Blog

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.

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.

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.

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.

Norwood, C., Moghaddam, N.G., Malins, S., & Sabin-Farrell, R. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology and Psychotherapy, 25, 797-808.

The working alliance is the collaboration between client and therapist on the tasks and goals of therapy, and it also includes the emotional bond. The alliance is the most researched concept in psychotherapy, and it is reliably related to good client outcomes. However, the alliance has been rarely studied in the context of videoconferencing psychotherapy (VCP). Delivering psychotherapy remotely was already gaining popularity prior to COVID-19 because of its potential to improve access to mental health care especially for people who live in remote areas. Some argue that face to face therapy might result in a higher therapeutic alliance because of the rich interpersonal cues, like eye contact and body posture that may facilitate collaboration and the bond. There is emerging evidence that VCP can be effective and that it may have comparable outcomes to face-to-face therapy. But what about the working alliance – does it develop in VCP similarly to face to face therapy?  In this meta-analysis, Norwood and colleagues conducted a systematic review of the existing research on the working alliance in VCP. They found only 4 direct comparison randomized controlled studies on the topic, and on average VCP resulted in a lower working alliance compared to face to face therapy, but the difference was not statistically significant (n = 4; SMD = -0.30; 95% CI: -0.67, 0.07; p = 0.11). People who received treatment via VCP had similar levels of symptom reduction compared to those who received face to face therapy (n = 4; SMD = −0.03; 95% CI [−0.45, 0.40], p = 0.90).

Practice Implications

With only four direct comparison randomized trials to draw from, the results of this meta-analysis remained ambiguous with regard to the therapeutic alliance. Although the difference between VCP and face to face therapy was not statistically significant, it was not ignorable – an effect size of SMD = -0.30 suggests a small advantage for face to face therapy when it comes to the alliance. However, symptom outcomes were comparable between face to face and VCP. The results suggest that therapists who use VCP during a pandemic, must pay particular attention to developing and maintaining a therapeutic alliance by collaboratively agreeing on goals and tasks of therapy, and by focusing on establishing an affective bond with patients despite the limited nonverbal cues available with online psychotherapy.

Effectiveness and Adherence of Telephone-Administered Psychotherapy

Castro, A., Gili, M., Ricci-Cagello, I., Roca, M., Gilbody, S., Perez-Ara, A., Segui, A., & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526.

The COVID-19 pandemic has resulted in psychotherapy providers moving to online and telephone-delivered interventions. But questions remain about the efficacy of delivering psychotherapy in these formats to patients with depression. Depression is highly prevalent as it affects about 320 million people around the world and causes serious disability and lowered quality of life. Psychotherapy is effective in treating depression, however there are significant barriers to people accessing face-to-face psychotherapy including cost, stigma, distance, and disability. Telephone-delivered psychotherapy may minimize these barriers. One potential question that may arise is whether patients will adhere to telephone-delivered psychotherapy. That is, will patients find telephone sessions acceptable as indicted by the rate of starting therapy and of attending sessions? In this systematic review and meta-analysis, Castro and colleagues evaluated whether telephone-delivered psychotherapy for depression is as effective as other active treatments and more effective than no-treatment. The authors also examined the level of adherence/acceptability to telephone administered treatment, determined by the percent of scheduled sessions actually attended by a patient. The sample of studies was small such the authors only found a total of 11 direct comparison randomized controlled trials. These trials represented almost 1400 patients. The only treatment tested in these trials were CBT-oriented. Four studies found that telephone-delivered therapy produced significantly larger reductions in depressive symptoms when compared to no treatment controls (mean SMD = -0.48; 95% CI: -0.82 to -0.14). In four other studies telephone-administered therapy was just as effective as an active control (e.g., medication or self-help). The weighted average percentage of scheduled telephone sessions that patients attended was 73%, and the percent of patients who started telephone therapy after the initial referral was about 90%. These percentages indicating adherence and acceptability are similar to findings reported from individual psychotherapy studies.

Practice Implications

There are few randomized controlled trials that assess the efficacy of telephone-administered psychotherapy, and these studies were limited to only one type of intervention. However, the findings from this meta-analysis suggested that telephone-delivered psychotherapy may be efficacious and as effective as some other active treatments. Further, telephone therapy may be acceptable to patients in that they start and attend sessions at a rate similar to face-to-face therapy. These preliminary findings provide clinicians who provide telephone psychotherapy during this period of physical distancing due to COVID-19 with some evidence for the utility of telephone delivered treatment.