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.

July 2016

Is it Feasible to Have a Nationally Funded Psychotherapy Service?

Community and Mental Health Team, Health and Social Care Information Centre (2015). Psychological therapies; Annual report on the use of IAPT services: England 2014/15.

There have been calls from mental health professional organizations and by the media to provide publicly funded psychotherapy in Canada. Rates of common mental disorders in Canada are high, such that about 20% of the population will personally experience a mental illness in their lifetime. In 1998, the estimated direct and indirect economic cost of mental illness in Canada was $7.9 billion (all figures are in Canadian dollars). Current estimates of costs to fund a public psychotherapy service in Canada may be about $1 billion to $2.8 billion – which far outweighs the cost. Most outpatient psychotherapy in Canada is provided by professionals in private practice who charge somewhere between $100 and $200 per session, costing Canadians nearly $1 billion per year. Some people are fortunate to have workplace insurance that covers some but not all of the costs, but most people in Canada do not have insurance and so they pay out of pocket or they go untreated. Research shows us that approximately 13 to 18 sessions are needed for 50% of clients to get better with psychotherapy. Which means that even with an insurance plan, many Canadians who need psychotherapy will find it to be a financial burden. Since 2008, the National Health Service in England implemented the Improving Access to Psychotherapies (IAPT) services to provide publicly funded psychotherapy to the population. The psychological treatments provided through IAPT are evidence-based (e.g., CBT, interpersonal psychotherapy, brief dynamic psychotherapy for depression). For mild to moderate problems, individuals get low intensity interventions first (i.e., self help, internet based interventions), followed by more intensive psychotherapy if needed. Treatment outcomes are measured from pre- to post-treatment with valid standardized measures of depression and anxiety. At post-treatment, patients are categorized as reliably deteriorated, not changed, improved, and recovered. The goal of the IAPT is to achieve 50% recovery rates among patients. In their online 2014-15 annual report, the IAPT service reported that it treated over 400,000 patients in that year. 44.8% of patients were rated as reliably recovered – that is over 180,000 mentally ill patients improved and no longer had a mental illness. Reliable improvement was seen in 60.8% of patients – this included recovered patients plus those who still had a disorder but were feeling significantly better than when they started. Recovery was highest for people 65 years and older (57.8%). Rates of recovery were similar for depression (44.6%) and anxiety (47.8%) disorders, and between men and women. Waiting times for treatment was less than 28 days for 66.0% of patients.

Practice Implications

The experience in England with the IAPT is instructive for Canada. The IAPT service provides evidence-based psychological therapies within a publicly funded national health service. The IAPT approached its target of 50% of patients recovering from mental illness, and over 60% of patients were reliably improved. Waiting times were low for most patients. Given the experience in England’s National Health Service, the implementation of a national strategy for psychotherapy appears to be feasible and effective. Will political leaders in Canada be able to see the financial and human value of publicly funded psychotherapy?
Long-Term Efficacy of Psychological Therapies for Irritable Bowel Syndrome

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.
Direct Psychological Interventions Reduce Suicide and Suicide Attempts

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.

June 2016

Is Therapist Effectiveness a Stable Characteristic?

Kraus, D. R., Bentley, J. H., Alexander, P. C., Boswell, J. F., Constantino, M. J., Baxter, E. E., & Castonguay, L. G. (2016). Predicting therapist effectiveness from their own practice-based evidence. Journal of Consulting and Clinical Psychology, 84(6), 473-483.

There is lots of evidence that there are differences between therapists in their patients’ outcomes. Some studies estimate that 5% to 7% of patient outcomes can be attributed to differences between therapists’ abilities and style of delivering treatment. But most of these studies measured outcomes only once, and so they could not estimate if therapist effects are stable across time. Further, many of these studies used only a global measure of patient distress as an outcome and did not measure domain-specific outcomes (e.g., depression, anxiety, mania, alcohol dependence, etc.). In this study by Krauss and colleagues, 59 therapists who treated 3,540 patients were included. Therapists had on average 10 years of experience and were from a variety of professions (psychologists, psychiatrists, social workers, counsellors etc.). The settings included mental health clinics, independent practice, hospitals, and others. The authors went to some effort to control for case-mix variables such as client problem difficulty, length of treatment, caseload size, and other variables. Client outcomes were measured for 12 different domains ranging from depression to sexual dysfunction to substance abuse. First, outcomes were assessed for 30 patients of each therapist, and then these were compared to outcomes of the same therapist’s next 30 patients. Therapists were classified as “exceptional”, “average”, or “below average” based on their patients’ outcomes. Fifty-seven percent of therapists who were rated as exceptional with the first 30 patients were likely to remain exceptional or above average with the next 30 patients. In other words, effective therapists tended to remain effective over time. Therapists had better patient outcomes when it came to depression, suicidality, and substance abuse, but therapists tended not to have as good outcomes when it came to mania, and sexual functioning.

Practice Implications

Effective therapists tend to remain effective over time for particular client problem areas. However, therapists are seldom effective for more than 4 or 5 client presenting problems, and less than 10 % of therapists are effective with all client problem areas. Therefore patients with differing problems are likely to achieve better or worse outcomes depending on the particular therapist and his or her strengths. Therapists can regularly assess patient outcomes and use that information to help with continuing education to improve their practice for a particular problem area.
Are Therapists Uniformly Effective Across Patient Outcomes?

Nissen-Lie, H. A., Goldberg, S. B., Hoyt, W. T., Falkenström, F., Holmqvist, R., Nielsen, S. L., & Wampold, B. E. (2016). Are therapists uniformly effective across patient outcome domains? A study of therapist effectiveness in two different treatment contexts. Journal of Counseling Psychology. Advance online publication.

What characterizes more or less effective therapists? Are some therapists more effective for certain types of client mental health problems? In this study by Nissen-Lie and colleagues the authors look at whether therapists are skilled across patient problem domains. They conducted two studies with over 6000 patients and almost 200 therapists. Patients were assessed with common outcome measures of mental health domains that included: social functioning, work functioning, relationship functioning and symptom distress. Therapists included psychologists and social work professionals (70%) and trainees (30%) who saw at least 10 patients each. Theoretical orientations ranged from CBT, psychodynamic, and supportive psychotherapy. Patients were symptomatic at the start of therapy and primarily had problems with anxiety and depression. Patient symptoms on average improved so that psychotherapy had a moderate to large effect. Therapists did not differ in caseload mix regarding client severity. The authors reported that the client mental health domains (i.e., symptom severity, work functioning, social functioning, and interpersonal functioning) were relatively distinct or unrelated areas (i.e., the domains were largely uncorrelated). The authors then calculated change scores for each client domain area and used these change scores in a multilevel factor analysis. They wanted to see if a therapist’s clients achieved greater change in one client domain versus in another client domain. The results showed that if clients of a therapist changed in one domain (e.g., depression) then that outcome was highly related to change in another domain (e.g., interpersonal functioning). In other words, if a therapist was effective (or ineffective) in reducing client symptoms, then that therapist was also likely effective (or ineffective) in reducing, work, social, and relationship problems.

Practice Implications

The results support the notion of therapist uniformity in terms of client outcome domains. In other words effective therapists tend to be effective with many types of client problems (but perhaps not all client problems – see my blog this month of the Kraus et al. (2016) study). The authors argue that effective therapists have three key qualities: flexibility in adapting treatments to clients, sensitivity to differences between clients, and responsiveness to clients’ reactions to therapeutic interventions. That is, effective therapists are willing and able to self correct when required.
Therapist Interpersonal Skills Account for Patient Outcomes

Schottke, H., Fluckiger, C., Goldberg, S.B., Eversmann, & Lange, J. (2016). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research, DOI: 0.1080/10503307.2015.1125546

Therapist effects, or differences between therapists, account for an important amount of patient outcomes (i.e., 5% to 7%). Two therapist characteristics most consistently proposed as predictors of patient outcomes are: therapist competence/adherence to a treatment manual, and therapist interpersonal skills. A recent meta analysis found that therapist adherence or competence were not significantly related to patient outcomes. However, there has been very little research on therapists’ interpersonal capacities. These capacities might include factors like: empathy, warmth, ability to respond well to patient hostility, sensitivity to interpersonal process in therapy, and ability to address alliance ruptures. In this paper, Schottke and colleagues (2016) conducted a five year study with 41 therapists and 264 patients in which they assessed the impact of therapist interpersonal skills on patient outcomes. The therapists were all post-graduate trainees and who practiced a manual oriented cognitive behavioral therapy (CBT) or psychodynamic therapy (PDT). The patients were adults mainly treated for depression, and many had co-morbid problems. What was unique about the study is that the therapist interpersonal skill was rated before they received formal training, and the rating were done by trained reliable judges. The judges rated the therapist trainees on interpersonal skills including: clear and positive communication, empathy, warmth, managing criticism, and willingness to cooperate. Patients were assessed pre- and post-treatment on general symptom outcomes. Higher therapist interpersonal skills were reliably associated with better patient outcomes, even after controlling for symptoms severity and number of comorbid diagnoses. In this study, therapist interpersonal capacities measured before receiving formal training and supervision was a significant predictor of patient outcomes after training was initiated.

Practice Implications

The findings of this study indicate that therapists’ talent should in part be characterized by interpersonal competencies that include clear communication, empathy, respectful management of criticism, warmth, and willingness to cooperate. It could be that therapist trainees with high interpersonal skills engage in an extensive degree of deliberate practice that may account for better patient outcomes.

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July 2016

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June 2016

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Psychotherapy Practice Research Network (PPRNet)