgiveness interventions may be the best choice to help a client to achieve resolution in the form of forgiveness. Other non-forgiveness therapeutic approaches may help but may not have as great an impact on forgiveness as those interventions that are specifically designed to improve forgiveness. Enright’s model delivered as an individual treatment was more effective than Worthington’s approach which is designed mostly as a group intervention. In addition to improving forgiveness, both approaches also had significant positive impact on depression, anxiety, and hope. The forgiveness interventions worked better if provided for longer duration and in the context of more severe offenses.
August 2014
Are Therapists or Clients Most Responsible for the Therapeutic Alliance-Outcome Relationship?
Del Re, A.C., Fluckiger, C., Horvath, A.O., Symonds, D., & Wampold, B.E. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642-649.
The therapeutic alliance, defined as the agreement on tasks and goals and the bond between therapist and patient, is one of the most researched concepts in psychotherapy. A meta-analysis of over 200 studies showed that the association between the therapeutic alliance and patient outcomes is moderate but robust (i.e., consistent across studies, patient types, and therapy types). Some have stated that the importance of the therapeutic alliance as reported in studies is an under-estimate of its real impact on patient outcomes. Del Re and colleagues argue that the main reason for this underestimation is that while the therapist’s effect on the alliance-outcome relationship might be large, the client’s effect might be quite small, and so the average of these two effects (which is what most studies report) will be diminished. Del Re and colleagues conducted the first meta analysis to assess the relative size of therapist versus client effects across many studies. Their strategy was clever. They looked at the ratio of the number of patients to therapists (PTR) within a study as a “predictor” of the alliance-outcome relationship across studies. This allowed them to examine the relative contribution of therapists and clients to the alliance-outcome relationship. Two extreme examples illustrate this ratio. (1) In one study, many patients might have been seen by only one therapist, in which case the alliance-outcome correlation could only be attributed to differences between clients since there was only one therapist. (2) In another study, each client might have been seen by a different therapist (i.e., there were as many therapists as clients), in which case the alliance-outcome correlation could only be attributed to differences between the therapists; that is, there are no differences between clients seen by the same therapist as this did not occur. The patient to therapist ratio (PTR) captures the variability between these two extreme examples across studies. Del Re and colleagues included 69 studies that provided enough information about the number of patients and therapists. The overall correlation between alliance and outcome was moderate, r = .27, which was very similar to what was found in a previous large meta-analysis. PTR was significantly associated with the alliance-outcome relationship even after controlling for a number of possible confounding variables. Patients accounted for almost 0% of the alliance-outcome relationship, whereas the effect of therapists was substantially larger, r = .40, accounting for 16% of the alliance-outcome association.
Practice Implications
Therapists’ capacity to develop an alliance with their patients is associated with outcomes. We also know that some therapists demonstrate better patient outcomes than others. So, therapists who consistently are better at forming alliances with patients likely have patients with better treatment outcomes. The quality of the alliance between patients and therapists appears to be the result of what therapists do or bring to the therapy. And so, on average, the therapist’s role in the alliance is most important for achieving good patient outcomes. Del Re and colleagues note that they were not able to look at the interaction between therapist and patient factors. For example, it may be possible that some therapists might form better alliances some types of patients, but not others. Integrating feedback systems so therapists can monitor the therapeutic alliance and patient outcomes may help therapists identify areas in which they need more training or supervision.
Long-Term Outcome of Psychodynamic Therapy and CBT in Social Anxiety Disorder
Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W. et al. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, Advance online publication: doi:10.1176/appi.ajp.2014.13111514.
Social anxiety disorder is a highly prevalent mental disorder, with lifetime prevalence of about 12% in the population. As Leichsenring and colleagues note, the disorder has an early onset and can have a chronic course leading to many psychosocial impairments. Also, social anxiety disorder often is comorbid with depression. There is good evidence for the efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder and some evidence for psychodynamic therapy (PDT), but most studies have only assessed short term outcomes. In this large mulit-center randomized controlled trial comparing CBT and PDT for social phobia, Leichsenring and colleagues report on outcomes up to 2 years post treatment. The study had 416 adult patients randomly assigned to one of the treatments, and 79 randomly assigned to a waiting list. Outcomes were reported at post, 6 months, 12 months, and 24 months post treatment, and included remission of social phobia, depression levels, and interpersonal problem scores. The CBT intervention for social phobia was based on the model by Clark and Wells. The PDT was based on Luborsky’s model but specifically adapted for social phobia. Participants received 25 sessions of individual therapy, and therapists received advanced training in the models. CBT resulted in significantly greater remission of social phobia than PDT at post treatment, but the difference was small. Remission rates at 6, 12, and 24 months post treatment were not different between treatments. At 2 years post treatment 39% of those receiving CBT and 38% of those receiving PDT no longer had clinical symptoms of social phobia. Results were similar for interpersonal problems in which CBT showed an earlier response, but the two treatments were equivalent at each follow up. Depression scores improved for both interventions at post and follow ups.
Practice Implications
The findings of this large study suggest that both CBT and PDT are effective treatments for social phobia. Although CBT had a small advantage at post treatment, PDT appeared to have an “incubation effect” in which patients continued to work on interpersonal problems and symptoms of social phobia over the longer term. Despite these positive outcomes, Leichsenring and colleagues suggest that there remains room for improvement in treating social phobia. Those who do not respond to these interventions may require different forms of treatment that is more specific, intense, or of longer duration. Leichsenring and colleagues also suggest integrating elements of the effective treatments within a single protocol. Although intuitively appealing, this integrated approach has not been tested.
July 2014
Comparing Seven Psychotherapies for Depression
Barth, J., Munder, T., Gerger, H., Nuesch, E., Trelle, S. et al. (2013) Comparative efficacy of seven psychotherapeutic Interventions for patients with depression: A network meta-analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454
As I wrote about in the June, 2014 blog, depression is a highly burdensome disorder and is the third leading cause of disability worldwide after lower respiratory infections and diarrhoeal diseases. Depression occurs in 4.4% of the world population. Identifying effective treatment for depression is critical to reduce its health and economic burden. There is broad based consensus that psychotherapy is effective for depression, but there remains ongoing debate about which therapies are more effective. Establishing the relative efficacy of psychotherapy for depression is important because many patients do not respond to any one type of treatment – and so they may benefit from different options. Although some meta-analyses have synthesized research that compared pairs of treatments against one another within studies, these meta analyses do not allow one to pool these comparisons of treatments across studies in a comprehensive way. The study by Barth and colleagues uses a relatively new method called network meta analysis in which many treatments can be compared to each other at once by pooling comparisons of treatments to alternate treatments across a number of studies. As a result the authors were able in one meta analysis to compare the relative efficacy of seven different treatments for depression. The seven therapies were defined as follows: (1) Interpersonal Psychotherapy: a brief and structured therapy that focuses on interpersonal issues in depression; (2) Behavioral Activation: raises the patient’s awareness of pleasant activities and seeks to increase the patient’s positive interactions with the environment; (3) Cognitive Behavioral Therapy: focuses on a patient’s negative beliefs, how they affect current and future behavior, and restructures the beliefs; (4) Problem Solving Therapy: defines a patient’s problems, proposes solutions for each problem, and then selects the best solution; (5) Psychodynamic Therapy: focuses on unresolved conflicts and relationships and the impact they have on a patient’s current functioning; (6) Social Skills Therapy: teaches skills that help to build and maintain healthy relationships; and (7) Supportive Counseling: aims to help patients talk about their experiences and emotions, and offers empathy. The network meta analysis included 198 clinical trials that represented 15,118 patients in which the seven psychotherapies were compared to each other or to a control condition. All seven psychotherapies were better than wait list controls or usual care, with moderate to large differences. That is, the average patient receiving psychotherapy was better off than about half those in a control condition. Researchers found small or no differences when the seven therapies were compared to each other. Treatments worked equally well for different patient groups (e.g., younger vs older; post natal depression; etc.), and in different modalities (individual vs group).
Practice Implications
All seven therapies were effective in reducing depression and none of the seven therapies in this network meta analysis stood out as superior to the others. The findings suggest that patients have a number of viable options for psychotherapeutic treatment for depression. This is important because, about 40% of patients do not benefit from the treatments they do receive, though they may benefit from another approach and will require other options. Client preferences may play a critical role in determining outcomes for some. If possible, patients should be given the option of the type treatment they may prefer or the option of the type of therapist with which they may be most comfortable.
June 2014
Meta Analysis on the Effectiveness of Psychodynamic Therapy for Anxiety Disorders
Keefe, J.R., McCarthy, K.S., Dinger, U., Zilcha-Mano, S., Barber, J.P. (2014). A meta analytic review of psychodynamic therapies for anxiety disorders. Clinical Psychology Review, http://dx.doi.org/10.1016/j.cpr.2014.03.004.
Anxiety disorders are one of the most prevalent psychiatric conditions, with combined lifetime prevalence near 17%. Anxiety disorders have high rates of comorbidity with other Axis I and II psychiatric disorders, and are associated with substantial physical and mental health burden. Several well-established treatments for anxiety disorders exist, including cognitive-behavioral therapies (CBT). However, not all patients with anxiety disorders benefit from current treatments, and there is some evidence that some aspects of CBT are not well tolerated leading to patient non-compliance with therapist directives. Hence, other treatment options such as psychodynamic therapies (PDTs). Should be tested for efficacy with patents with anxiety problems. PDTs have been studied and found to be efficacious for other types of disorders especially for depression. As Keefer and colleagues note, psychodynamic theory conceptualizes anxiety symptoms as originating from relational contexts that give rise to painful feelings (e.g., feelings of loss or abandonment, a wish to express anger or assert oneself). The patient engages in disavowal defenses against these intense, negative feelings and desires, and so avoids their experiences, and develops anxiety symptoms (e.g., panic attack triggered by experiences of loss or anger). Psychodynamic therapists encourage the patient to discuss the contexts in which their symptoms arise in order to understand the occurrence of symptoms. Therapists help the patient make connections between prior interpersonal and intrapsychic events that lead to negative feelings and anxiety-producing defenses. The goal is to allow the patient to try new ways of getting their needs met without anxiety while using more adaptive defenses. Exposure to feared or avoided situations during therapy sessions or in real life may also be encouraged by therapists. PDT may be less directive that CBT in treating anxiety disorders, and this may be useful for patients who do not respond well to directive interventions. Keefe and colleagues conducted a meta analysis of PDT for anxiety disorders and included 14 controlled studies of 1,037adults. Most of the treatments to which PDT was compared were CBT. PDT was significantly more effective than no treatment control conditions and the effect was medium. PDT did not differ significantly from alternative treatments like CBT at post-treatment, one year follow-up, and follow up beyond one year. Almost half of patients who received PDT were no longer symptomatic at post-treatment, and the drop out rate from PDT was 17%.
Practice Implications
The findings of this meta analysis suggests that psychodynamic therapy (PDT) is effective in treating anxiety disorders including generalized anxiety disorder, social phobia, panic disorder and others. PDT was well tolerated by patients as the drop out rate was relatively low at 17%. PDT was as effective as CBT when the two treatments were compared to each other. PDT provides therapists and patients with a primary or alternative approach to treatment of anxiety disorders, and should be considered for those patients who do not respond well to the more highly directive nature of CBT.
Global Burden of Depression
Ferrari, A.J., Charlson, F.J., Norman, R.E., Patten, S.B., Freedman, G., et al. (2013). Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine, 10(11): e1001547. doi:10.1371/journal.pmed.1001547.
Depressive disorders are among the most common mental disorders that previously were described as a leading cause of burden in the world. In epidemiological literature, burden is defined in several ways. One common metric is “disability adjusted life years” (DALYs) which represents loss of a healthy year of life. DALYs can be aggregated into the “years of life lived with disability” (YLD). Another metric is the “years of life lost due to premature mortality” (YLL). Each of these metrics of burden can be estimated from aggregating data from a number of studies and meta analyses that assess burden world wide. Such epidemiologic studies can also look at relative burden across countries, ages, and sex. In the 2000 Global Burden of Disease report, depressive disorders were the third leading cause of burden after lower respiratory infections and diarrhoeal diseases. Depression was also the leading cause of disability, responsible for 13.4% of years of life living with disability in women and 8.3% in men. In this study by Ferrari and colleagues, the authors provide a 2010 update to the Global Burden of Disease report for major depressive disorder and dysthymia. Major depressive episode is the experience of depressed mood almost all day, every day, for at least 2 weeks. Dysthymia involves a less severely depressed mood with duration of at least 2 years, a chronic rather than episodic course, but with low rates of remission. Ferrari and colleagues reviewed over 700 studies from 1980 to 2010. Prevalence (i.e., current rate) of major depression and dysthymia in the world population is 5.95%, representing nearly 400 million people. Major depression (4.4%) occurs more frequently than dysthymia (1.55%). Major depression occurs more frequently among women (5.5%) than men (3.2%). Major depression accounted for 8.2% of all years lost to disability, making it the second leading cause after low back pain. The percent of years lost due to disability increased since 1990, largely due to population increases and aging of the world population. The highest level of burden due to depression was seen in Afghanistan and the lowest in Japan. In terms of world regions, North Africa and Latin America showed the highest levels of burden due to depression. The authors also reported that 2.9% of disability adjusted life years from ischemic heart disease can be attributed to major depression.
Practice Implication
This study joins others in past decades to define depression as a leading cause of years lost to disability worldwide, with over 400 million people suffering from a depressive disorder. The increasing burden of depression is partly due to decreasing mortality caused by other diseases in developing countries and population aging. Countries that have recently experienced conflict (e.g., Afghanistan, North Africa, Middle East) were particularly burdened by depression. But research has also linked depression to intimate partner violence and child sexual abuse. Mortality is elevated with major depression, as is disability related to other medical problems like heart disease. This epidemiological research points to the importance of identifying and treating depression in the population. Psychotherapeutic interventions provide highly effective treatments for depression.