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.

March 2023

Psychotherapy for Borderline Personality Disorder

Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., Kernberg, O.F. (2023). Borderline personality disorder: A review. Journal of the American Medical Association, 329(8):670–679.

Borderline personality disorder (BPD) occurs in 0.7% to 2.7% of adults and has significant negative impacts on social, vocational, and psychological functioning (inability to hold a job, high rates of comorbid medical and mental health problems, high rates of suicide). Patients with BPD can experience intense anxiety and depressive affect and impulsive behavior. Comorbid rates of depression, anxiety, PTSD, or substance use are very high (30% to 85%). Rates of BPD are slightly higher for women (3%) than for men (2.7%). The etiology of BPD might include genetic factors that interact with adverse childhood events like sexual and physical abuse. BPD is characterized by sudden shifts between extremes of idealization (extremely positive views of self and others) and devaluation (extremely negative views of self and others). These shifts have a significant negative impact on self-image, emotion regulation, and interpersonal relationships. In this extensive review, Leichsenring and colleagues discuss the clinical management and psychotherapy of patients with BPD. A series of meta-analyses that included 75 randomized controlled trials of 4507 patients indicated that psychotherapy is efficacious in treating symptoms of BPD (SMD = -0.52 [95% CI: -0.70 to -0.33]). The meta-analysis looked at 17 studies that compared different forms of psychotherapy (DBT, psychodynamic, CBT, eclectic) and found no difference in the efficacy of these treatments. Stronger evidence was available for DBT and for psychodynamic therapy relative to usual care. DBT focuses on increasing a patient’s motivation and to identify problem solving strategies to help regulate emotions and interpersonal relationships. Psychodynamic therapy emphasizes identifying recurring patterns of behaviors related to self and others, exploring defense mechanisms related to avoidance, and discussing past experiences that influenced current problems. Despite the overall efficacy of psychotherapy for BPD, almost half of patients do not benefit from treatment. Although pharmacotherapy might be useful to reduce comorbid symptoms of depression and anxiety, the research suggests that medications are not effective in reducing symptoms of BPD.

Practice Implications

The treatment of patients with BPD is complicated by the interpersonal impact of the disorder on the therapist and on the therapeutic relationship. Often therapists might be embedded in the patient’s relational patterns of idealization and devaluation (“all good” and “all bad”) that can strain the therapeutic relationship. Sometimes therapists might have strong personal reactions to such patients (i.e., experience countertransference) which might manifest as anti-therapeutic behaviors on the part of the therapist (over- or under-involvement with the patient) which can be stressful. Leichsenring and colleagues make recommendations to help therapists manage the patient-clinician relationship such as: setting clear boundaries while maintaining empathy, developing and maintaining a therapeutic alliance including setting realistic goals, avoiding stigmatizing the patient as “difficult”, collaborating and communicating with other treating clinicians to avoid splitting (one as “all good” and the other as “all bad”), being aware of and managing one’s own feelings and reactions to the patient (countertransference), and using one’s knowledge of the patient’s biographical information (history of abuse) to help to understand the patient’s strong emotional reactions.
Capacity to Mentalize Predicted Outcomes in Inpatient Therapy for Resistant Depression

Halstensen, K., Gjestad, R., Luyten, P., Wampold, B., Granqvist, P., Stålsett, G., & Johnson, S. U. (2021). Depression and mentalizing: A psychodynamic therapy process study. Journal of Counseling Psychology, 68(6), 705–718.

Mentalizing, or reflective functioning, refers to someone’s capacity to view themselves and others in terms of mental states (i.e., behaviors are interpreted in terms of feelings, wishes, desires, values, and goals). This capacity underlies skills like empathy, emotion regulation, and interpersonal functioning. Diminished mentalizing can aggravate depressed mood through negative biases in one’s perceptions of others and relationships and might prevent the reflection needed to regulate emotions. Individuals with mentalizing deficits might hypo mentalize so that they are very uncertain about the thoughts, feelings, or attitudes that underlie their own and others’ behaviors. Such individuals may experience apathy associated with depression. Others might hyper mentalize, that is they are too certain about what goes on in the minds of others, which means they may misinterpret or misunderstand the intentions and behaviors of others. Such individuals can experience chronic emptiness due to the lack of genuine connection with others. In this study, Halstensen and colleagues assessed if mentalizing predicted outcomes in 57 patients with treatment resistant depression who received inpatient therapy in Norway. This was a naturalistic study of intensive psychodynamic inpatient therapy. The average chronicity of depression was 11.7 years, all patients received previous unsuccessful psychological or medical treatment, and most had a comorbid diagnosis (e.g., panic disorder, social anxiety disorder). Measurements of mentalizing and depression were taken pre-treatment, during therapy, and up to one year post treatment. Depressive symptoms improved from pre-treatment to one year follow-up with a large effect (d = 1.47; α mean = −.09 per week, p = .001). The capacity to mentalize did not improve on average during that period, although there was a lot of individual variability in mentalizing scores. Interestingly, there was an increase in depressive symptoms at the outset of treatment that then declined significantly by post-treatment. Higher pre-treatment levels of mentalizing were associated with better depressive symptom outcomes (b = −16.80, p = .043), and those patients who improved their mentalizing capacity experienced stronger improvements in depressive symptoms.

Practice Implications

Although all patients were severely and chronically depressed, their capacities to mentalize varied significantly (some had higher and others lower levels). Patients in this study who had a high initial level of mentalizing capacity profited most from the intensive therapy. They seemed to be able to engage in the emotional work associated with the initial phase of intensive inpatient treatment for depression. On the other hand, patients in this study who had low levels mentalizing skills were likely to be non-responsive to intensive treatment. Patients with limited mentalizing capacity may require more support and more work to help them develop the reflective capacities necessary to understand their own and others’ behaviors in terms mental states.
Negative Effects of Psychotherapy

Strauss, B., Gawlytta, R., Schleu, A., & Frenzl, D. (2021). Negative effects of psychotherapy: Estimating the prevalence in a random national sample. BJPsych Open, 7(6), E186.

The focus of psychotherapy research tends to be on establishing the effectiveness of psychotherapies for various disorders. Rarely do psychotherapy studies report negative effects or negative outcomes. Some researchers estimate that about 5% of patients experience worsening of symptoms by the end of psychotherapy. However, there are very few investigations of clients’ experiences of the negative impact of therapy and fewer still that ask clients in the general population who had a course of therapy. In this national survey of the general population, Strauss and colleagues asked 5562 individuals if they received psychotherapy in the past 6 years. Of the total sample, 244 indicated that they had or are currently in treatment. These individuals had characteristics similar to patients seen in treatment. The mean age was 55.1 years (SD = 15/2), 63.4% had shorter term therapy of less than a year, 41% reported an anxiety disorder and 77% had a mood disorder, 63.1% saw a female therapist, and 69.2% saw a psychologist. These individuals were asked a series of questions regarding their experiences as clients in therapy. Rates of positive change due to therapy varied by the problems that they noted. For example, 26.6% indicated that they had a better relationship with their parents due to therapy, whereas 67.7% experienced improved mood. On average 88.6% agreed that they had a positive working relationship with the therapist. However, about 19% dropped out of therapy and an additional 13.1% changed therapist during treatment, indicating negative experiences or outcomes. Patient problems that had the highest deterioration rates (i.e., worsened) were physical well-being (13.1%), ability to work (13.1%), vitality (11.1%), sexual problems (10.6%) and problems with self-esteem (10.3%). The most common negative effect attributed to specifically to the treatment was the resurfacing of unpleasant memories (57.8% in the total sample). Other such problems like sleep problems, stress, and unpleasant feelings were reported 27.9% to 36.9% of the time. Of the total sample, 56.6% reported having had at least one negative effect caused by their experience in psychotherapy. Boundary violations and malpractice were very rarely reported by this sample of patients.

Practice Implications

Much of the research and clinical writing of psychotherapy tends to focus on whether it is effective and to document its positive effects. However, an important minority of patients experience worsening of symptoms and/or unpleasant or negative effects of psychotherapy. Some might argue that painful feelings that emerge in some clients is a necessary process when the client works through conflicting feelings or perceptions of themselves and others. A collaborative agreement between therapist and client on how therapy might proceed, how it works, or the goals of therapy will go a long way to limit the negative impact of working through unpleasant feelings in therapy. Nevertheless, therapists should monitor dropout rates in their practice and worsening symptoms in their clients and adjust their therapy and interpersonal stances accordingly.

February 2023

Whose contribution (therapist or patient?) to the alliance mostly leads to change?

Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22, 25–41. https://doi.org/10.1002/wps.21035

The therapeutic alliance is possibly the most researched concept in psychotherapy. The alliance consists to a collaborative agreement patient and therapist on the goals of therapy, a collaborative agreement on the tasks of therapy (how therapy should proceed), and the relational bond between therapist and patient (mutual liking and trust). The most recent meta-analysis of almost 300 studies showed that the correlation between the therapeutic alliance and patient outcomes was moderate in size (r = .29) and very stable across studies, treatment modalities, and patient populations. Another meta-analysis of studies that assessed outcomes and therapeutic alliance after every session showed that there is a reciprocal relationship between alliance and outcomes, demonstrating that the alliance is not simply a consequence of symptom improvement. In this sweeping review of the therapeutic alliance research and clinical literature, Wampold and Fluckiger asked “who is most responsible for the effects of the alliance – the patient or the therapist?”. The alliance is a dyadic construct about the interaction between therapist and patient. It could be that the patient contribution to the alliance is most important to their outcomes. A patient with insecure attachment, more symptoms, comorbid personality disorder, or low motivation might experience a poorer alliance with any therapist. Conversely, some therapists might be able to form a better alliance than other therapists across a wide range of patients, and this might be what results in better outcomes. Studies that disaggregate the total correlation of the alliance and outcome into patient and therapist contributions generally demonstrate that it is the therapist that is primarily responsible for the alliance-outcome association. That is, therapists who can form a stronger alliance with a wide range of patients also generally have better outcomes than other therapists. Even patients who tend to form a weaker alliance with therapists will develop a stronger alliance with therapists who generally have the skills to develop a strong alliance.

Practice Implications

When it comes to the therapeutic alliance, the therapist matters even for patients who struggle to form an alliance. It turns out that gender, age, ethnicity, profession, and theoretical orientation of the therapist do not matter as much as their interpersonal skills. These interpersonal skills include a therapist’s capacity to communicate hope and positive expectations, persuasiveness, emotional expression, warmth, understanding, acceptance, empathy, and ability to repair alliance ruptures. If a therapist wants to make the most of the therapeutic alliance to help their patients, then the therapist should develop and nurture these interpersonal skills for themselves.
Quality of Life Outcomes in the Psychological Treatment of Persistent Depression

McPherson, S., & Senra, H. (2022). Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes. Psychotherapy, 59(3), 447–459.

The World Health Organization ranks depression as the largest cause of global disability accounting for 7.5% of all years lived with disability. Persistent forms of depression contribute to years lived with disability due to its chronic nature and its association with low levels of social and physical functioning, high rates of suicide, and high health care use. One way to look at disability as an outcome is to assess quality of life, which refers to performance in daily and social functioning and satisfaction with these activities. In this meta-analysis, McPherson and Senra examine 14 randomized controlled trials of psychological therapies for chronic or persistent depression in adults. The control condition included no treatment, waiting list, treatment as usual, or only antidepressant medication. The psychotherapies were mindfulness-based cognitive therapy (MBCT), CBT, interpersonal psychotherapy (IPT), long term psychoanalytic psychotherapy (LTPP), and DBT. Chronic depression was defined as a course of depression of at least 2 years and/or non-response to at least two treatments. The quality of life measure had to assess satisfaction with physical health, psychological state, level of independence, and social relationships. In general, the psychological treatments were associated with improvements in patients’ quality of life at the end of treatment (N=11; g=0.24; 95%CI: 0.13, 0.34). At follow up, the effect size was g=.21 (95%CI: 0.10, 0.32). That is, the effects were significant and positive, but small. The psychological interventions resulted in improvements in patient functioning at the end of treatment, g=.35 (95%CI: 0.21, 0.48), which is consistent with previous meta-analyses showing small to moderate effects of psychological treatments for persistent depression. Although there were too few studies to properly assess differences between therapy types, MBCT, IPT, and LTPP in combination with antidepressant medications had the largest effects among the therapies studied.

Practice Implications

In international surveys, patients seeking treatment for depression, informal caregivers, and health professionals list quality of life and social functioning as just as important or as more important than symptom reduction. Yet, these outcomes related to quality of life are not often assessed in clinical trials. This meta-analysis of a modest number of studies, suggests that some psychological therapies (MBCT, IPT, LTPP), in combination with antidepressant medications have the largest positive effects on quality of life for those persistent depression.
Cognitive Behavior Therapy vs. Control Conditions and Other Treatments

Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: A comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22, 105–115.

Depression is a highly prevalent mental disorder, with about 280 million people worldwide who have the disorder. Several evidence-based treatments are available for depression, including pharmacotherapies and psychotherapies. Cognitive behavior therapy (CBT) is the most researched type of psychotherapy for depression. To date there are 409 trials with over 52,00 patients. In this study, Cuijpers and colleagues conduct the largest meta-analysis of CBT versus control conditions (treatment as usual [TAU], no treatment, other active psychotherapies, and pharmacotherapy). Although early trials of CBT were of low quality (small sample sizes, high risk of bias), the quality of studies have improved over time. In this meta-analysis Cuijpers and colleagues found that CBT had a large to moderate effect compared to TAU or to no treatment (g=0.79; 95% CI: 0.70-0.89), suggesting that CBT is better than receiving no or limited treatment. These results were stable up to one year follow-up. One would have to treat 4.7 patients with CBT to see improvement in one patient relative to no or limited treatment. CBT was compared to other active treatments in 87 trials. CBT was no more effective than other psychotherapies such that the average difference was miniscule (g=0.06; 95% CI: 0-0.12). One would have to treat 63 patients with CBT for one patient to receive a better outcome relative to another psychotherapy. However, if differences did emerge between CBT and other psychotherapies, they were not reliable. The effects of CBT did not differ significantly from those of pharmacotherapies (anti-depressant medications) at the short term, but the effects of CBT were significantly larger than pharmacotherapies at 6–12-month follow-up (g=0.34; 95% CI: 0.09-0.58). However, these follow-up findings also were not reliable. Combined treatment of CBT plus anti-depressant medications was more effective than pharmacotherapies alone at the short (g=0.51; 95% CI: 0.19-0.84) and long term (g=0.32; 95% CI: 0.09-0.55), but combined treatment was not more effective than CBT alone at either time point.

Practice Implications

The authors concluded that CBT is effective in the treatment of depression compared to no or limited treatment in the short and longer term. Although CBT gets the lion’s share of attention in the psychotherapy literature, there is no evidence that it is more effective than any other form of psychotherapy or antidepressant medication in the short term. There is evidence that combined CBT and medications may be more helpful than medications alone for depression.

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