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Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.

In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.

Practice Implications

Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.

Jorm, A.F., Patten, S.B., Brugha, T.S., & Mojtabai, R. (2017). Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry, 16, 90-99.

Mental disorders are a major source of disability. However, many individuals remain untreated, such that 36% to 50% of serious cases in industrialized countries went untreated in the previous year. In 2001 the World Health Organization argued for making treatment more accessible and to train more mental health professionals. In this wide-ranging review, Jorm and colleagues look at data from the U.K, the U.S., Canada, and Australia to assess if in fact treatment provision has increased over time, and whether this increase was associated with declines in the prevalence of common mental disorders. In all of the countries surveyed, antidepressant use among those with mental disorders (mainly anxiety and depressive disorders) increased dramatically from 1990 to 2011, such that their use rose by 300% or more during that period. The use of psychotherapy increased in Australia by about 46% among those with a diagnosable disorder. While the rates of psychotherapy-use remained the same in the U.K., they declined dramatically in the U.S. from 71.1% in the late 1980s to 43.1% in 2007 (no data was available from Canada). At the same time however, the prevalence of mental disorders has been increasing or remaining the same in all of the four countries. For example, in England the prevalence of common mental disorders among women went from 18.1% in 1993 to 18.9% in 2007. The authors then speculated as to why the dramatic increase in the use of antidepressants was not followed by a decrease in diagnosed mental disorders. They were able to rule out a number of possibilities like increased reporting of mental illnesses, or an increase in risk factors in the communities involved. The authors did suggest however that antidepressant medications may not be prescribed as intended by primary health care providers. For example, in Australia, only 50% of people prescribed antidepressants receive them as recommended in clinical guidelines. In an Alberta, Canada study, 67.2% of those who reported taking an antidepressant had no active mood or anxiety disorder at the time of the survey. Among those with major depression, only 14.3% reported receiving psychotherapy.

Practice Implications

This large review highlights some findings that are already well known: that antidepressant use is dramatically on the rise, and that psychotherapy use is declining slightly over time. This may be due to the quick and easy availability of antidepressant medications, the direct to consumer advertising done by the pharmaceutical industry in some countries, and to a possible cultural need for easy fixes to complex problems. What is new in this review, is that the rise in available antidepressant medications appears not to have made a dent in the rate of mental illness in four industrialized countries.

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.

Some therapists achieve better patient outcomes than others. This seems obvious on the surface and yet few people talk about it, and the research literature seems to downplay or ignore this fact. To illustrate the differing outcomes achieved by therapists, I reviewed a unique study in the September 2013 PPRNet Blog. In that study, 10 cases were randomly selected from 700 therapists (N = 7000 patients), and therapist outcomes were assessed by averaging their patient outcomes. Depending on the presenting problem, as many as 67% of therapists were reliably effective, but as many as 16% were reliably harmful. Clearly therapists differ. Yet psychotherapy research typically treats therapists as if they are uniformly effective. In their chapter, Wampold and Imel review some of the research that estimates the therapist’s effect on outcomes. In other words, what is the impact of the particular therapist on the patient outcomes? Even in studies in which: (a) therapists are selected as experts to provide a specific type of therapy (i.e., CBT, psychodynamic, interpersonal, etc.), (b) therapists are highly trained to be adherent to a manual with repeated supervision, and (c) patients are randomly assigned to treatments, there remains a significant amount of variability in therapist outcomes. Indeed in many studies the therapist effect is as large or larger than the effect of the intervention that is being delivered. In other words, which therapist a patient gets in a treatment study matters just as much or more than what type of therapy they receive. This is also true in medication trials. Better psychiatrists (i.e., those with overall better patient outcomes) who gave a placebo had better patient outcomes than poorer psychiatrists who gave the active medication. A recent large meta analysis found that about 5% of patient outcomes in controlled psychotherapy trials was attributable to the therapist, and the effect is as high as 7% in naturalistic settings. For treatment of PTSD, therapist effects are as high as 12%. On the surface these look like small effects, but in reality they can have a big cumulative impact. Therapists with the best and worst outcomes differ dramatically. For example in one large study, the best performing therapists had a patient response rate of 80% compared to the worst performing therapists who had only 20% of their patients improve. Which therapist would you want a loved one to see?

Practice Implications

Wampold and Imel reported that that therapist effects generally exceed the effects of the specific treatment that is being tested or provided. Some therapists consistently achieve better patient outcomes than others. What are the characteristics and actions of effective therapists? Factors like therapist allegiance to the therapy, empathy, and the ability to form and maintain an alliance with clients appear to differentiate therapists who consistently have good patient outcomes versus those whose patients tend to have poor outcomes.

Angus, L., Watson, J.C., Elliott, R., Schneider, K., & Timulak, L. (2015) Humanistic psychotherapy research 1990–2015: From methodological innovation to evidence-supported treatment outcomes and beyond. Psychotherapy Research, 25, 330-347.

In this wide-ranging review, Angus and colleagues provide an overview of humanistic psychotherapy research from 1990-2015. For this blog I will focus on the efficacy research that they review. Humanistic psychotherapy addresses how people can come to know themselves and each other, and to fulfill their aspirations. This type of therapy emphasizes the personal, interpersonal, and contexts within which clients reflect on their relationships with the self, others, and the world. Carl Rogers is probably the best known early proponent of humanistic client centred psychotherapy. Humanistic psychotherapy focuses on a genuinely empathic therapeutic relationship to promote in-therapy client emotional experiencing, emphasizes meaning-making, and is person-centred. One of the questions raised by Angus and colleagues was: are humanistic psychotherapies efficacious. Here they mainly summarize a previous review by Elliot and colleagues (2013). In a meta analysis of 191 studies and over 14,000 clients, humanistic psychotherapies are associated with large pre to post therapy client change (g = .93) which are maintained over early (< 12 months) and late (> 12 months) follow ups. Further, in 31 studies of over 2,000 clients, those who received humanistic therapies show large gains compared to those who receive no treatment (g = .76). In 100 studies of over 6,000 clients, humanistic therapies had equivalent outcomes to other therapies (g = .01), including CBT (22 studies, g = -.06). Humanistic therapy was most effective for interpersonal/relational trauma, and depression (for which it is considered an evidence supported treatment). There is also good evidence for the efficacy of humanistic therapy for psychotic conditions. However, humanistic therapies may be less effective than CBT for anxiety problems.

Practice Implications

Humanistic psychotherapy that focuses on a genuinely empathic therapeutic relationship that emphasizes client emotional experiencing and meaning-making is efficacious for a number of mental health problems. Rogers argued that non-judgemental acceptance, warmth, and congruence were necessary for good client outcomes, and an accumulating body of research is supporting these early propositions. The evidence for the importance of therapist empathy to improve client outcomes is particularly compelling.

Author email: langus@yorku.ca

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.