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 therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
January 2017
Individual versus Group Psychotherapy
Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.
With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.
Practice Implications
When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.
Comparing Three Psychotherapies for Adolescents with Major Depression
Goodyear, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., ….Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, Online first publication: http://dx.doi.org/10.1016/S2215-0366(16)30378-9.
Major depression affects a large proportion of adolescents worldwide. The Global Burden of Disease Study Found that depressive disorders accounted for over 40% of disease burden caused by all mental and substance use disorders, with the highest burden occurring for those between the ages of 10 and 29. Although there is good evidence for cognitive-behavioral therapy (CBT) to treat depression in adolescents, data is scarce for long term outcomes – which is an important issue because maintaining treatment gains reduces the risk for relapse. There is also little research on alternative treatments to CBT and their long term effects. In this large study, Goodyear and colleagues (2016) randomly assigned 470 adolescents with major depression to receive CBT, short-term psychoanalytical therapy (STPT), or a brief psychosocial intervention (BPI). CBT was based on a commonly used model but adapted to include parents and emphasized behavioural techniques. The STPT model emphasized the child – therapist relationship in which the therapist emphasized understanding feelings and difficulties in ones life. STPT also included some family meeting. BPI on the other hand focused on psychoeducation about depression, was task and goal oriented, and emphasized interpersonal activities. The study also compared cost-effectiveness of the three treatments – that is, whether the treatments’ costs relative to their effectiveness were different. There were some advantages in terms of reduced depression to both CBT and STPT compared to BPI at 36 weeks and 52 weeks post treatment, but these advantages disappeared by 86 weeks follow-up. Across all three treatments, about 77% of adolescents with depression were in remission (i.e., no longer depressed) by 86 weeks post-treatment. There were no differences between the three treatments in terms of cost-effectiveness.
Practice Implications
This is one of those rare studies that is large enough to adequately compare the efficacy of alternative treatments for adolescents with major depression. CBT, STPT, and BPI were all associated with reduced depression in adolescents, and with maintenance of these improvements 1 year after the start of treatment. Both BPI and STPT provide alternative choices to CBT for patients and therapists.
Ways In Which Research Can Be Biased
Leichsenring, F. Abbass, A., Hilsenroth, M.J., Leweke, F., Luyten, P., ….Steinert, C. (2016). Bias in research: Risk factors for non-replicability in psychotherapy and pharmacotherapy research. Psychological Medicine, doi:10.1017/S003329171600324X.
An important feature of research is that it should be replicable. That is, another researcher should be able to obtain the same finding as the original study as a pre-requisite for the validity of the conclusions. A recent estimate for cognitive and social psychology research is that only about 36% to 47% of studies are successfully replicated. Another study showed similar low replicability of psychotherapy and pharmacotherapy research. Results that are neither replicable nor valid can lead to improper treatment recommendations. Leichsenring and colleagues review several research biases that affect the replicability of findings in psychotherapy and pharmacotherapy research, and they discuss how to limit these biases. Psychotherapy trials often involve an established treatment approach that is pit against a comparison treatment in a head to head contest. Below I list some of the biases detailed by Leichsenring and colleagues that may affect the validity of psychotherapy trials. First, in psychotherapy trials a large proportion of the differences in outcomes between a treatment and a comparison may be due to the researcher’s allegiance to a particular therapy modality. This may be expressed unconsciously by selecting outcome measures that are more sensitive to the effects of one type of treatment versus another. For example the Beck Depression Inventory (BDI) is particularly sensitive to changes in cognitions, whereas the Hamilton Depression Rating Scale (HDRS) is particularly sensitive to physiological side effects related to antidepressant medications. One way to deal with researcher allegiance effects is to include researchers and therapists who have an allegiance to both of the treatments that are under study. Second, the integrity of the comparison treatment may be impaired. That is the comparison treatment may not be carried out exactly as originally intended. This could occur in pharmacological trials in which doses do not match clinical practice, or in psychotherapy trials in which therapists in the comparison treatment may be told to ignore key symptoms. Properly training and supervising therapists and not constraining them by the study protocol is important to avoid this type of bias. Third, some studies make a lot of noise about small effects that are statistically significant. When two bona-fide psychotherapies are compared the differences tend to be small – this is a common finding. Small differences, even if statistically significant, often turn out to be random, unimportant, and of little clinical significance. Concurrent with this problem is that sometimes researchers will use multiple outcome measures, find significant differences only with some, and report these as meaningful. This refers to selectively emphasizing a small number of findings among a larger number of analyses, which are likely due to chance variation and therefore not replicable.
Practice Implications
What should a clinician do when reading a comparative outcome study of psychotherapy? There are some technical red flags for research bias that require specialized knowledge (e.g., small sample sizes and their effect on reliability, over-interpreting statistical significance in the context of small effects, and non-registration of a trial). But there are a few less technical things to look for. First, I suggest that clinicians focus primarily on meta-analyses and not on single research studies. Although not perfect, meta-analyses review a whole body of literature, and are more likely to give a reliable estimate of the state of the research in a particular area. Second, clinicians should ask some important questions about the particular study: (a) are the results unusual (i.e., when comparing 2 bona-fide treatments, is one “significantly” better; or are the results spectacular); (b) does the research team represent only one treatment orientation; and (c) do the researchers reduce the integrity of the comparison treatment in some way (e.g., by not training and supervising therapists properly, by unreasonably limiting what therapists can do)?
December 2016
Effects of Combining Psychotherapy and Pharmacotherapy on Quality of Life in Depression
Kamenov, K., Twomey, C., Cabello, M., Prina, A.M., & Ayuso-Mateos, J.L. (2016). The efficacy of psychotherapy, pharmacotherapy, and their combination on functioning and quality of life in depression: A meta-analysis. Psychological Medicine, doi: 10.1017/S0033291716002774.
Both psychotherapy and pharmacotherapy are efficacious for reducing symptoms of depression. Some studies suggest that functioning (i.e., the ability to engage in work, school, and social activities) and quality of life (i.e., satisfaction with these activities and perception of one’s health) are just as important to depressed patients as is reducing their symptoms. In fact, many patients place greater priority on improving functioning compared to reducing symptoms. In this meta analysis, Kamenov and colleagues assess the relative efficacy of psychotherapy vs pharmacotherapy in improving functioning and quality of life. They also evaluate if combining psychotherapy and pharmacotherapy is efficacious relative to either treatment alone. The meta analysis included k = 153 studies of over 29,000 participants. Psychotherapies often included CBT and interpersonal psychotherapy. Compared to control groups (k = 37 to 52) both psychotherapy (g = 0.35, 95% CI = 0.24, 0.46) and medications (g = 0.27, 95% CI = 0.21, 0.32) significantly improved functioning. Also, compared to controls both psychotherapy (g = 0.35, 95% CI = 0.26, 0.44) and medications (g = 0.31, 95% CI = 0.24, 0.38) significantly improved quality of life in depressed participants. In studies that directly compared psychotherapy and medications, there were no significant differences when it came to improving functioning, but there was a small significant advantage to psychotherapy over medication for improving quality of life (g = 0.21, 95% CI = 0.01, 0.43). Combined psychotherapy and medications (k = 19) was more effective to improve functioning compared to pharmacotherapy alone (g = 0.34, 95% CI = 0.18, 0.50) and compared to psychotherapy alone (g = 0.32, 95% CI = 0.14, 0.49). Combined treatment was also more efficacious for improved quality of life compared to medications alone (g = 0.36, 95% CI = 0.11, 0.62) and to psychotherapy alone (g = 0.39, 95% CI = 0.19, 0.58).
Practice Implications
Combined treatment of medications and psychotherapy is more effective than either treatment alone for improving functioning and quality of life. However, most patients prefer psychotherapy to medications, and some studies indicate that many patients choose not to get treated at all rather than receive medications. Further, quality of life can be substantially compromised by medication side effects. Clinicians should take these factors into account when considering monotherapy with antidepressant medications or combined treatment of pharmacotherapy and psychotherapy for depression.
Placebo Response Rates in Antidepressant Trials
Furukawa, T.A., Cipriani, A., Atkinson, L.A., Leucht, S., Ogawa, Y., … Salanti, G. (2016). Placebo response rates in antidepressant trials: A systematic review of published and unpublished double-blind randomised controlled studies. Lancet Psychiatry, 3, 1059-1066.
The placebo response in medication trials is an interesting and important phenomenon. Placebo response refers to improvement in clients that is due to therapeutically powerful factors like client’s expectations that an intervention will be effective and to the therapeutic relationship with the health care provider. In medication trials, placebo is seen as problematic because researchers typically want to demonstrate the effectiveness of the active medication (e.g., selective serotonin re-uptake inhibitors) independent of any other factors. For this reason, randomized clinical trials of medications are often double-blind and placebo controlled (i.e., clients and clinicians are unaware of who received the active medication and who received the inert placebo pill). It has widely been suspected that over the years the placebo response has been increasing in antidepressant trials possibly due to the types of patients included in trials (i.e., more recently, patients with more severe symptoms are included) and to other methodological issues (e.g., use of multi-centre trials, dosing schedule). An increasing placebo response is suspected of contributing to the growing number of failed anti-depressant trials (i.e., trials that show little or no effectiveness of the medication). Using advanced statistical methods, Furukawa and colleagues evaluated in a meta analysis if placebo response in medication trials was increasing over time. They defined a response as a 50% or greater reduction in observer-rated depression scale scores from baseline to 8 weeks. Their review included 252 placebo controlled trials of antidepressants from 1978 to 2015. Placebo response rates ranged widely from 0% to 70% (I2 = 74.1%) with a mean placebo response of 35% to 40%. Year of publication was not significantly related to placebo response rate after controlling for methodological variables like length of the trial, multi-centre trials, and dose regimen. That is, once change in the methodology of conducting trials over time was accounted for, the placebo response appeared to remain largely the same from year to year.
Practice Implications
The placebo response is very real and complicates our understanding of how and why antidepressants might work for some patients. About 35% to 40% of patients who benefit from antidepressants may be benefitting largely because of the expectation of getting better. Greater treatment response to antidepressants for a large proportion of patients appears to be dependent on the therapeutic features of supportive contact with a caring health professional.
The Poor State of Psychotherapy Research for Indigenous People
Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.
Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.
Practice Implications
The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.