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.

November 2016

When Clients and Therapists Agree on Client Functioning

Bar-Kalifa, E., Atzil-Slonim, D., Rafaeli, E., Peri, T., Rubel, J., & Lutz, W. (2016, October 24). Therapist–client agreement in assessments of clients’ functioning. Journal of Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/ccp0000157.

There has been a lot of research in the past decade on progress monitoring (i.e., regularly providing reliable feedback to therapists on client outcomes, the alliance, and client functioning). This research indicates that client outcomes can be enhanced if therapists have ongoing information on how their client or the relationship is progressing. In this innovative research by Bar-Kalifa and colleagues, the authors studied 77 therapists who saw a total of 384 clients. The therapists were experienced at providing cognitive-behavioral therapy. Clients for the most part had a depressive or anxiety disorder and were seen for an average of 36 sessions. Client outcomes were measured pre- and post-treatment. Emotional and psychological functioning during the past week was rated by the client before each session, and the same measure was given to the therapist to rate their client at the end of each session. After therapists made their rating, they were given ongoing feedback (i.e., progress monitoring) about how their clients’ rated their own functioning during the past week. Did clients and therapists agree on level of client functioning, was this agreement stable over time, and was this agreement or disagreement related to client outcomes? The authors used sophisticated statistical modeling to separate the effects of client ratings of their functioning from therapists’ ratings, and to examine the impact of the changing relationship between therapist and client ratings over time on client outcomes. The authors found little difference in the level of client and therapist ratings of client functioning, and they found that therapists tended to be accurate (i.e., congruent with clients) in tracking client functioning over time. More importantly, the ability of therapists to accurately track client functioning from session to session was related to better client outcomes in terms of key symptoms of depression and anxiety.

Practice Implications

The ability of therapists to accurately track client functioning over time was related to better client outcomes. This means that therapists who were aware of their clients’ functioning through feedback methods were better equipped to help their clients. In particular, information about how client functioning was changing from session to session might have allowed therapists to take corrective action for clients who were not doing well from one session to another. This information might have allowed therapists to reconsider a treatment formulation for a particular client, for example. Therapists should be aware of how a client is doing at a particular session, but more importantly therapists should be sensitive to fluctuations in client functioning across sessions. This might be best achieved with ongoing progress monitoring.
Do All Depression Scales Do a Good Job of Measuring Depression?

Fried, E.I. (2016). The 52 symptoms of major depression: Lack of content overlap among seven common depression scales. Journal of Affective Disorders.

Depression is a leading cause of disability in the world and an important reason why people seek psychotherapy. Depression is also the most commonly studied disorder in psychological treatment studies. Measuring depression with self-report or clinician rating scales seems straight forward, but it turns out that it is not. This is important for clinicians because we assume that scales assess depressive symptoms in a reliable way, and that this measurement gives a valid indicator of a patient’s level of depression and improvements in the depressive symptoms. In this review Fried examined the content of the seven of the most common measures of depression including: the Beck Depression Inventory (BDI), the Centre for Epidemiological Studies Depression Scale (CESD), and the Hamilton Rating Scale for Depression (HRDS). Many might assume depression to represent a single construct – meaning depression is sometimes thought to represent one unitary thing that is consistent across individuals. Because of that assumption, some might consider depression scales to be interchangeable. But according to Fried, these seven scales listed a total of 52 different symptoms. Using a statistical approach called a Jaccard Index, Fried found that the overlap in symptoms among the different depression scales was low (i.e., different scales seemed to be tapping into different symptoms). When he reviewed the content of each scale, this low overlap seemed clear. For example, the BDI (developed by the founder of CBT) emphasizes cognitive symptoms of depression, the CESD has a number of items that are only indirectly related to depressive symptoms (like interpersonal sensitivity), and the HRDS (often used in medication trials to evaluate side effects) emphasizes somatic symptoms like insomnia, fatigue, and sexual dysfunction. Perhaps this lack of overlap is not so surprising given that the concept of depression is likely multidimensional and not representative of a single uniform construct.

Practice Implications

So what does this mean for clinical practice? Many clinicians use a depression scale to assess their patients and monitor their outcomes. Which scale one uses seems to make a difference in terms of what is being measured and what outcomes are monitored. Using the BDI will emphasize the cognitive aspects of depression, whereas ratings with the HRDS may emphasize the somatic aspects of depression. Fried recommends that researchers use more than one scale, and if the findings differ across scales, then that provides more nuanced information about the effects and outcomes of depression and its treatment. Perhaps the same can be said for clinical practice – if clinicians use only one depression scale, then they should be aware of what aspects of depression or what kind of information about their patent’s depression that the scale is providing.
Cultural Adaptation of Psychotherapy

Hall, G.C.N., Ibarak, A.Y., Huang, E.R., Marti, C.N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy.

Cultural adaptation of psychological interventions involves identifying cultural contexts of behaviors and developing constructs of mental health functioning relevant to the cultural context. Most cultural adaptation of psychotherapies involves taking existing treatments originally developed for those of European ancestry and adapting them for another specific cultural group or context. However, a few efforts exist in which new treatments were developed within a particular culture to address culture-specific concerns. Eight dimensions along which interventions could be culturally adapted include: language, people, metaphors, content, concepts, goals, methods, and context. Some researchers have expressed concern that cultural adaptation could distance an intervention from its evidence-base, and reduce its effectiveness. In this meta analysis by Hall and colleagues, the researchers look closely at the effects all culturally adapted treatments and prevention methods. They reviewed 78 studies that included nearly 14,000 participants. All studies included culturally adapted interventions for individuals of non-European ancestry. For example, these included studies that adapted CBT interventions for various disorders (mainly depression and anxiety disorders), or studies that match therapist to client in terms of ethnicity. Only 5% of studies created a new intervention developed within a particular culture, whereas the vast majority of studies adapted an existing treatment initially developed for clients of European ancestry. The average effect size was g = .67 (confidence intervals not reported), indicating that culturally adapted interventions produced better outcomes than comparison conditions. Culturally adapted interventions were also more likely to result in better outcomes than the same interventions that were not adapted (g = .52). Effect sizes for cultural adaptation in treatment studies (g = .72) were larger than for prevention studies (g = .25), likely because participants in treatment studies had higher levels of initial psychopathology. There was little evidence that matching therapist and client on ethnicity was helpful.

Practice Implications

This meta analysis provides compelling evidence that cultural adaptation of existing treatments can result in more positive outcomes compared to not adapting the same treatment. The effect sizes may even underestimate the true effects of cultural adaptation because the outcome variables like measures of depression were rarely adapted to a specific culture (e.g., depression among Chinese participants may be expressed differently than depression among European participants, and most depression measures were created by and for Europeans).

October 2016

The Long Reach of Nurturing Family Environments

Waldinger, R.J. & Schulz, M.S. (2016). The long reach of nurturing family environments: Links with midlife emotion-regulatory styles and late-life security in intimate relationships. Psychological Science. DOI: 10.1177/0956797616661556.

Although, not a psychotherapy study, this research has important implications for psychological treatment of adults, including older adults. This research, drawn from the original Grant study, is extraordinary because the sample is from a 78-year long study of 81 men. The original cohort of over 200 men were first assessed as adolescents and young adults between 1939 and 1942. At that time, the original authors conducted intensive interviews of the adolescents` family experiences and current life situations. These men were re-interviewed in mid-life in the 1960s (aged between 45 and 50 years), which included interviews and assessments of challenges in relationships, work functioning, and physical health. Waldinger and Schulz recently re-interviewed these men and their current partner in late-life (aged between 75 and 85 years), with interviews focusing on their current partner relationship. Raters reviewed audio recordings and notes from all the interviews and coded for: (a) quality of family environment in childhood (distant, hostile vs cohesive, warm) - taken from the first interview; (b) style of regulating emotions (suppressive, maladaptive vs engaged, adaptive) – taken from the midlife interview; and (c) security of attachment with their current partner (secure, comforting vs insecure, anxious) – taken from the late-life interview. The authors found that more nurturing early family environments were significantly linked with late-life attachment security with a partner (r = .23, 95% CI = .01, .45), and early family environment was significantly related to midlife adaptive emotion regulation strategies (r = .29, 95% CI = .06, .50). Also, adaptive emotion regulation strategies in midlife were significantly correlated with greater late-life attachment security (r = .23, 95% CI = .05, .51). These are medium-sized correlations, but they are remarkable because they represent associations between variables that were assessed decades apart. Through a statistical mediation analysis, the authors also reported that adaptiveness of emotion-regulation strategies partially explained why positive childhood family environments may lead to late-life attachment security (accounting for 6% of the variance).

Practice Implications

This compelling study adds to the argument that early family environment shapes the way adults regulate their emotions, which in turn affects how they experience relationships in old age. More securely attached adults were better able to meet two challenges associated with aging: accepting vulnerability in depending on a partner, and accepting the responsibility of being depended upon by that partner. The early family environment indeed has a long reach. Psychotherapy directed at reducing the effects of childhood adversity takes on a heightened meaning in the context of these findings. Treatment for adults who struggle with the consequences of non-nurturing early environments should include improving emotion regulation strategies.
Clients’ Experiential Depth in Therapy Predicts Better Outcomes

Pascual-Leone, A. & Yeryomenko, N. (2016). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process, Psychotherapy Research, DOI: 10.1080/10503307.2016.1152409

A key issue in existential-humanistic psychotherapy is the degree to which therapy encourages clients to explore new feelings and meanings in relation to the self. This is often called ‘experiential depth’ or simply ‘experiencing’. Carl Roger highlighted the need for clients to increase their awareness, accept their feelings, and use their feelings as information to further explore and understand themselves. The notion of ‘depth of experiencing’ refers to the degree to which clients engage and explore their feelings moment by moment in therapy to increase personal meaning-making. One way of assessing experiential depth is with the Client Experiencing Scale. Low scores on the scale indicate unengaged levels of experiencing, in which clients recount events in an emotionally neutral or disengaged manner. High scores indicate more introspection as clients begin to process their experiences and identify feelings that lead to creating new meanings that contribute to resolving their problems. In this meta analysis of the Client Experiencing Scale, Pascual-Leone and Yeryomenko systematically reviewed the research literature and found 10 studies of 406 clients that evaluated the scale`s association with client outcomes. The therapies in the meta analysis included experiential-humanistic approaches, CBT, and interpersonal psychotherapy. Overall, they found a moderate association (r = .25; 95% CI: .16, .33) between higher client experiencing and better treatment outcomes. The association was similar for different therapeutic orientations and stages of therapy. On average, client depth of experiencing tended to increase from the early to later stages of treatment.

Practice Implications

Compared to those who did not engage with their experiences in a meaningful way, clients who were internally focused, engaged in exploration, referred to their emotions, and who reflected on their experiences had better outcomes. Experiential depth allowed clients to create new meanings to resolve personal problems. Therapist interventions that deliberately point the client to a deeper level of experiencing, are likely to result in clients following suit and deepen their own process.
The Quality of Psychotherapy Research Affects The Size of Treatment Effects for CBT

Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M., Huibers, M.J.J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245-258.

You might think that an esoteric topic like study quality should not really be of interest or concern to clinicians – but it is an important topic with practice implications. In this meta analysis Pim Cuijpers and his research group updated the meta analytic evidence for the efficacy of cognitive behavioral therapy (CBT) for a variety of disorders (major depressive disorder [MDD], generalized anxiety disorder [GAD], panic disorder [PAD], and social anxiety disorder [SAD]). The important thing about meta analyses is that the method combines the effect sizes from all relevant studies into a single metric – an average effect size. These average effect sizes are much more reliable than findings from any one single study. In fact, whenever possible, clinical decision-making should be based on a meta analysis and systematic review and not on a single study. Meta analyses also allow one to give more weight to those studies that have larger sample sizes, and that employ better methodologies. Even more, meta analytic techniques allow one to adjust the averaged effect size by taking into account publication bias (i.e., an indication of the effects from studies that might have been completed but were never published, likely because they had unfavorable findings). Usually, average effect sizes are lower when they are adjusted for study quality and publication bias. Cuijpers and colleagues’ meta analyses found that the unadjusted average effects of CBT were large for each of the disorders (ranging from g = .75 to .88 [confidence intervals not reported]). However adjusting for publication bias reduced the effects to medium-sized for MDD (g = .65) and GAD (g = .59). Only 17.4% of the individual studies of CBT were considered to be of “high quality” (i.e., studies that use the best methodology to reduce bias, like random allocation, blinding, using all the available data, etc.). After adjusting for study quality, the effects of CBT for SAD (g = .61) and PAD (g = .76) were also reduced to medium-sized. Not surprisingly, the effects of CBT were largest when the treatment was compared to a wait-list no-treatment control group. The effects were small to moderate when CBT was compared to treatment as usual or to a placebo.

Practice Implications

Even when adjusting for study quality and publication bias, the average effects of CBT were medium-sized for a variety of common disorders compared to control conditions. Unfortunately, the quality of the studies was not high for most trials, reducing the effect sizes and lowering our confidence in the efficacy of the treatment. Nevertheless, the findings of this meta analysis suggest that CBT will likely have moderate effects for the average patient with MDD, SAD, PAD, and GAD.

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November 2016

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October 2016

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Psychotherapy Practice Research Network (PPRNet)