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
December 2022
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
Practice Implications
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.
November 2022
How and for Whom Does the Therapeutic Alliance Work?
Research and understanding of the role of the therapeutic alliance in helping patients get better is evolving quickly. The therapeutic alliance is composed of patient-therapist collaborative agreement on the tasks and goals of therapy, and their relational bond. It is the most consistent predictor of patient outcomes. Much of the recent evolution in the research and theory of the alliance is driven by advances in statistical methods that disentangle (1) trait-like alliance from (2) state-like alliance. Trait-like alliance refers to the patient’s characteristic capacity to cooperate and make use of a therapeutic opportunity. State-like alliance refers the patient’s session by session increase or decrease in their alliance to the therapist regardless of their characteristic capacity. In this review of advances in research and theory on trait-like and state-like alliance, Zilcha-Mano and colleagues discuss the roles of these differing aspects of the alliance in helping to determine what therapist interpersonal stances will work best for which patient. The authors review research indicating that trait-like alliance (patients’ and therapists’ pre-therapy interpersonal capacity to cooperate and form a bond) provides a context for therapeutic interventions. That is, therapists with better interpersonal skills and patients with fewer interpersonal problems (i.e., alliance traits) tend to quickly and easily form a therapeutic alliance that provides a fertile ground for therapeutic interventions to take root. For these patients and therapists, a good alliance allows specific interventions of CBT (exposure and response prevention), psychodynamic therapy (transference interpretations), EFT (two chair technique) and others to work. The authors also review research indicating that state-like alliance (session by session growth in the therapeutic alliance) may be the key therapeutic tool for patients who begin therapy with greater interpersonal problems and lower trait alliance capacity. For these patients, an increase in their trust and bond with the therapist results in better treatment outcomes. Strengthening the alliance across therapy sessions may be a mechanism by which a corrective interpersonal experience with the therapist produces change in how the patient sees themselves (as deserving positive regard from others) and sees others (as caring and trustworthy).
Practical Implications
Clinicians working with patients who have lower interpersonal problems and a higher characteristic trait-like capacity to cooperate will do well to come to a collaborative agreement with the patient on a treatment plan and goals early in therapy. Such patients will do well with many types of therapeutic interventions. However, for patients with greater interpersonal problems (difficulties trusting, problems with interpersonal boundaries, lower reflective capacity), the key to effective therapy may be to grow the alliance from session to session. Therapists may engage in supportive interpersonal stances that include warmth, positive regard, empathy, and active listening. Therapists should focus their training on increasing their responsiveness to patients based on patient characteristics, and to assess the level of the therapeutic alliance at the start of therapy and from session to session.
What are Best Practices for Psychotherapy with Indigenous Peoples
In 2016 2.8% of the Canadian population identified as First Nations, 1.7% as Metis, and 0.2% as Inuit. In Canada there are 634 First Nations each with their own traditions, governance structures, and land claims. Colonial violence and land dispossession has led to Indigenous Peoples suffering from many mental health inequities. Indigenous samples are rarely evaluated in clinical trials of psychotherapy. And psychotherapy, as typically delivered, is a practice that is embedded in European cultural values which may not be appropriate for Indigenous Peoples. Defining best practices in psychotherapy with Indigenous Peoples may indeed be thorny given the historical context and values inherent in psychotherapy practice. In this article, Wendt and colleagues review four paths to providing psychotherapy to Indigenous clients, but each path has their challenges. The first path is to offer on empirically supported therapies for specific identifiable disorders. However, out of the hundreds of clinical trials available, only six were conducted that specifically focused on American Indian clients and all for alcohol use problems. Most empirically supported therapies were not validated for use with Indigenous clients, and some argue that this may make these treatments potentially harmful. The second path is to culturally adapt interventions so that the original therapies are maintained but adapted to the needs and culture of the Indigenous population. Some research suggests that cultural adaptations result in moderately better outcomes. Deeper adaptations incorporate cultural beliefs and promote cultural identity and connections to the Indigenous community. However, cultural adaptations tend to preserve a disorder-centric approach to problems rather than seeing problems in terms of a balance between mental, emotional, and spiritual health. The third path involves emphasizing the psychotherapy relationship, the working alliance, and promotion of hope – also known as the common factors approach to psychotherapy. This is highly collaborative approach to how therapy progresses and to maintaining a reciprocal balance in the therapeutic relationship. However, this approach does not necessarily address the European cultural values inherent in most psychotherapies. The fourth path involves efforts to strengthen and revitalize traditional Indigenous practices and cultural education as a means of healing. These might include integrating sweat lodges, the Medicine Wheel, and talking circles. This path embodies a “culture as treatment” approach in which problems are seen within historical losses of identity, purpose, and place. A report from the Canadian Psychological Association and the Psychology Foundation of Canada calls for psychologists to “view themselves as facilitators and supporters of the healing wisdom and knowledge that is already present in Indigenous communities”. However, as Wendt and colleagues note, there are practical barriers to this approach, and even if “culture as treatment” is seen by some as self-evidently effective, it has rarely been researched.
Practice Implications
Mental health professionals should avoid being unwitting agents of assimilation when providing clinical care to Indigenous clients. Primarily, clinicians should maintain a stance of cultural humility. Traditional indigenous approaches to mental health are important as a long-term strategy, including traditional understandings of problems, traditional healing, and Indigenous-led cultural interventions. All of this, however, is limited by inadequately addressed colonial harms, poverty, and legal obstacles to Indigenous Nations’ sovereignty.
July 2022
The Efficacy of Group Therapy
Burlingame, G.M. & Strauss, B. (2021). Efficacy of small group treatments: Foundations for evidence-based practice. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 17.
Group therapy involves one or more therapists treating more than two individuals together in a group setting. Ideally, group therapy not only includes specific individualized interventions of a theoretical orientation (cognitive restructuring, behavioral activation, transference interpretations) but also makes use of group-specific factors known to predict patient outcomes (development of group cohesion, social learning, peer feedback). In this chapter, Burlingame and Strauss report on the efficacy of group therapy for a number of disorders and relative to individual therapy. In a meta-analysis of 68 studies for a variety of disorders and different theoretical orientations, there was no difference between individual therapy and group therapy in terms of primary symptom outcomes (g = -0.03). One of the challenges of practicing group therapy is that some patients and providers might perceive group therapy as less effective or less desirable than individual therapy. However, meta-analyses of patient acceptance of treatment (percent of patients assigned to group or individual therapy and who follow through with treatment) or of patient drop out after starting treatment shows no difference between individual and group therapy. Regarding outcomes for specific disorders, over 11 meta-analyses have been published in the past decade as part of an international effort to document the effects of group therapy. For major depressive disorder, group therapy was more effective than treatment as usual (g = 0.69) and as effective as pharmacotherapy (g = 0.08). Group therapy was more effective than no treatment for social anxiety disorder (g = 0.84), panic disorder (g = 1.08), OCD (g = 0.97), eating disorders (g = 0.79), substance use disorder (g = 0.28), and PTSD (g = 0.70). For all these disorders, group therapy was as effective as another active treatment to which it was compared (individual therapy or pharmacotherapy).
Practice Implications
Patients and practitioners may have concerns about group therapy (that it is not private, that the time is divided among several patients, that outcomes may not be as good as individual therapy). Clinicians are advised to take these concerns seriously and to respond to them with an explanation based on the research – that is, that group therapy: is as effective as individual therapy, is probably more cost efficient than individual therapy, and is as well tolerated as individual therapy. Many group therapists use pre-group preparation of patients to help them understand the utility of group therapy. Referral sources may need to be educated about the accumulating research on the efficacy of group therapy. This seems particularly important as clinics, hospitals, private practices, and community agencies grapple with fewer resources to provide adequate care. Group therapy, when done well by clinicians who are adequately trained in group interventions may be a means of increasing accessibility to care for many.
Cognitive-Behavioral Therapy for Depression
Newman, M.G., Agras, W.S., Haaga, D.A.F., & Jarrett, R.B. (2021). Cognitive, behavioral, and cognitive-behavioral therapy. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 14.
Cognitive-behavioral therapy (CBT) is the most researched psychotherapy for many disorders including depressive disorders. Depression is a global health problem that affects physical and emotional health and is associated with many adverse effects (substance dependence, poverty, illness). And so, finding good treatment options for patients with depression is an important goal. Many treatment guidelines view CBT as one of the first-line treatments for depression based on the research that demonstrates its efficacy. In this chapter of the Handbook, Newman and colleagues review the research on the efficacy of CBT. Immediately post-treatment, the effect sizes for CBT were medium to large when compared to treatment as usual (g = .59, 95% CI [0.42, 0.76]), placebo control groups (g = 0.51, 95% CI [0.32, 0.69]) and wait list/no treatment control groups (g = 0.83, 95% CI [0.72, 0.94]). The effects of CBT for depression tend not to differ from other bona-fide psychotherapies including interpersonal psychotherapy (IPT) (g = –0.09, 95% CI [–0.39, 0.20]), psychodynamic therapies (g = 0.25, 95% CI [–0.07, 0.58]), and supportive psychotherapy (g = 0.15, 95% CI [–0.06, 0.25]). The effects of CBT are also similar to those achieved with anti-depressant medications (g = 0.03, 95% CI [-0.13, 0.18]). Approximately 41% of patients with major depression who receive CBT have significantly fewer depressive symptoms immediately post-treatment than the average patient treated in a placebo or waiting list/no treatment control group. There have been some criticisms of the effect size estimates for CBT in some of these studies. For example, research indicates that newer and higher quality studies have resulted in smaller effects. And so there remains concerns that the overall effects of CBT for depression may be over-estimated.
Practice Implications
Treatment guidelines indicate that CBT is one of the first-line treatment for depressive disorders along with anti-depressant medications and other psychological therapies. CBT appears to improve both short-term and longer-term outcomes for some adults. There is also some evidence that if CBT is combined with pharmacotherapy, then patients might experience even greater improvement. CBT may result in patients learning something about themselves and their depression, which might reduce relapse and recurrence of the depression, although evidence for the latter is still uncertain.
Are Humanistic Psychotherapies Effective?
Elliot, R., Watson, J., Timulak, L., & Sharbanee, J. (2021). Research on humanistic-experiential psychotherapies: Updated review. In Barkham, W., Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 13.
Humanistic or experiential psychotherapies have a long history going back to the work of Carl Rogers and Fritz Pearls in the 1960s. This is a broad umbrella of therapies that include person-centred therapy, gestalt, emotion-focused, psychodrama, and existential therapies. Most of these therapies see the therapeutic relationship as central and curative. The therapist tries to enter the client’s subjective world with empathy to understand the client’s experience and to provide a validating and corrective emotional experience. The goals of humanistic-experiential therapy include self-awareness, personal growth, and meaning-making in clients’ lives. In this chapter, Elliott and colleagues review and update the meta-analytic evidence for the effectiveness and efficacy of humanistic-experiential therapy. The uncontrolled pre- to post-treatment change from receiving humanistic-experiential therapy estimated from 97 studies was .86 (k = 94; 95% CI [.74, .97]), representing a large effect. Clients maintained their immediate post-treatment gains during the year following therapy (ESw = .88; k = 41; 95% CI [.67, 1.1]) and beyond (ESw = .92; k = 15; 95% CI [.52, 1.31]). Compared to no-treatment control groups in 15 randomized studies, humanistic-experiential therapy showed a large pre-post effect ESwc= .98 (95% CI [.55, 1.20]). Compared to all other therapies in 56 randomized trials, humanistic-experiential therapy produced equivalent outcomes, (ESwc = –.07; 95% CI [–.21, .07]). The outcomes compared specifically to CBT in which only bona-fide humanistic-experiential therapies were included (i.e., only studies in which the humanistic-experiential therapies were meant to be effective) also indicated a non-significant difference, (ES = –.15; k = 9; 95% CI [–.27, .03]).
Practice Implications
Dating back to the work of Carl Rogers, humanistic-experiential therapies have had an important impact on how many types of therapy is offered today. The emphasis of many therapies on empathy, the therapeutic relationship, and corrective emotional experience are hallmarks of humanistic-experiential therapies. The results of these updated meta-analyses indicate that humanistic-experiential therapies are effective in the short and longer term and are as effective as other forms of well-research psychotherapies.