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.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Side-Effects of Psychotherapy
Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted events and side effects in cognitive behavior therapy. Cognitive Therapy and Research, 42(3), 219-229.
Unwanted events are negative consequences for clients that may or may not be related to treatment (i.e., events outside of therapy or inside of therapy that may negatively affect clients). These might include: occupational problems, stigmatization, strains in personal relationships, changes in the social network, patients feeling overwhelmed, undermined self-efficacy, deterioration of symptoms, emergence of new symptoms, suicidality, and others. Side effects refer to negative reactions in clients directly related to appropriately delivered therapy. Research estimates that between 5% and 20% of patients report side effects of psychotherapy. One could argue that side effects may be inevitable even in well-delivered therapy, and therapists who are aware of the potential for side effects may be better equipped to help clients to manage. In this study, Schermuly-Haupt, interviewed 100 psychotherapists who provided CBT in outpatient clinics in Germany about side effects among their clients. All therapists were supervised as part of their work and so the authors assumed the therapy was appropriately delivered. Therapists had on average 5 years of experience and were trained to provide CBT. The interview asked therapists about their most recent treatment case in which the client attended at least 10 sessions. Clients typically had major depression, an anxiety disorder, or a personality disorder, and had attended 28 sessions of therapy on average. During the interview, therapists identified if an unwanted event occurred for a client from a standardized list, and then rated the duration and severity of the effects. They also rated the degree to which the unwanted event was directly related to therapy (i.e., a side effect). Prior to the interview, only 26% of therapists reported their client experienced side effects. However, the interview process found that almost all clients experienced an unwanted event (98%) that may or may have been related to therapy, and 43% experienced at least one side effect that was at least somewhat related to treatment. The most frequent side effects were: “negative wellbeing/distress” (27% of clients), “deterioration of symptoms” (9% of clients) and “strains in family relations” (6% of clients). Of the therapists, 46% rated the side effects as at least moderately severe, and 8.8% of side effects were rated as persistent (lasting more than a month).
Unwanted events outside of therapy are very common among our clients, but so are side effects from appropriately delivered treatment. Psychotherapy is not always harmless, and it may be best to acknowledge and prepare both clients and therapists for side effects. These may represent ruptures in the alliance that can be managed through alliance-focused therapy, for example. That is, side effects may be caused a mismatch between the goals of a therapist and client, or a disagreement on how to proceed in therapy given what a client needs at the time. Goals and tasks of therapy may need to be renegotiated following the experience of a side effect.
Is Short-Term Prolonged Exposure Effective to Treat PTSD in Military Personnel?
Foa, E., McLean, C.P., Zang, Y., Rosenfield, D., Yadin, E… Peterson, A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. Journal of the American Medical Association, 319, 354-364.
Post-traumatic stress disorder (PTSD) can affect 10% to 20% of military personnel returning from combat. PTSD is often chronic and debilitating, and is associated with symptoms that are distressing, that lower quality of life, and that negatively impact family and loved ones. Prolonged exposure therapy (PE) has been tested in the past, and researchers have claimed that it is an efficacious treatment in civilians and veterans. PE is a form of behavior therapy and cognitive behavioral therapy characterized by re-experiencing the most traumatic event through remembering it and engaging with, rather than avoiding reminders of the trauma. In their treatment guidelines, the American Psychological Association (APA) proposed PE as a recommended treatment for PTSD. In this randomized controlled trial, Foa and colleagues assess if providing PE in intensive short time frame (massed exposure; 10 sessions over 2 weeks) was as effective as standard exposure (10 sessions over 8 weeks) for 370 military personnel in the US with PTSD. That is, the authors were interested to see if providing the same amount of therapy based on exposure in a shorter time was just as effective. They also compared the two versions of PE (massed and standard exposure) to two control conditions: present centred therapy (PCT) that is largely supportive therapy that does not rely on exposure to the trauma, and a no treatment control condition. The main outcomes were reductions in level of PTSD symptoms and reductions in PTSD diagnoses at post-treatment and up to 6 months post-treatment. Massed and standard PE were equally effective in reducing symptoms and diagnoses of PTSD compared to no treatment. However, PE was not more effective than PCT in reducing symptoms and diagnoses, and PCT was more effective than no treatment. Overall, reductions in PTSD symptoms and reduction in PTSD diagnoses were modest. Drop out rates were high at about 50% for all conditions.
Drop out rates were high and outcomes were modest for these short-term psychological treatments for PTSD in military personnel, such that over 60% still had a diagnosis of PTSD at 6 months follow up. And PE therapy did no better than a control condition (PCT) that simply provided support with no exposure to the trauma. These findings are similar to other research in this area. Psychotherapy for trauma may require more time to work, and perhaps different models of understanding and treating the disorder. As Shedler recently remarked, it takes at least 20 sessions/weeks before 50% of clients improve. So it may not be surprising that 2 or 8 weeks of therapy had only a small impact on PTSD symptoms.
Therapist Characteristics That Affect Client Outcomes
Lingiardi, V., Muzi, L., Tanzilli, A., & Carone, N. (2017). Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review. Clinical Psychology & Psychotherapy. Advance online publication.
Psychotherapists differ in their effectiveness such that some therapists are more effective than others, and these differences account for up to 9% of client outcomes. Despite this, not many studies have looked at therapist personal characteristics that might be associated with better or worse outcomes. In this systematic literature review, Lingiardi and colleagues focus on empirical studies of psychodynamic therapists and their personal characteristics that might affect therapeutic processes and client outcomes. The authors included only quantitative studies. Thirty studies representing nearly 1,400 therapists and 6,000 clients were included in the review. Most studies occurred in a naturalistic setting, and most therapists were female (66%) with an average of over 9 years of experience. The studies looked at various therapist personal characteristics and their association with therapeutic processes and client outcomes. Therapist attachment security (ability to engage in meaningful loving relationships and adaptively manage emotions) was associated with better client outcomes. Similarly, therapists who reported better experiences of parental care and better quality relationships with attachment figures tended to have clients who rated a more positive therapeutic alliance. In addition, therapist interpersonal functioning was evaluated in several studies. Therapists who were rated as more affiliative (warm, friendly) and less hostile (cold, rejecting) tended to have clients who achieved better outcomes. Further, therapist facilitative interpersonal skills (emotional expressiveness, verbal fluency, warmth, empathy) were associated with better client outcomes in short-term therapy. Finally, several studies assessed therapist self-concept (stable means by which one treats oneself). Therapists who were more hostile or negative toward the self tended to be more critical or ignoring of clients, which lead to poorer client outcomes.
Therapist personal characteristics (attachment security), interpersonal skills (warmth, friendliness, empathy), and self concept (how one treats oneself) may account for why some therapists are more effective than others. Problems in these areas might lead to problematic countertransference (emotional reactions on the part of therapists triggered by client issues) or therapeutic alliance ruptures, both of which are related to poorer client outcomes. Therapists can learn methods of managing countertransference and repairing alliance ruptures. If the personal characteristics are persistent and problematic, therapists might consider personal therapy.
Effects of Computerized CBT May be Overestimated
So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A., & McCrone, P. (2013). Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry, 13, 113.
Depression is a major cause of disability in the world, and so efforts to improve access to its treatment have been ongoing for several decades. In particular, many researchers and clinicians propose cognitive behavioural therapy (CBT) as an effective treatment with a good evidence-base. There have been many clinical trials showing the efficacy of CBT. In recent years, there have also been attempts to computerize CBT (CCBT) as a self help intervention in order to increase its accessibility for those with depression, and perhaps also to improve its cost effectiveness. In fact, the Increasing Accessibility to Psychotherapy (IAPT) program in the UK provides CCBT as the most common first treatment for depression. However there remain questions about the longer term effectiveness of CCBT to reduce symptoms of depression, its potentially high patient dropout rate (a negative outcome), and its effects on quality of life of those burdened by depression. In this meta analysis, the largest of its kind, So and colleagues assess these issues with regard to CCBT. They reviewed 14 direct comparison randomized controlled trials that provided 16 comparisons of CCBT versus a control condition (wait list or treatment as usual) for adults with depression. At post-treatment, CCBT was more effective than controls in reducing depression −0.48 [95% CI −0.63 to −0.33]. However, at follow up (up to 6 months), the effects of CCBT disappeared −0.05 [95% CI −0.19 to 0.09]. Also improvement in functioning and quality of life were not significantly different between CCBT and control conditions, −0.05 [95% CI −0.31 to 0.22]. The rate of drop out from CCBT (32%) was almost double that of control conditions (17%), RR = 1.68 [95% CI 1.31 to 2.16]. There was also evidence of publication bias (i.e., a tendency for some researchers not to publish non-significant findings), so that the positive post-treatment results in favour of CCBT might be inflated.
Although CCBT may be touted as a way to increase access to treatment for depression, this meta analysis indicates some concerns about the widespread implementation of CCBT. The effects of CCBT appear to be limited to a short-term reduction of depressive symptoms that may not be sustained in the longer run. There was no appreciable impact of CCBT on quality of life relative to controls, and so CCBT may have a limited impact on the burden of depression. Most troubling was a high drop out rate of 32%. Drop out from CCBT in the IAPT program in the UK is about 50%, and this may be indicative of the actual drop out rate in real world practice.
Cost-effectiveness of Short-term Versus Long-term Psychotherapy
Maljanen, T., Knekt, P., Lindfors, O., Virtala, E., Tillman, P., et al. (2016). The cost-effectiveness of short-term and long-term psychotherapy in the treatment of depressive and anxiety disorders during a 5-year follow-up. Journal of Affective Disorders, 190, 254-263.
There is substantial evidence that short-term psychotherapy is effective for depressive and anxiety disorders, including at follow-up. There are also a few meta-analyses showing the effectiveness of longer term therapy. Although there is research indicating the cost-effectiveness of short-term treatments, less research has evaluated the cost-effectiveness of longer term therapy, and even less research at long term follow-ups. In this study from the Helsinki Psychotherapy Study Group, the authors evaluated the cost-effectiveness of short-term therapy (solution-focused therapy [12 sessions] or short-term dynamic therapy [20 sessions]) versus long term dynamic psychotherapy (2-3 sessions weekly for up to 3 years). Participants (N = 326) with anxiety or mood disorders were randomized to one of the three therapies. Symptoms and work ability were assessed at pre-treatment, post-treatment, and several times during a 5 year follow-up period. A previous publication with this sample showed that long-term treatment resulted in greater recovery with regard to symptoms and work ability (recovery for both outcomes exceeding 60%) compared to short-term treatment (50% recovered). For this study the authors asked: is long-term treatment cost-effective – in other words, is the better outcome from long-term treatment justified by greater cost? Both direct costs (health care utilization) and indirect costs (lost productivity) were calculated in this study using standard econometrics. Long-term therapy cost 3 times as much as short-term treatments. This amount was smaller than expected because those who received short-term treatments had higher auxiliary costs (i.e., the need for other treatments after the short term therapy ended). Shorter therapies were equally cost-effective, but both were more cost-effective than the longer treatment. That is, despite being more effective and requiring less auxiliary treatment, the longer-term therapy was more costly per unit of improvement with regard to symptoms and productivity compared to the shorter treatments.
From an economic point of view, short-term treatments make the most sense. However, given that many patients needed other treatments after the end of short-term therapy, and given that on average the longer-term therapy was more effective in the long run, a clinician may want to weigh the economics with the specific needs and preferences of each patient.
Does Continuation of Anti-Depressant Medication Reduce Relapse?
Gueorguieva, R., Chekroud, A.M., & Krystal, J.H. (2017). Trajectories of relapse in randomised, placebo-controlled trials of treatment discontinuation in major depressive disorder: An individual patient-level data meta-analysis. Lancet Psychiatry.
Individuals with a history of depression who get better have a 30% to 50% chance of relapse in the first year. That is, major depression tends to take a recurrent course, so that about a third to half of patients who initially improve will then experience a re-emergence of symptoms. In this meta-analysis, Gueorguieva and colleagues looked at whether they could identify classes of patients who respond differently to antidepressant medications depending on whether they discontinued or continued with the medications after symptoms improved. The meta-analysis included over 1,400 patients from four studies of duloxetine or fluoxetine (i.e., Cymbalta or Prozac) who participated in a discontinuation trial. A discontinuation trial design involves randomly assigning patients who respond positively to the medication either (1) to stay on the effective medication or (2) to discontinue the treatment and receive a placebo. Such a design gives us an estimate of the advantage of maintenance versus discontinuation of medications to reduce relapse of depression in the longer term. Gueorguieva and colleagues found that 33% of those in the medication continuation condition relapsed (i.e., 33% those who responded well to the initial trial of medications and who then continued with medications had a recurrence of depressive symptoms). By contrast, 46% of those in the placebo/medication discontinuation condition relapsed (i.e., 46% of those who responded well to the initial trial of medications and who then received a placebo had a recurrence of depressive symptoms). In other words, continuation of antidepressant medications resulted in a small 13% reduction in relapse rates compared to continuation with a placebo.
This meta analysis indicates that continuing with antidepressant medications after depressive symptoms remit provides only a modest level of protection against a relapse of depression. Thus continuation with antidepressants after symptoms improve may not be worth it for patients who struggle with medication side effects and complications, or who cannot afford continuation of the medications. There is growing evidence that psychotherapy is effective for preventing relapse, likely because psychotherapy teaches patients ways of coping and interacting with others that allows them to manage life stresses more effectively after the treatment is over.