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Levitt, H.M., Pomerville, A., & Surace, F.I. (2016). A qualitative meta-analysis examining clients’ experiences in psychotherapy: A new agenda. Psychological Bulletin. Online First Publication, April 28, 2016.

Much of psychotherapy research over the past several decades has focused on therapy outcomes, with the general conclusion that outcomes are equivalent across major psychotherapy orientations. Some of the effects of psychotherapy can be explained by relational factors (e.g., therapeutic alliance). There is also a growing and interesting line of research about therapist variables and therapist effects (see this month’s PPRNet blog on differences between therapists’ outcomes in a large UK sample). Many experts argue that client effects and characteristics account for the largest amount of variance in therapy outcomes. That is, who clients are and what experiences they have are the largest determinants of whether psychotherapy will be helpful. However the client’s experience is often neglected in psychotherapy research reviews. Levitt and colleagues conducted a qualitative meta analysis of qualitative studies of clients’ experiences in psychotherapy. Qualitative research typically involves interviewing clients about their experiences in therapy and coding the transcripts of these interviews. Methods of synthesizing and categorizing themes from client narratives, such as the grounded theory method and thematic analysis, create a rich source of understanding about how clients experience change in psychotherapy. Levitt and colleagues applied qualitative methods to synthesize 109 qualitative studies of over 1400 clients as a way of analysing this research. Six clusters or themes emerged from their qualitative meta analysis: (1) clients experienced therapy as a process of identifying and understanding personal patterns; (2) clients who felt understood and had their experiences validated were able to internalize the therapist’s voice; (3) clients experienced the structure of therapy (spacing of sessions and time allotted to sessions) and therapist expertise as generating credibility for the therapy, but also at times the structure reduced clients’ experience of therapeutic relationship’s authenticity; (4) clients experienced an inherent power differential with therapists that was sometimes compounded by differences in race, gender, and class; (5) clients played a major role in the therapeutic process, and clients felt pleased when they were invited to take the lead; (6) clients’ experiences of being cared-for supported their ability to recognize maladaptive patterns and address unmet vulnerable needs.

Practice Implications

This qualitative meta analysis highlights the important role played by the client’s experience and by the therapy context in promoting good outcomes. The results suggested that better outcomes may be achieved when: (1) therapists encourage clients’ curiosity about their cognitive, emotional and relational patterns; (2) therapists engage in an accepting and caring relationship in order to help clients decrease their defensiveness about vulnerable topics; (3) therapists maintain the therapeutic structure in order to increase clients’ sense of confidence in the process; (4) therapists explicitly acknowledge power differences and repair alliance ruptures; (5) therapists encourage clients to take an active role in therapy as a means of self-healing; and (6) therapists regularly check with clients about the fit of interventions, in-session needs, and treatment goals.

Xu, H. & Tracey, T.J.G. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63, 359-365.

Cultural congruence refers to providing psychotherapy that is consistent with the client’s cultural context in its description of the etiology of symptoms and in its therapeutic procedures. In general, congruence of treatments with clients’ expectation, preferences, and beliefs is related to greater psychotherapy efficacy. And specifically identifying culturally appropriate or adapted treatments is important because this is often related to better therapy outcomes for ethnic and racial minorities. Psychotherapy as a professional practice developed recently in China. Cognitive-behavioral, existential-humanistic, and psychodynamic therapies have taken their place along side indigenous therapies including Naikan therapy, Taoism cognitive therapy, and Morita therapy. Historically in China mental health problems were seen as a disturbance in ying-yang or a sin committed in a previous life. Healing practices included engaging in altruism or religious practices to achieve redemption. Xu and Tracey argue that Chinese culture strongly endorses an experiential and subjective orientation and is less aligned with analytic and objective orientations. Using this understanding, the authors expected that experiential-humanistic and indigenous therapies would be more congruent and therefore more effective than cognitive-behavioral education or psychodynamic therapy in alleviating mental health issues. In this meta analysis, Xu and Tracey reported on 235 studies conducted in China that compared the various treatments to a control condition or to each other. There were too few studies of psychodynamic therapy, so it was not included in the analyses. All treatments were effective compared to a control condition with large effect sizes (g = .85 to 1.18). However, whereas experiential-humanistic and indigenous therapies were equally effective, each was significantly more effective (g = .34) than cognitive-behavioral psychoeducation.

Practice Implications

The three modalities, experiential-humanistic, indigenous, and cognitive-behavioral psychoeducation were effective. However the two therapies that were more experiential and subjective in nature were more effective to reduce Chinese clients’ symptoms. When working with Chinese clients, therapists may achieve better outcomes if they work on more experiential components (e.g., feelings and therapeutic relationship) and focus on subjective experiences (e.g., introspection and reflection). The results of the meta analysis suggest that when working with Chinese clients interpersonal processes and emotions should be the clinical focus and take priority over dysfunctional cognitions and psychoeducation.

Laird, K.T., Tanner-Smith, E.E., Russell, A.C., Hollon, S.D., & Walker, L.S. (2016). Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology. 

Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that affects 5% to 16% of the population. People with IBS have reduced quality of life similar to those with heart disease, heart failure, and diabetes. Previous meta analyses indicated that psychological therapies are just as effective as antidepressant medications immediately after treatment for improving symptoms of IBS. However, whether psychological therapies have longer lasting effects is unknown. It is important to patients and providers to know the longer term effects of psychological treatments for IBS because the disorder has a fluctuating course, and so symptoms may reappear after treatment is completed. In their meta analysis, Laird and colleagues reviewed 41 studies that recruited almost 2,300 adult patients. [A note about meta analysis: Meta analysis combines the standardized effect sizes (d) across many studies to estimate an average effect size. This means that meta analyses are much more reliable than any single study, and when possible they should be the basis for practice recommendations]. Psychological therapies for IBS often included cognitive behavioral therapy (CBT), but also included relaxation therapy, mindfulness, hypnosis, behavioral treatment, and psychodynamic therapies. Control conditions often were: supportive therapy, education, fake treatment for biofeedback or hypnosis, online discussion groups, treatment as usual, or wait-list controls. Psychological therapies were more effective than control conditions immediately post-treatment in improving GI symptoms, and the effects were moderately large (d = .69). Psychological therapies remained more effective than control conditions up to 6 months post-treatment (d = .76), and from 6 months to 1 year post-treatment (d = .73). CBT and other treatments (e.g., relaxation, hypnosis) were equally effective; and individual and group delivered treatments were no different in their efficacy. The number of sessions, duration of sessions, and frequency of sessions did not impact the efficacy of psychological interventions.

Practice Implications

Determining the longer term efficacy of psychological treatment for IBS is important because the symptoms tend to be recurrent and sometimes are chronic. Psychological treatments reduce GI symptoms in adults with IBS, and the effects appear to be long lasting – at least up to 1 year post-treatment. The average individual who received psychotherapy was better off than 75% of control condition participants.

Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S., & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry.

The World Health Organization reports that more than 800,000 people die of suicide per year around the world. However suicide prevention efforts over the past decade have fallen short of targets. In fact, the prevalence rates of suicide in the US have risen steadily since 2000 to about 1.3% of the population in 2014. Many who kill themselves have a mental disorder like depression, anxiety disorders, substance abuse, psychoses, or personality disorders. Best practices suggest that directly addressing suicidal thoughts and behaviors during treatment, rather than only addressing symptoms like depression and hopelessness, are most effective in reducing suicide. However, there are no meta analyses of randomized controlled trials that specifically assess the relative utility of direct versus indirect psychological interventions. In their meta analysis, Meerwijk and colleagues looked at psychosocial interventions aimed to prevent suicide or to treat mental illness associated with suicide. They included 31 studies representing over 13,000 participants. Interventions included cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), case management, social skills training, and supportive telephone calls. Depending on the target problem, the interventions either directly addressed suicidal behavior or they indirectly addressed suicidal behavior. Mean duration of treatment was over 11 months. Studies that looked at direct or indirect interventions were each compared to control groups that received some form of usual care in the community, or psychiatric management, or general practitioner care. Individuals who received usual care were 1.5 times more likely to die of or attempt suicide compared to those receiving direct or indirect psychological interventions. There was a 35% lower odds of suicide and attempts with direct interventions compared to usual care; and an 18% lower odds of suicide and attempts with indirect interventions compared to usual care. The difference between the effectiveness of direct versus indirect interventions was large (d = .77), suggesting that direct interventions were more effective than indirect interventions at reducing suicide and suicide attempts.

Practice Implications

This is the largest meta analysis of its kind. Most direct interventions to prevent suicide and suicidal behaviors were based on CBT and DBT. Indirectly addressing suicide by focusing on depressive symptoms, anxiety, and hopelessness was somewhat effective compared to usual care. However, direct interventions that included talking about the patient’s suicidal thoughts and behaviors and how best to cope were most effective.

Kivlighan, D.M., Goldberg, S.B., Abbas, M., Pace, B.T., …Wampold, B.E. (2015). The enduring effects of psychodynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal meta-analysis. Clinical Psychology Review, 40, 1-14.

There is a great deal of evidence that indicates uniform efficacy of a variety of psychotherapies for many common disorders. For example, in the July 2014 PPRNet Blog, I reviewed a meta-analysis comparing 7 psychotherapies for depression indicating no differences between the various treatments in terms of patient outcomes. Nevertheless proponents of cognitive behavioural therapy have claimed superiority to alternative treatments for decades. On the other hand proponents of psychodynamic therapies have argued that these treatments focus on personality change rather than symptoms, and so benefits of psychodynamic therapies will be longer lasting. In this meta analysis, Kivlighan and colleagues put these claims to the test. They selected studies in which a psychodynamic therapy was compared to one or more alternative treatment. Both the psychodynamic therapy and the alternative (most often CBT) had to be judged as “bona fide” therapies by independent raters (i.e., they had to be therapies that were delivered in a manner in which they could be expected to be effective by clients and therapists). Outcomes not only included specific symptoms (e.g., depression), but also non-targeted outcomes (e.g., improved self esteem in a study of treatment of anxiety), and personality outcomes. Effect sizes for outcomes were assessed at post-treatment and also at follow-ups. Twenty five studies directly comparing psychodynamic and non-psychodynamic therapies were included, representing 1690 patients. At post treatment, no significant differences were found between psychodynamic and non-psychodynamic treatments on targeted outcomes, non-targeted outcomes, and personality measures (all gs < .10). There was also no significant or meaningful effect of time to follow up on outcomes, indicating no differences between treatment types at any of the follow up periods.

Practice Implications

Psychodynamic and non-psychodynamic treatments were equally effective at post treatment and at follow ups for all outcomes, including personality variables. This challenges the belief that psychodynamic treatments uniquely affect personality and have longer lasting effects compared to other treatments. It also challenges the notion that CBT (by far the most common comparison treatment) is a superior therapy for patient outcomes. Pan-theoretical psychotherapy factors (client contributions, expectations, therapeutic alliance) may be more promising factors in understanding the long term benefits of psychotherapy. 

Author email: kivlighan@wisc.edu

Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ open, 3(4).

In another in a series of meta analyses by this primarily Dutch group, Cuijpers and colleagues tackle the question of whether the longer term effects of cognitive behavioral therapy (CBT; a short time-limited treatment for depression) outweighs the long term effects of continuation on anti depression medications. CBT is considered an efficacious treatment for depression (see my June 2014 Blog). CBT also has comparable effects as antidepressant medications, but CBT tends to have lower rates of treatment drop outs. What is not clear is whether short term CBT leads to lasting change that is comparable to long term use of medications for depression. One could argue for example, that short term CBT or other comparable psychological interventions teaches patients skills or changes psychological functioning such that future recurrences of depression are less likely. That is, psychological interventions may cause changes that eventually will prevent relapse. Pharmacotherapy on the other hand, may not result in psychological change or acquisition of new skills to forestall a relapse. In fact, patients with chronic depression tend to be kept on medications indefinitely, and patients who recently remit (i.e., no longer have symptoms of depression) are typically kept on pharmacotherapy for another 6 to 12 months to reduce the risk of recurrence. Information about the relative longer term effects of short term treatment with a psychological intervention like CBT versus longer term maintenance on pharmacotherapy can help practitioners and patients decide on the best course of action depending on patient preferences. Cuijpers and colleagues asked: is short term CBT without continuation of treatment as effective as short term treatment of pharmacotherapy with and without long term continuation? They conducted a meta analysis in which the effects of short term CBT were compared to pharmacotherapy in adults diagnosed with depression across follow up periods of 6 to 18 months. Nine studies representing 506 patients were included in the meta analysis. There was a non-significant trend showing that short term CBT outperformed continuation pharmacotherapy at one-year post treatment. On the other hand, CBT resulted in better long term outcomes compared to pharmacotherapy that was discontinued at post treatment. The odds of dropping out of treatment were significantly higher for those receiving pharmacotherapy compared to CBT. There were no differences in any of the findings for type of antidepressant medications.

Practice Implications

The findings reaffirm CBT as a first-line treatment of depressive disorders. It also suggests that equally effective other psychological treatments may also have similar enduring effects compared to pharmacotherapy. Patients and providers need to consider all of the evidence when weighing the pros and cons of psychotherapy or medications for the treatment of depression. Although pharmacotherapy might be more widely available to patients through primary care physicians, the research is suggesting that enduring effects and treatment compliance are higher among those who have access to psychological interventions.