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 psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
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
March 2022
Patient Expectations and Preferences
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
In this chapter, Constantino and colleagues review the effects of patient expectations of benefit and patient preferences for treatment. Patient outcome expectations is broadly related to the placebo effect. That is, there is a commonly known positive effect when patients expect that a treatment will help them get better. This effect occurs across all psychotherapies and is also seen in medical and pharmacological interventions. A meta-analysis of almost 13,00 patients in 81 studies found a small to moderate relationship (r = .18) between patient expectations of positive outcomes and the extent to which they improved. There is also evidence that outcome expectations improve the therapeutic alliance. The more optimistic patients are about getting better, the more they are likely to engage in a collaborative working relationship with their therapist. A related line of research addresses patient preferences for treatment. This refers to what is done in therapy, the characteristics of the therapist, and the length of therapy among others. Preferences can be grouped into three categories: activity preferences are the patient's desire for the psychotherapy to include specific therapist behaviors or interventions; treatment preferences are the patient's desire for a specific type of intervention to be used, such as psychotherapy vs. medication, or CBT vs. person-centered therapy; and therapist preferences are the patient's desire to work with a therapist who possesses specific characteristics (e.g., a certain gender, race, or interpersonal style). In a meta-analysis of 28 studies, patients who received their preferences were 1.79 times less likely to drop out of therapy compared to those who did not get their preference. The effect on patient outcomes were statistically significant but small (d = .28). The beneficial effect of preferences was stronger for those with anxiety or depressive disorders.
Practice Implications
Patients who have higher expectations of getting better are on their way to feeling remoralized, they are more likely to engage in a therapeutic relationship, and they are more likely to be collaborative in the therapy. Therapists can improve patient expectations by providing patients with a clear rationale for the interventions, a realistic sense of how long therapy will take, and a non-technical summary of the research evidence for the therapy they are providing. Patients who get what they prefer in a therapy or therapist also may experience better outcomes, especially if they have an anxiety or depressive disorder. Listening to what patients expect and want from therapy may help therapists to tailor the treatment to the patient’s wishes. Providing patients with more than one treatment option when possible may be one means of meeting patient expectations.
February 2022
What Have We Learned from Practice-Research Networks?
Castonguay, L.G., Barkham, M., Youn, S.J., & Page, A. (2021). Practice-based evidence: Findings from routine clinical settings. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 6.
Practice-based evidence refers to research that is conducted as part of routine clinical practice. Often these studies do not impose strict research conditions like randomization of patients, and so they produce findings that are more relevant to psychotherapy as practiced real-world. In studies from practice-research networks, clinicians are often involved in the design and implementation of the study. Our Psychotherapy Practice-Research Network (PPRNet) is an example of a collaboration between researchers and clinicians to produce practice-based evidence. In a large survey, we found that most clinicians regardless of theoretical orientation wanted more research on the therapeutic relationship and on professional development. And so PPRNet developed a research program on training psychotherapists to identify and repair therapeutic alliance ruptures and microaggressions. In this chapter, Castonguay and colleagues review some of the key findings from practice research networks. First, White patients report better outcomes than Black patients in routine care, and these differences were linked back to the clinicians. That is, therapists varied in their effectiveness with racial and ethnic minority patients. Second, patients benefit when clinicians monitor the therapeutic alliance and outcomes on a session-to-session basis using reliable and valid measures. Noticing when a patient’s ratings of the alliance decline from one session to the next, might indicate a problem in the therapeutic relationship. Third, when monitoring the alliance, therapists should also rate the alliance. If a therapist’s ratings of the alliance are higher than their patients, then this may be a sign that the therapist is not paying attention to problems in the alliance. Fourth, developing and maintaining a strong therapeutic alliance likely will improve patient outcomes. Fifth, a reliable and valid assessment of client’s past and current interpersonal difficulties is likely to improve a therapist’s treatment plan for that patient.
Practice Implications
Doing research in clinical practices is not as well controlled as clinical trials research. But practice-based evidence is more relevant to how psychotherapy is done in the real world with real patients. The research is not so clear about why some therapists are more effective with racial and ethnic minority (REM) patients. However, complementary research suggests that some therapists who have a previously high level of multicultural orientation (cultural humility, open to conversations about culture, and cultural comfort) are more effective with REM patients. Also monitoring the therapeutic alliance with a valid scale on a session-to-session basis leads to better outcomes. Such monitoring will alert the therapist to resolve an alliance rupture if a patient’s ratings decrease from one session to the next. If therapists also rate the alliance and find that their scores are higher than their patient’s, then this may alert the therapist to a potential problem. Finally, knowing if a patient has current and past interpersonal problems can inform a therapist to focus on how those problems affect current symptoms and to talk about how those problems manifest themselves in the therapeutic relationship.
Psychological Therapies for Culturally Diverse Populations
Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 5.
Psychological therapies are culturally bound practices with certain values built into them. For example, common therapies prize independence in patients and rapport in the therapeutic relationship. However, some cultures may value community rather than independence, and respect rather than rapport. In this part of the chapter, Barkham and Lambert ask: what is the effect of a conventional psychotherapy that is based on the values of a dominant culture when applied to a different ethnic or racial group? In one small meta-analysis of 9 and 16 studies, culturally adapted interventions were significantly more effective than unadapted interventions g = 0.52 (95% CI [0.15, 0.90]) and resulted in close to 5 times greater odds of remission. Adaptation usually refers to incorporating some cultural practices into the therapy, adapting the language of the therapist, or providing a therapist who is from the same culture as the patient. Similarly, there is research on the effects of a multicultural competency and multicultural orientation of the therapist. These competencies refer to therapists who learn about a patient’s culture, use culturally relevant treatment strategies, and are aware of their own assumptions and biases regarding the patient’s culture. A meta-analysis of 18 studies reviewed the impact of a therapist’s multicultural competence on various aspect of therapy. Therapist multicultural competence accounted for 37% of the working alliance, 52% of patient satisfaction, 38% of a patient’s perception of therapist competence, and 34% of depth of the session. However, therapist multicultural competence accounted for only 8% of patient outcomes. More recently, some authors have discussed the importance of multicultural orientation, which refers to a therapist’s cultural humility as an attitude towards the patient’s culture, a therapist’s willingness to explore the patient’s racial and cultural identities, and the therapist’s comfort with cultural diversity.
Practice Implications
The research on the impact of psychotherapy on diverse patient populations is still rather small, but some practice implications can be gleaned. Adapting therapies to the patient’s culture and identity likely will improve patient mental health outcomes. The adaptation might include incorporating cultural practices, metaphors, and values into the therapy, and providing therapy in the language of the patient, or finding a therapist from the same cultural background as the patient. Similarly, there is evidence that therapists who are multiculturally competent (learn about the patient’s culture and checks their own biases) can provide a deeper therapeutic experience for their patients. Emerging research on therapist multicultural orientation suggests that a therapist’s cultural humility, willingness to engage in cultural conversations, and comfort with diverse cultures may lead to better experiences of therapy for their patients.
January 2022
How Much Therapy is Necessary?
Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 5.
For decades now, researchers have been trying to address the question of how many sessions of therapy is optimal for the average patient. In this part of the chapter, Barkham and Lambert review some of the research related to the question: how much therapy is necessary? Early research noted that it took about 13 sessions for 50% of patients to achieve clinically significant change, and 50 sessions was necessary for 75% of patients to achieve significant change. In other words, the number of sessions need to be doubled for another 25% of patients to improve. (Of note, half of patients did not improve after 13 sessions). Such research suggests a dose-response relationship, such that more therapy sessions result in more patients getting better – but the rate of return slows considerably with more sessions. The problem with this approach to estimating how many sessions are necessary is that it assumes that all patients improve at a consistent rate across sessions, but that may not be the case. Other researchers suggest that patient rate of change is individual, and that when a patient achieves a good enough level of change, they will terminate therapy. The research area is complicated by several factors. First, much of the research was conducted in university counselling centers with therapists in training, student patients, and bounded by the semester system. So, by definition, the therapy is time-limited and patients may be homogenous with regard to symptom severity. Second, some of the data in meta-analyses come from randomized controlled trials that by necessity represent brief treatments. Third, different modes of delivery in different countries appear to have an impact on how many sessions are delivered and what kind of therapy is offered. Fourth, patient severity at baseline may be related to longer treatments and slower rates of change.
Practice Implications
Although the dose-response research has been used in some settings to arbitrarily select treatment length offered to all patients, the results of this research may not be reliable. Predetermined fixed treatment lengths are likely not appropriate for patients. For example, greater patient severity at the start of treatment, and comorbidity and complexity of problems will likely result in such patients requiring a higher number of treatment sessions. A one-size-fits-all approach to determining how many sessions are offered to patients will likely negatively affect the most vulnerable of patients.
December 2021
How Much Psychotherapy is Necessary?
Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 4.
The question of how many psychotherapy sessions are necessary to achieve good patient outcomes, or how frequently sessions should occur has been on the minds of practitioners and researchers for over a century. In this part of the chapter, Lutz and colleagues review some of the research related to how many sessions of psychotherapy is necessary to achieve positive outcomes for patients. A meta-analysis of 70 randomized controlled trials (RCT) of psychotherapy did not demonstrate any correlation between the number of sessions a patient receives and their outcomes. Other research indicates that receiving psychotherapy twice a week is more effective than receiving treatment once a week for depression. The findings of these two lines of research suggest that treatment length may not matter as much as treatment frequency. However, RCTs of psychotherapy tend to test only time limited therapies and they may not reflect exactly what happens in the real world with diverse patients who have complex problems. Perhaps the most relevant research for clinicians may be what is called the dose-response studies. These are studies that indicate how many sessions it takes for patients to get better regardless of treatment length. The dose-response research showed that 50% of patients starting treatment in the dysfunctional range required 21 sessions to achieve clinically significant change. That also means that half of patients did not change meaningfully with 21 sessions of therapy. More than 35 sessions were necessary for 70% of patients to achieve clinically meaningful change (and still, 30% of patients did not benefit). It is likely that some patients get better with a few sessions, but as severity or complexity of problems increase so does the number of required sessions. To add to the complexity, optimal duration of therapy varies according to practice settings. For example, for CBT in controlled studies the average patient needed about 17 sessions to get better, while 35 sessions of CBT was necessary in real world settings for the average patient to improve (again, that means that 50% did not yet improve).
Practice Implications
The findings from this line of research of the optimal number of sessions suggest that it is difficult to translate findings from controlled trials to real world practice. Most RCTs limit therapy to a brief number of sessions whether patients get better or not. Some patients do improve with a few sessions but over half of patients require more than 21 sessions to achieve clinically meaningful change, and about 30% of patients require more than 35 sessions. There is some evidence that more sessions per week leads to better outcomes as well.
November 2021
Psychological Treatments for Panic Disorder
Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148
Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.
Practice Implications
The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.