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 empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
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 2014
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.
May 2014
Indirect Exposure to Trauma Can Lead to Job Burnout and Secondary Traumatic Stress Among Mental Health Providers.
Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C.C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological Services, 11, 75-86.
The concept of job burnout was originally developed to document negative consequences of work related exposure to stressful situations experienced by various professionals such as police officers, paramedics, emergency room clinicians, etc. Job burnout can be defined as emotional exhaustion and disengagement. However, recent research on mental health providers has extended the focus beyond job burnout caused by direct exposure, to investigate the consequences of indirect exposure through contact with people who have experienced traumatic events, exposure to graphic trauma content reported by the survivor, or exposure to people’s cruelty to one another. These are sometimes referred to as secondary exposure or indirect exposure to trauma. Professionals indirectly exposed to trauma through their work could experience consequences or symptoms that have been conceptualized as secondary post-traumatic stress, vicarious traumatization, and compassion fatigue, which can collectively be called secondary traumatic stress (STS). STS may include three clusters of symptoms: intrusive re-experiencing of the traumatic material, avoidance of trauma triggers and emotions, and increased physical arousal. Compassion fatigue was defined as a substantial reduction in the mental health providers’ empathic capacity. Cieslak and colleagues (2014) conducted a meta analysis to assess the strength of associations between job burnout and other psychosocial consequences of work-related indirect exposure to trauma in professionals working with trauma survivors. They reviewed 41 studies that included 8,256 workers. The association between secondary traumatic stress (STS) and job burnout in professionals was significant and large. Workers were more likely to experience compassion fatigue and emotional exhaustion compared to PTSD-like symptoms and depersonalization, however, even the association with PTSD-like symptoms and depersonalization was moderate and significant. Both women and men were susceptible to STS, but the effect was larger in women.
Practice Implications
Burnout and other consequences of indirect exposure to trauma are likely to be high among mental health professionals. Burnout will affect professionals’ well being and quality of life, and will diminish their effectiveness with patients through reduced empathy and increased disengagement. Mental health professionals who are exposed to secondary trauma should be aware of the potential for negative personal consequences, and assess their own level of emotional exhaustion, empathic capacity, and engagement. Mental health professionals should seek help if they re-experience the events, engage in avoidance of trauma triggers and emotions, and experience heightened arousal. Taking care of oneself through consultation with trusted colleagues, change in work contexts, social supports, and personal therapy could help to forestall compassion fatigue and burnout. Educational programs to improve self awareness and mindful communication may reduce burnout in mental health professionals.
Patients with High Levels of Resistance Respond Better to Less Directive Psychotherapy.
Beutler, L.E., Harwood, T.M., Michelson, A., Song, X., & Holman, J. (2011). Resistance/Reactance level. Journal of Clinical Psychology, 67, 133-142.
Patient resistance to psychotherapy is a persistent and perplexing problem. Resistance can be defined as patient behavior that is directly or indirectly contrary to therapist recommendations or to the health of the patient. However, the label “resistance” implies that the problem lies entirely within the patient, i.e., that the patient is the problem. Beutler and colleagues (2011) argue that it is more accurate to define the problem as “reactance”, which refers to the relational or co-constructed nature of psychotherapy. The notion of reactance (instead of resistance) suggests that the therapist also plays a role in the resistance, since the therapist is also responsible to create a context within which highly ambivalent clients do or do not thrive. Failure to thrive could be viewed as a poor fit between patient and therapy. Using social psychological theory, Beutler and colleagues conceptualized reactance as a state of mind aroused in the patients when he or she perceives their freedom to be limited by the therapy. A therapist may elicit resistant behavior from a patient by assuming more control of the patient’s behavior within and outside of the therapy sessions than is tolerable, by using confrontational techniques, and by creating and failing to repair alliance ruptures. Beutler and colleagues argued that therapist directiveness was a key factor in determining reactance in the therapy. Therapist directiveness refers to the extent to which a therapist dictates the pace and direction of therapy. Beutler and colleagues conducted a meta analysis to assess if therapist directiveness was associated with poorer outcome in patients who were more resistant in therapy. The meta analysis included 12 studies with 1,103 patients. They found that higher patient resistance was related to poorer outcomes, and the effect was moderate. The interaction between therapist directiveness and patient level of resistance directly affected outcomes, and this effect was significant and large. That is, greater therapist directiveness with patients who were more resistant resulted in poorer outcomes. Conversely, patients who were low in resistance responded well to more directive therapy.
Practice Implications
Therapists should view some manifestations of client resistance as a signal that they are using ineffective methods. A therapist’s response to resistant states in a patient requires: acknowledgement and reflection of the patient’s concerns; discussion of the therapeutic relationship; and renegotiation of the therapeutic contract regarding goals and therapeutic roles. These therapist responses are designed to provide the patient with a greater sense of control over the process. High reactance indicates that a treatment should: de-emphasize therapist authority and guidance, employ tasks that are designed to provide the patient with control and self-direction, and de-emphasize the use of rigid homework assignments. As Beutler and colleagues indicate, resistance is best characterized as a problem of the therapy relationship (not of the patient) and as such, becomes a problem for the therapist and patient to solve. The skilled therapist can find a way to stimulate change and reduce a patient’s fear of losing control or freedom.
April 2014
Medication Versus Psychotherapy for Depressive and Anxiety Disorders
Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds III CF (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12, 137-148.
Both psychotherapy and antidepressant medications are efficacious treatments for depression and anxiety disorders. However, there remains some debate about whether they are equally effective for all disorders, and whether psychotherapy and antidepressants are equally efficacious for each disorder. As I indicated in the March 2014 blog, antidepressant medications alone have become the first line of treatment for many who have depressive and anxiety disorders. However, a recent meta analysis concluded that monotherapy with medication alone was not optimal treatment for most patients, and that adding psychotherapy results in clinically meaningful improvement for most patients. Cuijpers and colleagues (2013) reported on an overall meta analysis of the studies in which psychotherapy and medication were directly compared to each other in adults with depressive disorders, panic disorder, generalized anxiety disorder (GAD), social anxiety disorder (SAD), or post-traumatic stress disorder (PTSD). They combined the effects of 67 studies including 5,993 patients. Forty studies included depressive disorders and 27 included anxiety disorders. Most therapies (49 of 78) were characterized as cognitive behavioral therapy (CBT), and the others included interpersonal psychotherapy, psychodynamic therapy, and non-directive counselling. Most patients were seen in individual treatment for 12 to 18 sessions. The most commonly prescribed medications were selective serotonin reuptake inhibitors (SSRI). The overall mean effect size for the difference between psychotherapy and medications was almost zero, indicating no significant difference. Regarding specific disorders and treatments, pharmacotherapy was more effective for dysthymia, but the effect size was small. By contrast, psychotherapy was more effective for OCD, and the effect size was moderately large. SSRI had similar effects to psychotherapy, but non-directive counselling was less effective than pharmacotherapy, though the effect was small.
Practice Implications
This meta analysis by Cuijpers and colleagues found that the differences between psychotherapy and antidepressant medications were non-existent for major depression, panic disorder, and SAD. Although antidepressants were more effective for dysthymia, the difference was small and disappeared when study quality was controlled, and so this finding is not reliable. Psychotherapy was clearly more effective for OCD even after adjusting for study quality and other factors. This is the first meta analysis to show the relative superiority of psychotherapy for OCD, and suggests psychotherapy as a first line treatment. The meta analysis only looked at post treatment results and not at longer term effects. There is evidence from other research showing that antidepressants do not have strong effects after patients stop taking them, whereas psychotherapy’s effects tend to be sustained in the longer term.
March 2014
Adding Psychotherapy to Medications for Depression and Anxiety
Cuijpers, P., Sijbrandij, E.M., Koole, S.L., Andersson, G., Beekman, A.T. & Reynolds, C.F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. World Psychiatry, 13(1), 56-67.
Anxiety and depressive disorders occur at a high rate and are very burdensome to those who suffer. These disorders are also related to high levels of health care costs, loss of productivity, and lower quality of life. Both pharmacological and psychotherapeutic interventions are effective, yet in recent years there has been a trend for patients to receive psychotropic interventions alone rather than psychotherapy. Cuijpers and colleagues (2014) conducted a meta analysis comparing pharmacotherapy alone versus pharmacotherapy combined with psychotherapy. Studies in the meta analysis included a variety of disorders such as depressive disorders and anxiety disorders. (Meta analysis is an important tool to review and combine the effects of interventions across a large number of studies. Rather than simply counting studies with positive, neutral, or negative findings, meta analysis allows one to calculate an effect size, average the effect sizes across different studies, and look at predictors or moderators of the effects. Aggregated effect sizes in a meta analysis are much more reliable [i.e., dependable] than any single study result). Cuijpers and colleagues’ meta analysis included 52 studies with 3,623 patients. Most studies tested cognitive behavioral therapy, though a large minority also included interpersonal psychotherapy and psychodynamic therapy. Most studies used selective serotonin reuptake inhibitors (SSRI), though some included tricyclic antidepressants and others. There was a moderately large overall difference between pharmacotherapy versus combined pharmacotherapy plus psychotherapy for major depression, panic disorder, and obsessive compulsive disorder (OCD). That is, adding psychotherapy resulted in a clinically meaningful improvement above and beyond pharmacotherapy alone. There were no significant differences found for type of antidepressant medication or for type of psychotherapy. Eleven studies included a placebo control condition to which medication alone vs medication plus psychotherapy was compared. The effect of combining medication and psychotherapy was twice as large as the effect of medication alone when compared to a placebo control condition. Nineteen studies followed patients after treatment (from 3 to 24 months post treatment), and the superiority of combined treatment versus medication alone remained strong and significant well into follow up.
Practice Implications
There has been a trend over the past decade to provide medication as a first line of treatment for depression and anxiety disorders. However, the results of this meta analysis indicate that monotherapy with medication alone is not optimal treatment for most patients, and that psychotherapy results in additive clinically meaningful improvement for most patients. The additive effects of psychotherapy are especially pronounced for major depression, panic disorder, and OCD.
February 2014
Separation Anxiety in Childhood is Related to Adult Panic and Anxiety Disorders
Kossowsky, J., Pfaltz, M., Schneider, S., Taeymans, J., Locher, C., & Gaab, J. (2013). The separation anxiety hypothesis of panic disorder: A meta-analysis. American Journal of Psychiatry, 170, 768-781.
The concept of separation anxiety is intimately tied to attachment theory. Problematic early attachments have negative consequences for adults’ ability to experience and internalize positive relationships which help to develop mental capacities to self sooth, tolerate anxiety, and modulate affect. Separation anxiety is the persistent, excessive, and developmentally inappropriate fear of separation from major attachment figures, like parents. It is one of the most frequently diagnosed childhood anxiety disorders, with a lifetime prevalence of 4.1% to 5.1%. If we knew that separation anxiety is truly related to or causes adult psychopathology, then we would have a better understanding of the development of adult mental disorders and greater reason to quickly and aggressively treat childhood separation anxiety. A meta analysis by Kossowsky and colleagues (2013) begins to address this relationship between separation anxiety and adult disorders. They looked at case-control, prospective, and retrospective studies comparing children with and without separation anxiety disorder with regard to future panic disorder, major depressive disorder, any anxiety disorder, and substance use disorders. The meta analysis included 25 studies of 14, 855 participants. Children with separation anxiety were 3.45 times more likely to develop a panic disorder later on; and 5 studies suggested that children with separation anxiety were 2.19 times more likely to develop future anxiety disorders. Childhood separation anxiety disorder did not increase the risk of future depressive disorders or of future substance use disorders. In a subsequent paper, Milrod and colleagues (2014) reviewed the literature on separation anxiety and psychotherapy outcomes of adult anxiety and mood disorders. Separation anxiety is associated with poor response to treatment of adult anxiety and mood disorders possibly because separation anxiety disrupts the therapeutic relationship. Separation anxiety also predicted non-response to antidepressant medications.
Practice Implications
As Kossowsky and colleagues (2013) indicate, it is possible that children suffering from separation anxiety disorder may be hindered early on in developing skills to help cope with anxiety and strong emotions. Nevertheless, the findings draw our attention to the importance of recognizing and treating separation anxiety as early as possible. A few psychological treatment studies show that disorder-specific parent-child cognitive behavioral therapy is successful in treating separation anxiety in children. For adults, poorer treatment response may reflect difficulty forming and maintaining attachments, including the therapeutic relationship. Milrod and colleagues (2014) suggest that psychotherapies that focus on relationships and separation anxiety by using the dyadic therapist-patient relationship to revisit earlier problematic parent-child relationships may benefit adults with separation anxiety.