Blog

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Change in dysfunctional attitudes or cognitions is one of the specific mechanisms by which cognitive therapy (CT) is thought to be effective in the treatment of depression. In this part of their book, Wampold and Imel discuss the evidence that addresses the specific change mechanisms for CT. The reason they focus on CT is that CT is by far the most researched psychotherapy approach, and there is a substantial number of CT studies that have addressed this issue of change mechanisms. In an early meta analysis, Oei and Free (1995) found a significant relationship between change in cognitions and CT. However, in the same meta analysis, the authors found that CT and non-cognitive therapies did not differ in terms of their effects on cognitions. That is, most treatments, whether CT or not, appeared to change cognitions. In another study, three different interventions (behavioral activation, CT, and CT plus behavioral activation) all resulted in change in cognitions and improved depression. In other words, cognitive interventions do not seem to be needed to alter cognitions and reduce depression. Wampold and Imel argue that nonspecific processes in CT (and other psychotherapies for that matter) are largely responsible for the effectiveness of psychotherapy. For example, there is evidence to suggest that a number of patients show substantial symptom improvement early in treatment before specific cognitive techniques are introduced. Some have argued that this early favourable response is largely due to the effects of client expectations, reassurance, and remoralization rather than the specific procedures of the therapy. Moreover, patients who experience this remoralization early-on may be better at successfully applying techniques taught in CT. A large review of this literature concluded that there was insufficient evidence to support the notion that challenging thoughts was responsible for the positive effects of CT.

Practice Implications

This line of research appears to indicate that the specific practice of challenging thoughts or dysfunctional attitudes is not primarily responsible for patient change in CT. It may be that for any psychological treatment that has a cogent rationale for the disorder and is administered by an acknowledged expert, client progress may be determined largely by contextual factors. These factors may include a therapeutic alliance, client expectations of benefit, and client remoralization, which may in turn allow clients to benefit from the specific interventions of psychological treatments.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

The narrative about the relative efficacy of psychotherapies for depression has shifted over the past several decades. In the early days (1970s – 1980s) there appeared to be accumulating evidence that cognitive behavioural therapy (CBT) was more efficacious than “other psychotherapies”. However, today one look at the Society for Clinical Psychology list of empirically supported treatments for depression indicates that a variety of interventions are efficacious. In this part of their book, Wampold & Imel examine this change. Early in their book, they defined psychotherapy as: (1) based psychological principles, (2) involving a trained therapist and a client who is seeking help for a mental disorder, (3) intended to be helpful for the client’s complaints, and (4) adapted to the client’s problem. Wampold and Imel argue that many of the treatments compared to CBT in the early days did not meet this definition of psychotherapy. That is, many of the early comparison treatments were not bona-fide therapies; so the comparisons were not expected to be therapeutic. Common comparisons to CBT were “usual care”, “supportive therapy”, and “self directed care” that for the most part did not meet the definition of psychotherapy. Further, the providers of usual care or supportive therapy had no allegiance to the treatment or expectation that the intervention was useful, which eroded the credibility of these interventions for the client. When bona-fide psychotherapies are compared to each other, the effect sizes tend to be small or negligible. For example, Braun and colleagues (2013) conducted a large meta analysis of 53 studies with nearly 4,000 patients.  When they looked specifically at studies of bona fide therapies, and pairs of treatments that were compared in at least 5 studies, there were no differences between the treatments. Similar findings are reported in large a network meta analysis by Barth and colleagues (2013) (198 studies with 15,118 patients) that was summarized in the July 2014 PPRNet Blog.

Practice Implications

Psychotherapies that are based on sound psychological principles, delivered by trained therapists for clients who seek help and that are intended to be helpful for the client’s complaint are likely to be equally effective for depressive disorders. A variety of psychotherapies including, CBT, emotionally-focused therapy, interpersonal psychotherapy, and short-term psychodynamic therapy have demonstrated empirical support for their efficacy in treating depression. Client expectations of receiving benefit and therapist allegiance to treatment enhance the effectiveness of treatments.

Lichtman, J.H., Froelicher, E.S., Blumenthal, J.A., Carney, R.A., Doering, L.V., et al. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: Systematic review and recommendations: A scientific statement from the American Heart Association. Circulation, 129, 1350-1369.

There are about 15.4 million US adults with coronary heart disease. About 20% of those hospitalized for an acute coronary syndrome (ACS; that includes myocardial infarction or unstable angina) meet diagnostic criteria for major depression. An even larger percentage of those with heart disease show sub-clinical levels of depressive symptoms. As I reported in the June 2014 PPRNet Blog about 4% of the population suffer from depression, and so the rates of depression are substantially higher among those with ACS. There is a large body of research showing a reliable association between depression and increased morbidity and mortality after ACS. The goal of this scientific statement by the American Heart Association is to review current evidence for the role of depression as a risk factor among patients with ACS. The authors were particularly interested in studies looking at: (1) all cause mortality, (2) cardiac mortality, and (3) composite outcomes including mortality and nonfatal events. Fifty three studies, representing tens of thousands of patients were included in the review. Twenty one of 32 published studies indicated that depression is a risk factor for all-cause mortality after ACS. Fewer studies looked at the relationship between depression and cardiac mortality, but 8 of 12 studies suggested that depression is a risk factor for cardiac mortality after ACS. Finally evidence from 17 of 22 studies suggested that depression was a risk factor for combined outcomes of cardiac mortality, all cause mortality, and nonfatal cardiac events. The authors also reported on meta analyses looking at the association between depression and mortality following myocardial infarction. Depression increased the risk in individuals of mortality from 1.6 to 2.3 times. The authors concluded that the American Heart Association should elevate depression to the status of a risk factor for adverse medical events in patients with ACS.

Practice Implications

This scientific statement by the American Heart Association published in a technical journal read by cardiologists is important because it acknowledges a mental health problem as a risk factor for mortality from a common medical disease. The evidence is quite strong that depression increases the risk of death in those with heart disease, especially acute coronary syndrome (ACS). Some of the mechanisms for the risk may include genetic/physiological factors like inflammation, platelet aggregation, and the serotonin system that are associated with both depression and ACS. In addition, depression can result in less physical activity and poorer self care which could exacerbate a number of health problems that increase the risk for cardiac disease. Depression is also associated with increases in high risk health behaviors like smoking, sedentary lifestyle, and non-adherence to medical treatment. Assessing for and treating depression among patients who have a history of or are at risk of heart disease is important. If such a patient is depressed or has elevated depressive symptoms, then the depression should be treated in order to reduce the risk of death due to medical problems. In the July 2014 PPRNet Blog, I reported on a network meta analysis showing the positive effects of 7 psychotherapies for depression.

Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.

Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.

Practice Implications

CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In this section of their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research on: (1) specific techniques of cognitive behavioural therapy (CBT), and (2) change mechanisms of CBT for depression. Research on techniques and mechanisms of change tests the specific or unique effects of a treatment and the rationale for its use. The first issue addresses whether therapist adherence and competence in using CBT techniques produce desired outcomes in patients. CBT techniques include: following an agenda, reviewing homework, asking about specific beliefs, practicing rational responses with patients, and asking patients to keep thought records. Crits-Christoph and colleagues (2013) report that the research findings on the association between using specific CBT techniques and depression outcomes are mixed. The strongest evidence is for concrete techniques such as setting agendas, reviewing homework, and practicing rational responses. However the number of studies that control for prior symptom change and other factors like therapeutic alliance is small, and so the evidence for the specific effects of CBT techniques remains meagre. The second issue addresses whether targeting depressogenic cognitions with CBT results in positive outcomes. Generally, CBT theory argues that the mechanisms by which CBT works is to focus on core depressogenic schemas (i.e., less consciously long held negative beliefs about the self), conscious negative automatic thoughts, and dysfunctional attitudes (i.e., patterns of automatic thoughts) that lead to or maintain depression. Theoretically, addressing these cognitions in CBT should reduce depressive symptoms. Overall, the research shows that both CBT and medication treatment for depression reduce self-reported negative thinking; that is, the effects on negative thinking were not specific to CBT. Few studies show that changes in cognitions precede changes in depressive symptoms, which is a key CBT tenet. The most promising findings suggest that learning compensatory skills (i.e., finding alternative explanations for negative events and thoughts, and problems solving) may be part of the mechanism by which CBT works, but again this mechanism may not be specific to CBT.

Practice Implications

CBT is an effective treatment for depression. CBT theory suggests that the reason for its effectiveness is the use of specific techniques (i.e., reviewing homework, asking for specific beliefs, practicing rational responses with patients, and asking patients to keep thought records) that target the purported causes of depression (i.e., depressogenic shemas, negative thoughts, and dysfunctional attitudes). Currently there is little research evidence that supports the specificity of CBT techniques or that supports the notion that specific changes in cognitions as a result of CBT reduce depression. Nevertheless, in general, concrete techniques (i.e., setting agendas, reviewing homework, and practicing rational responses) are clinically useful for depressed patients, as is learning compensatory skills like problem solving.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.